Atrial Failure: What Do We Know About It?

Heart failure is the end of all pathological conditions in the heart. Most accepted paradigms in heart failure are always preceded by left ventricle disfunction. Currently, there are several clinical studies that show that heart failure may occur without prior left ventricular dysfunction. Left atrial dysfunction may play a more important role in heart failure than previously expected. Failure of the left atrium can exist independently of left ventricle dysfunction and mitral valve abnormalities. Atrial failure, just like left ventricular failure, can lead to global heart failure. Etiology, pathomechanism and clinical symptoms of atrial failure are complex and not well understood. This review will explain atrial failure.

Combined transepicardial and transseptal implantation of autologous CD 133+ bone marrow cells during bypass grafting improves cardiac function in patients with low ejection fraction.

OBJECTIVES: Autologous CD133+ bone marrow stem cells may improve cardiac function. This randomized, single-blind clinical trial inquired whether a combined transepicardial and transseptal implantation of CD133+ stem cells during coronary artery bypass grafting (CABG) improve cardiac function with ejection fraction (EF) changes as a primary endpoint in patients with low EF. METHODS: Thirty patients with coronary heart disease and EF <35% were randomized to undergo CABG alone or CABG with transseptal and transepicardial implantation of CD133+. Cardiac function was evaluated using cardiac magnetic resonance imaging (MRI) before and 6 months after CABG. RESULTS: Preoperative EF was lower in the intervention group (25.88% ± 5.66%) than in the control group (30.18% ± 3.85%; P = .04). The adverse event incidence was similar between both groups. At 6 months, EF changes were significantly higher (8.69% ± 9.49; P = .04) in the CD133+ group than in the CABG-only group. Compared to the control group, significant improvements were seen in the wall motion score index (P = .003) and scar size proportion (P = .047) in the CD133+ group. The quality of life (QOL), assessed by a 6-minute walking test, showed considerable improvement in the CD133+ group compared to that in the control group (P = .03). The Minnesota Living with Heart Failure Questionnaire (MLHFQ) scale did not show improvement in the intervention group (P = .09, vs control). CONCLUSION: Combined transepicardial and transseptal autologous CD133+ BMC implantation during bypass grafting improved cardiac function in low EF coronary artery disease patients.

Cardiac Performance by Echocardiography, Cardiovascular Biomarker, Kidney Function, and Venous Oxygen Saturation as Mortality Predictors of Septic Shock.

BACKGROUND: cardiac function in patients with septic shock at the cellular level can be assessed by measuring troponin I and NT Pro BNP levels. Venous oxygen saturation is measured to evaluate oxygen delivery and uptake by organ tissue. Our study may provide greater knowledge and understanding on pathophysiology of cardiovascular disorder in patients with septic shock. This study aimed to evaluate the roles of echocardiography, cardiovascular biomarkers, venous oxygen saturation and renal function as predictors of mortality rate in patients with septic shock. METHODS: this is a prospective cohort study in patients with infections, hypotension (MAP < 65 mmHg) and serum lactate level of > 2 mmol/L. On the first and fifth days, septic patients underwent echocardiography and blood tests. Statistical analysis used in our study included t-test or Mann-Whitney test for numeric data and chi-square test for nominal data of two-variable groups; while for multivariate analysis, we used Cox Regression model. RESULTS: on 10 days of observation, we found 64 (58%) patients died and 47 (42%) patients survived. The mean age of patients was 48 (SD 18) years. Patients with abnormal left ventricular ejection fraction (LVEF) had 1.6 times greater risk of mortality than those with normal LVEF (RR 1.6; p = 0.034). Patients with abnormal troponin I level showed higher risk of mortality as many as 1.6 times (RR: 1.6; p = 0.004). Patients with impaired renal function had 1.5 times risk of mortality (RR 1.5; p = 0.024). Patients with abnormal troponin I level and/or impaired renal function showed increased mortality risk; however, those with normal troponin I level and impaired renal function also showed increased mortality risk. Multivariate analysis revealed that left ventricular ejection fraction and troponin I level may serve as predictors of mortality in patients with septic shock. (HR 1.99; 95% CI: 1.099  ̶  3.956 ; p = 0.047 and HR: 1.83 ; 95%CI: 1.049  ̶ 3,215 ; p = 0.043). CONCLUSION: left ventricular ejection fraction and biomarkers such as troponin I level are predictors of mortality in septic shock patients.

Endothelial dysfunction in the young adult: a retrospective cohort study on the effect of low birth weight.

AIM: to investigate the effect of low birth weight (LBW) on endothelial function, and to determine the role of plasma adiponectin in endothelial dysfunction by conducting flow mediated brachial artery (FMBA) test or vasodilation response (VR) and by measuring plasma asymmetrical dimethylarginine (ADMA) of young adults born with LBW. METHODS: in a retrospective cohort study, subjects were randomly selected from the growth study cohort of Tanjungsari Sumedang district West Java. They consisted of 67 LBW and 67 NBW (Normal Birth Weight) young adults. Dependent variables were plasma adiponectin, plasma ADMA, and VR. The correlation between plasma adiponectin and ADMA level was examined using Pearson's correlation. RESULTS: the relative risk for LBW to have low brachialis artery vasodilation response was 2.94, (95% CI:1.91-4.53), and to have low of plasma adiponectin concentration 1.53, (95% