High-Sensitivity Troponin I after Cardiac Surgery and 30-Day Mortality.

BACKGROUND: Consensus recommendations regarding the threshold levels of cardiac troponin elevations for the definition of perioperative myocardial infarction and clinically important periprocedural myocardial injury in patients undergoing cardiac surgery range widely (from >10 times to ≥70 times the upper reference limit for the assay). Limited evidence is available to support these recommendations. METHODS: We undertook an international prospective cohort study involving patients 18 years of age or older who underwent cardiac surgery. High-sensitivity cardiac troponin I measurements (upper reference limit, 26 ng per liter) were obtained 3 to 12 hours after surgery and on days 1, 2, and 3 after surgery. We performed Cox analyses using a regression spline that explored the relationship between peak troponin measurements and 30-day mortality, adjusting for scores on the European System for Cardiac Operative Risk Evaluation II (which estimates the risk of death after cardiac surgery on the basis of 18 variables, including age and sex). RESULTS: Of 13,862 patients included in the study, 296 (2.1%) died within 30 days after surgery. Among patients who underwent isolated coronary-artery bypass grafting or aortic-valve replacement or repair, the threshold troponin level, measured within 1 day after surgery, that was associated with an adjusted hazard ratio of more than 1.00 for death within 30 days was 5670 ng per liter (95% confidence interval [CI], 1045 to 8260), a level 218 times the upper reference limit. Among patients who underwent other cardiac surgery, the corresponding threshold troponin level was 12,981 ng per liter (95% CI, 2673 to 16,591), a level 499 times the upper reference limit. CONCLUSIONS: The levels of high-sensitivity troponin I after cardiac surgery that were associated with an increased risk of death within 30 days were substantially higher than levels currently recommended to define clinically important periprocedural myocardial injury. (Funded by the Canadian Institutes of Health Research and others; VISION Cardiac Surgery ClinicalTrials.gov number, NCT01842568.).

Gene therapy for refractory angina and cell therapy for heart failure: experience of a Brazilian research group.

Cell therapy has shown impressive effects in experimental cardiomyopathy models. To a lesser extent, gene therapy has also been studied. In both cases, translation to clinical therapy has been disappointing. This paper is intended to describe the experience and achievements of a multicenter working group located in Porto Alegre, southern Brazil, in experimental and translational research projects for cell-based and gene therapy methods in the treatment of dilated and ischemic cardiomyopathies. The results of preclinical and clinical studies showed that bone marrow mononuclear stem cells indeed have an effect in improving myocardial perfusion and contractile function, but the overall results are poorly translated to the clinical level. Gene therapy studies with direct myocardial injections of naked VEGF 165 plasmid showed improvement in myocardial perfusion and function in animal models. A randomized clinical trial found that this method is safe and improved myocardial perfusion, but the benefits disappeared after 1 year. An animal experiment associating VEGF 165 with angiopoietin was undertaken in mini pigs to extend the durability of that therapy. In conclusion, our efforts to better understand the mechanisms and functions of gene and cell-based therapies in cardiology resulted in significant findings and propose a future look at cell-free therapeutic approaches.

Short-term diuretic withdrawal in stable outpatients with mild heart failure and no fluid retention receiving optimal therapy: a double-blind, multicentre, randomized trial.

AIMS: Although loop diuretics are widely used to treat heart failure (HF), there is scarce contemporary data to guide diuretic adjustments in the outpatient setting. METHODS AND RESULTS: In a prospective, randomized and double-blind protocol, we tested the safety and tolerability of withdrawing low-dose furosemide in stable HF outpatients at 11 HF clinics in Brazil. The trial had two blindly adjudicated co-primary outcomes: (i) symptoms assessment quantified as the area under the curve (AUC) of a dyspnoea score on a visual-analogue scale evaluated at 4 time-points (baseline, Day 15, Day 45, and Day 90) and (ii) the proportion of patients maintained without diuretic reuse during follow-up. We enrolled 188 patients (25% females; 59 ± 13 years old; left ventricular ejection fraction = 32 ± 8%) that were randomized to furosemide withdrawal (n = 95) or maintenance (n = 93). For the first co-primary endpoint, no significant difference in patients' assessment of dyspnoea was observed in the comparison of furosemide withdrawal with continuous administration [median AUC 1875 (interquartile range, IQR 383-3360) and 1541 (IQR 474-3124), respectively; P = 0.94]. For the second co-primary endpoint, 70 patients (75.3%) in the withdrawal group and 77 patients (83.7%) in the maintenance group were free of furosemide reuse during follow-up (odds ratio for additional furosemide use with withdrawal 1.69, 95% confidence interval 0.82-3.49; P = 0.16). Heart failure-related events (hospitalizations, emergency room visits, and deaths) were infrequent and similar between groups (P = 1.0). CONCLUSIONS: Diuretic withdrawal did not result in neither increased self-perception of dyspnoea nor increased need of furosemide reuse. Diuretic discontinuation may deserve consideration in stable outpatients with no signs of fluid retention receiving optimal medical therapy. CLINICALTRIALS.GOV IDENTIFIER: NCT02689180.

Coronary sinus cannulation predicts atrioventricular nodal reentry as mechanism of supraventricular tachycardia.

INTRODUCTION: Common clinical teaching, for invasive electrophysiology, is that if the first year fellow cannulates the coronary sinus (CS) in his first attempt, the arrhythmia is more likely to be atrioventricular nodal reentry tachycardia (AVNRT). This general perception has not yet been clinically tested. We evaluated this theory in prospective patients undergoing an electrophysiological study (EPS) for paroxysmal supraventricular tachycardia (PSVT). METHODS: Cohort study. CS ease of cannulation (CSCS) was graded as: 1) 1st year fellow cannulates in first attempt; 2) 1st year fellow needs more than one attempt or maneuver to cannulate the CS; 3) staff physician cannulates in first attempt after the fellow was unsuccessful; 4) staff physician requires more than one maneuver to cannulate the CS; 5) staff physician judges that the cannulation process was extremely difficult. RESULTS: Of the 1361 patients undergoing EPS in our institution, 165 were selected. Age was 49 ±â€¯15 years. AVNRT occurred in 77.6%, atrioventricular reentry tachycardia (AVRT) in 15.1% and atrial tachycardia (AT) in 7.3% of cases. The CSCS = 1 was more prevalent in AVNRT, 89% versus 68% AVRT and 58.3% of AT (P = 0.0005). Patients with CSCS = 1 have a higher chance of the PSVT being AVNRT (odds ratio: 4.41; 95CI: 1.84-10.56; P = 0.0009). CONCLUSION: The CSCS predicts the likelihood of the induced PSVT being AVNRT as compared to AVRT and AT. More studies are required to try to associate this finding to clinical patient characteristics to create a score for PSVT mechanism prediction.

Rational and design of a randomized, double-blind, multicenter trial to evaluate the safety and tolerability of furosemide withdrawal in stable chronic outpatients with heart failure: The ReBIC-1 trial.

AIMS: Furosemide is commonly prescribed for symptom relief in heart failure (HF) patients. Although few data support the continuous use of loop diuretics in apparently euvolemic HF patients with mild symptoms, there is concern about safety of diuretic withdrawal in these patients. The ReBIC-1 trial was designed to evaluate the safety and tolerability of withdrawing furosemide in stable, euvolemic, chronic HF outpatients. This multicenter initiative is part of the Brazilian Research Network in Heart Failure (ReBIC) created to develop clinical studies in HF and composed predominantly by university tertiary care hospitals. METHODS: The ReBIC-1 trial is currently enrolling HF patients in NYHA functional class I-II, left ventricular ejection fraction ≤45%, without a HF-related hospital admission within the last 6 months, receiving a stable dose of furosemide (40 or 80 mg per day) for at least 6 months. Eligible patients will be randomized to maintain or withdraw furosemide in a double-blinded protocol. The trial has two co-primary outcomes: (1) dyspnea assessment using a visual-analogue scale evaluated at 4 time points and (2) the proportion of patients maintained without diuretics during the follow-up period. Total sample size was calculated to be 220 patients. Enrolled patients will be followed up to 90 days after randomization, and diuretic will be restarted if clinical deterioration or signs of congestion are detected. Pre-defined sub-group analysis based on NT-proBNP levels at baseline is planned. PERSPECTIVE: Evidence-based strategies aiming to simplify HF pharmacotherapy are needed in clinical practice. The ReBIC-1 trial will determine the safety of withdrawing furosemide in stable chronic HF patients.

Meta-analysis of continuous oral anticoagulants versus heparin bridging in patients undergoing CIED surgery: reappraisal after the BRUISE study.

BACKGROUND: Management of patients treated with oral anticoagulation (OAC) requiring a cardiovascular implantable electronic device (CIED) surgery is a challenge that requires balancing the risk of bleeding complications with the risk of thromboembolic events. Recently the approach of performing these procedures while the patient remains with a therapeutic international normalized ratio has gained interest due to several publications showing its relative safety. OBJECTIVES: To evaluate the safety and effectiveness of continuous use of OAC compared with heparin bridging in the perioperative setting of CIED surgery using a meta-analysis. METHODS: A systematic review of PubMed/MEDLINE, Ovid, and Elsevier databases was performed. Eligible randomized controlled trials and cohort studies were included. The outcomes studied were risk of clinically significant bleeding and of thromboembolic events. Our analysis was restricted to OAC with vitamin K antagonists. RESULTS: Of 560 manuscripts initially considered relevant, seven were included in the meta-analysis, totaling 2,191 patients. Data are reported as odds ratios (ORs) with confidence interval (CI) of 95%. Maintenance of OAC was associated with a significantly lower risk of postoperative bleeding compared with heparin bridge (OR = 0.25, 95% CI 0.17-0.36, P < 0.00001). There was no difference noted in the risk of thromboembolic events between the two strategies (OR = 1.86, 95% CI 0.29-12.17, P = 0.57). CONCLUSIONS: Uninterrupted use of OAC in the perioperative of CIED surgery was associated with a reduced risk of bleeding. This strategy should be considered the preferred one in patients at moderate-to-high risk of thromboembolic events.

Prognosis of programmed ventricular stimulation in adult patients with syncope of unexplained origin: A historical cohort.

Background: Programmed ventricular stimulation (PVS) during electrophysiological study (EPS), is a globally accepted tool for risk stratification of sudden cardiac death (SCD) in some specific clinical situations. The aim of this study was to evaluate the prognosis of ventricular arrhythmia induction in a cohort of patients with syncope of undetermined origin (SUO). Methods: This is a historical cohort study in a population of patients with SUO referred for EPS between the years 2008-2021. In this interval, 575 patients underwent the procedure. Results: Patients with induced ventricular arrhythmias had a higher occurrence of structural heart disease (36.7% vs. 76.5%), ischemic heart disease (28.2 vs. 57.1%), heart failure (15.5% vs. 34.4%), and lower left ventricular ejection fraction (59.16% vs. 47.51%), when compared to the outcome with a negative study. PVS triggered ventricular arrhythmias in 98 patients, 62 monomorphic and 36 polymorphic. During a median follow-up of 37.6 months, 100 deaths occurred. Only the induction of sustained ventricular arrhythmias showed a significant association with the primary outcome (all-cause mortality) with a p value <.001. After the performance of EPS, 142 patients underwent cardioverter-defibrillator (ICD) implantation. At study follow-up, 30 patients had therapies by the device. Only the induction of sustained monomorphic ventricular arrhythmia showed statistically significant association with appropriate therapies by the device (p = .012). Conclusion: In patients with SUO, the induction of sustained monomorphic ventricular arrhythmia after programmed ventricular pacing is related to a worse prognosis, with a higher incidence of mortality and appropriate therapies by the ICD.

Electrophysiological study as a predictor of mortality in unexplained syncope.

Background: Electrophysiological study can help in the diagnosis of arrhythmic syncope. According to the electrophysiological study finding, the prognosis of patients with syncope is still a matter of study. Objective: The aim of this study was to assess the survival of patients undergoing electrophysiological study according to their findings and to identify clinical and electrophysiological independent predictors of all-cause mortality. Methods: A retrospective cohort study included patients with syncope who underwent electrophysiological study from 2009 to 2018. A Cox logistic regression analysis was performed to identify independent prognostic factors for all-cause mortality. Results: We included 383 patients in our study. During a mean follow-up of 59 months, 84 (21.9%) patients died. The split His group had the worst survival compared with the control group, followed by sustained ventricular tachycardia and HV interval ≥ 70 ms, respectively (p = .001; p < .001; p = .03). The supraventricular tachycardia group showed no differences compared with the control group (p = .87). In the multivariate analysis, independent predictors of all-cause mortality were Age (OR 1.06; 1.03-1.07; p < .001); congestive heart failure (OR 1.82; 1.05-3.15; p = .033); split His (OR 3.7; 1.27-10.80; p = .016); and sustained ventricular tachycardia (OR 1.84; 1.02-3.32; p = .04). Conclusion: Split His, sustained ventricular tachycardia, and HV interval ≥ 70 ms groups had worse survivals when compared to the control group. Age, congestive heart failure, split His, and sustained ventricular tachycardia were independent predictors for all-cause mortality.

Atrial Fibrillation Ablation: Impact of Intracardiac Echocardiography in Reducing Procedure Time and Hospitalization. / Ablação da Fibrilação Atrial: Impacto da Ecocardiografia Intracardíaca na Redução do Tempo de Procedimento e Internação.

BACKGROUND: Intracardiac echocardiography (ICE) allows visualization of cardiac structures and recognition of complications during atrial fibrillation ablation (AFA). Compared to transesophageal echocardiography (TEE), ICE is less sensitive to detecting thrombus in the atrial appendage but requires minimal sedation and fewer operators, making it attractive in a resource-constrained setting. OBJECTIVE: To compare 13 cases of AFA using ICE (AFA-ICE group) with 36 cases of AFA using TEE (AFA-TEE group). METHODS: This is a single-center prospective cohort study. The main outcome was procedure time. Secondary outcomes: fluoroscopy time, radiation dose (mGy/cm2), major complications, and length of hospital stay in hours. The clinical profile was compared using the CHA2DS2-VASc score. A p-value <0.05 was considered a statistically significant difference between groups. RESULTS: The median CHA2DS2-VASc score was 1 (0-3) in the AFA-ICE group and 1 (0-4) in the AFA-TEE group. The total procedure time was 129 ± 27 min in the AFA-ICE group and 189 ± 41 min in the AFA-TEE group (p<0.001); the AFA-ICE group received a lower dose of radiation (mGy/cm2, 51296 ± 24790 vs. 75874 ± 24293; p=0.002), despite the similar fluoroscopy time (27.48 ± 9. 79 vs. 26.4 ± 9.32; p=0.671). The median length of hospital stay did not differ; 48 (36-72) hours (AFA-ICE) and 48 (48-66) hours (AFA-TEE) (p=0.27). CONCLUSIONS: In this cohort, AFA-ICE was related to shorter procedure times and less exposure to radiation without increasing the risk of complications or the length of hospital stay.

FUNDAMENTO: O ecocardiograma intracardíaco (EIC) permite visualizar estruturas cardíacas e reconhecer complicações durante a ablação da fibrilação atrial (AFA). Comparado ao ecocardiograma transesofágico (ETE), o EIC é menos sensível para detecção de trombo no apêndice atrial, porém requer mínima sedação e menos operadores, tornando-o atrativo num cenário de recursos restritos. OBJETIVO: Comparar 13 casos de AFA utilizando EIC (grupo AFA-EIC) com 36 casos de AFA utilizando ETE (grupo AFA-ETE). MÉTODO: Trata-se de corte prospectiva realizada em um único centro. O desfecho principal foi o tempo de procedimento. Desfechos secundários tempo de fluoroscopia, dose de radiação (mGy/cm2), complicações maiores e tempo de internação hospitalar em horas. O perfil clínico foi comparado pelo escore CHA2DS2-VASc. Um valor de p <0,05 foi considerado uma diferença estatisticamente significativa entre os grupos. RESULTADOS: A mediana do escore de CHA2DS2-VASc score foi 1 (0-3) no grupo AFA-EIC e 1 (0-4) no grupo AFA-ETE. O tempo total de procedimento foi de 129 ± 27 min grupo AFA-EIC e 189 ± 41 no AFA-ETE (p<0,001); o grupo AFA-EIC recebeu uma dose menor de radiação (mGy/cm2, 51296 ± 24790 vs. 75874 ± 24293; p=0,002), no entanto, o tempo de fluoroscopia em minutos mostrou-se semelhante (27,48 ± 9,79 vs. 26,4 ± 9,32; p=0,671). As medianas do tempo de hospitalização não se mostraram diferentes, 48 (36-72) horas (AFA-EIC) e 48 (48-66) horas (AFA-ETE) (p=0,27). CONCLUSÃO: Nesta coorte, AFA-EIC foi relacionado a menores tempos de procedimento e menor exposição à radiação, sem aumentar o risco de complicações ou o tempo de internação hospitalar.

Unscheduled Emergency Visits after Cardiac Devices Implantation: Comparison between Cardioverter Defibrillators and Cardiac Resynchronization Therapy Devices in less than one year of Follow Up.

BACKGROUND: The use of Cardiovascular Implantable Electronic Devices (CIED), such as the Implantable Cardioverter Defibrillator (ICD) and Cardiac Resynchronization Therapy (CRT), is increasing. The number of leads may vary according to the device. Lead placement in the left ventricle increases surgical time and may be associated with greater morbidity after hospital discharge, an event that is often confused with the underlying disease severity. OBJECTIVE: To evaluate the rate of unscheduled emergency hospitalizations and death after implantable device surgery stratified by the type of device. METHODS: Prospective cohort study of 199 patients submitted to cardiac device implantation. The groups were stratified according to the type of device: ICD group (n = 124) and CRT group (n = 75). Probability estimates were analyzed by the Kaplan-Meier method according to the outcome. A value of p < 0.05 was considered significant in the statistical analyses. RESULTS: Most of the sample comprised male patients (71.9%), with a mean age of 61.1 ± 14.2. Left ventricular ejection fraction was similar between the groups (CRT 37.4 ± 18.1 vs. ICD 39.1 ± 17.0, p = 0.532). The rate of unscheduled visits to the emergency unit related to the device was 4.8% in the ICD group and 10.6% in the CRT group (p = 0.20). The probability of device-related survival of the variable "death" was different between the groups (p = 0.008). CONCLUSIONS: Patients after CRT implantation show a higher probability of mortality after surgery at a follow-up of less than 1 year. The rate of unscheduled hospital visits, related or not to the implant, does not differ between the groups.

Early Emotional Symptoms Predicting Carotid Atherosclerosis in Youth: Results From a Birth Cohort in Latin America.

Background Emotional disorders are risk factors for atherosclerosis and consequent cardiovascular disease. However, it is not clear whether emotional symptoms (ESs) have direct effects on cardiovascular disease. The aim of the present study is to investigate the effects of early ESs on carotid atherosclerosis in young adults. Methods and Results We tested the association between expression of ESs at 11 and 15 years of age and carotid intima-media thickness at 18 years of age in the 1993 Pelotas Birth Cohort (N=5249, n=4336 with complete mental health data). ES s were assessed using the Strengths and Difficulties Questionnaire. Propensity score weighting procedure was run using generalized boosted regression model to adjust for potential confounding between exposure and outcome. We also tested whether traditional cardiovascular risk factors could mediate this relationship. Adjusted high expression of ESs , both at 11 and 15 years of age, led to mean increases in carotid intima-media thickness of 1.84 and 2.58 µm, respectively, at 18 years of age (both P<0.001). Longitudinal effects of ESs on atherosclerosis were direct and not significantly mediated by traditional cardiovascular risk factors. Male sex at age 15 years significantly enhanced the effects of ESs on carotid intima-media thickness at age 18 years ( P<0.001 for interaction): although high expression of ESs led to mean increases of 1.14 µm in females ( P<0.05), it led to mean increases of 5.83 µm in males ( P<0.001). Conclusions In this large birth cohort, expression of ESs in adolescence was longitudinally associated with a higher carotid intima-media thickness in young adults. The association is direct and not mediated by traditional cardiovascular risk factors. Interactions by sex might have important implications for designing future interventions.

Autologous transplantation of bone marrow mononuclear stem cells by mini-thoracotomy in dilated cardiomyopathy: technique and early results.

CONTEXT AND OBJECTIVES: There are few studies concerning bone marrow mononuclear cell (BMMC) transplantation in cases of nonischemic dilated cardiomyopathy. This study describes a novel technique of BMMC transplantation and the results up to one year after the procedure. DESIGN AND SETTING: This was a case series to evaluate the safety and viability of the procedure, at Instituto de Cardiologia do Rio Grande do Sul. METHODS: Nine patients with symptomatic dilated cardiomyopathy, functional class III/IV and left ventricular ejection fraction (LVEF) < 35% received BMMC (9.6 +/- 2.6 x 107 cells) at 20 sites in the ventricular wall, by means of thoracotomy of length 5 cm in the fifth left intercostal space. Echocardiograms and nuclear magnetic resonance (NMR) were performed. RESULTS: There were no major complications. The functional class results for the first six patients (preoperatively and at two, four, eight and twelve-month follow-ups, respectively) were: [IV-2, III-4] to [I-5, II-1] to [I-3, II-3] to [I-2, II-3] and [I-2, II-3]. Echocardiograms showed LVEF: 25.9 +/- 8.2; 32.9 +/- 10.4; 29.4 +/- 7.2; 25.1 +/- 7.9; 25.4 +/- 6.8% (p = 0.023); and % left ventricular (LV) fiber shortening: 12.6 +/- 4.4; 16.4 +/- 5.4; 14.3 +/- 3.7; 12.1 +/- 4.0; 12.2 +/- 3.4% (p = 0.021). LV performance variation seen on NMR was non-significant. CONCLUSION: Intramyocardial transplantation of BMMC in dilated cardiomyopathy cases is feasible and safe. There were early improvements in symptoms and LV performance. Medium-term evaluation revealed regression of LV function, although maintaining improved functional class.

Ablação da Fibrilação Atrial: Impacto da Ecocardiografia Intracardíaca na Redução do Tempo de Procedimento e Internação / Atrial Fibrillation Ablation: Impact of Intracardiac Echocardiography in Reducing Procedure Time and Hospitalization

Resumo Fundamento O ecocardiograma intracardíaco (EIC) permite visualizar estruturas cardíacas e reconhecer complicações durante a ablação da fibrilação atrial (AFA). Comparado ao ecocardiograma transesofágico (ETE), o EIC é menos sensível para detecção de trombo no apêndice atrial, porém requer mínima sedação e menos operadores, tornando-o atrativo num cenário de recursos restritos. Objetivo Comparar 13 casos de AFA utilizando EIC (grupo AFA-EIC) com 36 casos de AFA utilizando ETE (grupo AFA-ETE). Método Trata-se de corte prospectiva realizada em um único centro. O desfecho principal foi o tempo de procedimento. Desfechos secundários tempo de fluoroscopia, dose de radiação (mGy/cm2), complicações maiores e tempo de internação hospitalar em horas. O perfil clínico foi comparado pelo escore CHA2DS2-VASc. Um valor de p <0,05 foi considerado uma diferença estatisticamente significativa entre os grupos. Resultados A mediana do escore de CHA2DS2-VASc score foi 1 (0-3) no grupo AFA-EIC e 1 (0-4) no grupo AFA-ETE. O tempo total de procedimento foi de 129 ± 27 min grupo AFA-EIC e 189 ± 41 no AFA-ETE (p<0,001); o grupo AFA-EIC recebeu uma dose menor de radiação (mGy/cm2, 51296 ± 24790 vs. 75874 ± 24293; p=0,002), no entanto, o tempo de fluoroscopia em minutos mostrou-se semelhante (27,48 ± 9,79 vs. 26,4 ± 9,32; p=0,671). As medianas do tempo de hospitalização não se mostraram diferentes, 48 (36-72) horas (AFA-EIC) e 48 (48-66) horas (AFA-ETE) (p=0,27). Conclusão Nesta coorte, AFA-EIC foi relacionado a menores tempos de procedimento e menor exposição à radiação, sem aumentar o risco de complicações ou o tempo de internação hospitalar.

Abstract Background Intracardiac echocardiography (ICE) allows visualization of cardiac structures and recognition of complications during atrial fibrillation ablation (AFA). Compared to transesophageal echocardiography (TEE), ICE is less sensitive to detecting thrombus in the atrial appendage but requires minimal sedation and fewer operators, making it attractive in a resource-constrained setting. Objective To compare 13 cases of AFA using ICE (AFA-ICE group) with 36 cases of AFA using TEE (AFA-TEE group). Methods This is a single-center prospective cohort study. The main outcome was procedure time. Secondary outcomes: fluoroscopy time, radiation dose (mGy/cm2), major complications, and length of hospital stay in hours. The clinical profile was compared using the CHA2DS2-VASc score. A p-value <0.05 was considered a statistically significant difference between groups. Results The median CHA2DS2-VASc score was 1 (0-3) in the AFA-ICE group and 1 (0-4) in the AFA-TEE group. The total procedure time was 129 ± 27 min in the AFA-ICE group and 189 ± 41 min in the AFA-TEE group (p<0.001); the AFA-ICE group received a lower dose of radiation (mGy/cm2, 51296 ± 24790 vs. 75874 ± 24293; p=0.002), despite the similar fluoroscopy time (27.48 ± 9. 79 vs. 26.4 ± 9.32; p=0.671). The median length of hospital stay did not differ; 48 (36-72) hours (AFA-ICE) and 48 (48-66) hours (AFA-TEE) (p=0.27). Conclusions In this cohort, AFA-ICE was related to shorter procedure times and less exposure to radiation without increasing the risk of complications or the length of hospital stay.

Uninterrupted Use of Oral Anticoagulants for the Ablation of Atrial Flutter: A Single Center Cohort of 154 Patients.

BACKGROUND: The uninterrupted use of oral anticoagulation (OAC) with vitamin K antagonists (VKAs) for electrophysiology procedures has been more and more recommended. The clinical practice in our service recommends the continuous use of these drugs for atrial flutter ablation. There is little evidence as to the uninterrupted use of non-vitamin K antagonist oral anticoagulants (NOACs) in this scenario. OBJECTIVE: To compare the rates of complications related with the uninterrupted use of different types of oral anticoagulants in patients referred to atrial flutter (AFL) ablation. METHODS: Historical, single-center cohort of ablation procedures by AFL conducted from November 2012 to April 2016. The primary outcome was the occurrence of hemorrhagic or embolic complication during the procedure. The secondary outcome was the occurrence of stroke or transient ischemic attack (TIA) in follow-up. The statistical significance level was 5%. RESULTS: There were 288 ablations per AFL; 154 were carried out with the uninterrupted use of OAC (57.8% with VKA and 42.2% with NOAC). Mean age was 57 ± 13 years. The rate of hemorrhagic complication during the procedure was 3% in each group (p = NS). The rate of stroke/TIA was, respectively, of 56/1,000 people-year in the VKA group against zero/1,000 people-year in the NOAC group (p = 0.02). CONCLUSION: In our population there were no hemorrhagic complications regarding the procedure of OAC use uninterruptedly, including NOACs. There was higher occurrence of stroke/TIA in the follow-up of the group of patients undergoing VKAs; however, this difference may not only be a result of the type of OAC used.

Combined Analysis of Endothelial, Hematopoietic, and Mesenchymal Stem Cell Compartments Shows Simultaneous but Independent Effects of Age and Heart Disease.

Clinical trials using stem cell therapy for heart diseases have not reproduced the initial positive results obtained with animal models. This might be explained by a decreased regenerative capacity of stem cells collected from the patients. This work aimed at the simultaneous investigation of endothelial stem/progenitor cells (EPCs), mesenchymal stem/progenitor cells (MSCs), and hematopoietic stem/progenitor cells (HSCs) in sternal bone marrow samples of patients with ischemic or valvular heart disease, using flow cytometry and colony assays. The study included 36 patients referred for coronary artery bypass grafting or valve replacement surgery. A decreased frequency of stem cells was observed in both groups of patients. Left ventricular dysfunction, diabetes, and intermediate risk in EuroSCORE and SYNTAX score were associated with lower EPCs frequency, and the use of aspirin and ß-blockers correlated with a higher frequency of HSCs and EPCs, respectively. Most importantly, the distribution of frequencies in the three stem cell compartments showed independent patterns. The combined investigation of the three stem cell compartments in patients with cardiovascular diseases showed that they are independently affected by the disease, suggesting the investigation of prognostic factors that may be used to determine when autologous stem cells may be used in cell therapy.

Analysis of Dyssynchrony and Ventricular Function in Right Univentricular Stimulation at Different Positions.

INTRODUCTION: Chronic stimulation of the right ventricle with pacemaker is associated with ventricular dyssynchrony and loss of contractility, even in subjects without previous dysfunction. In these patients, there is a debate of which pacing site is less associated with loss of ventricular function. OBJECTIVE: To compare pacemaker-induced dyssynchrony among different pacing sites in right ventricular stimulation. METHODS: Cross-sectional study of outpatients with right ventricle stimulation higher than 80% and preserved left ventricular ejection fraction. Pacing lead position (apical, medial septum or free wall) was assessed through chest X-rays. Every patient underwent echocardiogram to evaluate for dyssynchrony according to CARE-HF criteria: aortic pre-ejection time, interventricular delay and septum/posterior wall delay on M mode. RESULTS: Forty patients were included. Fifty-two percent had apical electrode position, 42% mid septum and 6% free wall. Mean QRS time 148.97±15.52 milliseconds. A weak correlation between the mean QRS width and pre-aortic ejection time (r=0.32; P=0.04) was found. No difference in QRS width among the positions could be noted. Intraventricular delay was lower in apical patients against mid septal (34.4±17.2 vs. 54.3±19.1 P<0.05) - no difference with those electrode on the free wall. No difference was noted in the pre-aortic ejection time (P=0.9). CONCLUSION: Apical pacing showed a lower interventricular conduction delay when compared to medial septum site. Our findings suggest that apical pacing dyssynchrony is not ubiquitous, as previously thought, and that it should remain an option for lead placement.

Pulmonary congestion evaluated by lung ultrasound predicts decompensation in heart failure outpatients.

BACKGROUND: Pulmonary congestion is the main cause of hospital admission among heart failure (HF) patients. Lung ultrasound (LUS) assessment of B-lines has been recently proposed as a reliable and easy tool for evaluating pulmonary congestion. OBJECTIVE: To determine the prognostic value of LUS in predicting adverse events in HF outpatients. METHODS: Single-center prospective cohort of 97 moderate-to-severe systolic HF patients (53±13years; 61% males) consecutively enrolled between November 2011 and October 2012. LUS evaluation was performed during the regular outpatient visit to evaluate the presence of pulmonary congestion, determined by B-lines number. Patients were followed up for 4months to assess admission due to acute pulmonary edema. RESULTS: During follow-up period (106±12days), 21 hospitalizations for acute pulmonary edema occurred. At Cox regression analysis, B-lines number≥30 (HR 8.62; 95%CI: 1.8-40.1; p=0.006) identified a group at high risk for acute pulmonary edema admission at 120days, and was the strongest predictor of events compared to other established clinical, laboratory and instrumental findings. No acute pulmonary edema occurred in patients without significant pulmonary congestion at LUS (number of B-lines<15). CONCLUSION: In a HF outpatient setting, B-line assessment by LUS identifies patients more likely to be admitted for decompensated HF in the following 4months. This simple evaluation could allow prompt therapy optimization in those patients who, although asymptomatic, carry a significant degree of extravascular lung water. CONDENSED ABSTRACT: Pulmonary congestion is the main cause of hospital admissions among heart failure patients. Lung ultrasound can be used as a reliable and easy way to evaluate pulmonary congestion through assessment of B-lines. In a cohort of heart failure outpatients, a B-lines cutoff≥30 (HR 8.62; 95%CI: 1.8-40.1) identified patients most likely to develop acute pulmonary edema at 120-days.

Simple risk stratification score for prognosis of syncope.

PURPOSE: The aim of this study is to describe a new simple score to predict the occurrence of severe adverse events in patients admitted for syncope to a tertiary cardiology referral center. METHODS: Three hundred ninety-three subjects with emergency department visits for syncope were identified and followed prospectively. The primary endpoint was death or unplanned hospital admission after the syncopal episode. The score consisted of sum of the following: previous syncope (2 points), an abnormal electrocardiogram (3 points), and history of heart disease (4 points). The accuracy of our score was compared to other scores available in the literature. RESULTS: Of the 393 subjects, 87 were diagnosed with syncope secondary to structural or electrical heart disease and 306 with noncardiac syncope. The primary endpoint occurred in 202 cases, including death occurring in 25 patients during the 12-month follow-up. The 30-day event rate for the primary endpoint was 26.5 %. The c-statistic for the new score was 0.76 (95 % CI 0.71-0.80) similar to other scores when applied to our sample. Patients with a score of 3 out of 9 had a hazard ratio of 3.46 (95 % CI 1.22-6.11) for death during the follow-up. CONCLUSIONS: In the study population, the new syncope score detected patients with an increased risk of death after discharge from a syncopal event. Our score predicted adverse events comparably to other scores reported in the literature. It has the advantage of being simple and easily obtained from the history and an inexpensive noninvasive test-the ECG.

Direct intramyocardial transthoracic transplantation of bone marrow mononuclear cells for non-ischemic dilated cardiomyopathy: INTRACELL, a prospective randomized controlled trial.

OBJECTIVE: We tested the hypothesis that direct intramyocardial injection of bone marrow mononuclear cells in patients with non-ischemic dilated cardiomyopathy can improve left ventricular function and physical capacity. METHODS: Thirty non-ischemic dilated cardiomyopathy patients with left ventricular ejection fraction <35% were randomized at a 1:2 ratio into two groups, control and treated. The bone marrow mononuclear cells group received 1.06±108 bone marrow mononuclear cells through mini-thoracotomy. There was no intervention in the control group. Assessment was carried out through clinical evaluations as well as a 6-min walk test, nuclear magnectic resonance imaging and echocardiogram. RESULTS: The bone marrow mononuclear cells group showed a trend toward left ventricular ejection fraction improvement, with magnectic resonance imaging - at 3 months, showing an increase from 27.80±6.86% to 30.13±9.06% (P=0.08) and returning to baseline at 9 months (28.78%, P=0.77). Magnectic resonance imaging showed no changes in left ventricular ejection fraction during follow-up of the control group (28.00±4.32%, 27.42±7.41%, and 29.57±4.50%). Echocardiogram showed left ventricular ejection fraction improved in the bone marrow mononuclear cells group at 3 months, 25.09±3.98 to 30.94±9.16 (P=0.01), and one year, 30.07±7.25% (P=0.001). The control group showed no change (26.1±4.4 vs 26.5±4.7 and 30.2±7.39%, P=0.25 and 0.10, respectively). Bone marrow mononuclear cells group showed improvement in New York Heart Association functional class, from 3.40±0.50 to 2.41±0.79 (P=0.002); patients in the control group showed no change (3.37±0.51 to 2.71±0.95; P=0.17). Six-minute walk test improved in the bone marrow mononuclear cells group (348.00±93.51m at baseline to 370.41±91.56m at 12 months, P=0.66) and there was a non-significant decline in the control group (361.25±90.78m to 330.00±123.42m after 12 months, P=0.66). Group comparisons were non-significant. CONCLUSION: The trend of intragroup functional and subjective improvement was not confirmed when compared to the control group. Direct intramyocardial application of bone marrow mononuclear cells in non-ischemic dilated cardiomyopathy was not associated with significant changes in left ventricular function. Differences observed within the bone marrow mononuclear cells group could be due to placebo effect or low statistical power.

The five-point Likert scale for dyspnea can properly assess the degree of pulmonary congestion and predict adverse events in heart failure outpatients.

OBJECTIVES: Proper assessment of dyspnea is important in patients with heart failure. Our aim was to evaluate the use of the 5-point Likert scale for dyspnea to assess the degree of pulmonary congestion and to determine the prognostic value of this scale for predicting adverse events in heart failure outpatients. METHODS: We undertook a prospective study of outpatients with moderate to severe heart failure. The 5-point Likert scale was applied during regular outpatient visits, along with clinical assessments. Lung ultrasound with ≥15 B-lines and an amino-terminal portion of pro-B-type natriuretic peptide (NT-proBNP) level >1000 pg/mL were used as a reference for pulmonary congestion. The patients were then assessed every 30 days during follow-up to identify adverse clinical outcomes. RESULTS: We included 58 patients (65.5% male, age 43.5 ± 11 years) with a mean left ventricular ejection fraction of 27 ± 6%. In total, 29.3% of these patients had heart failure with ischemic etiology. Additionally, pulmonary congestion, as diagnosed by lung ultrasound, was present in 58% of patients. A higher degree of dyspnea (3 or 4 points on the 5-point Likert scale) was significantly correlated with a higher number of B-lines (p = 0.016). Patients stratified into Likert = 3-4 were at increased risk of admission compared with those in class 1-2 after adjusting for age, left ventricular ejection fraction, New York Heart Association functional class and levels of NT-proBNP >1000 pg/mL (HR = 4.9, 95% CI 1.33-18.64, p = 0.017). CONCLUSION: In our series, higher baseline scores on the 5-point Likert scale were related to pulmonary congestion and were independently associated with adverse events during follow-up. This simple clinical tool can help to identify patients who are more likely to decompensate and whose treatment should be intensified.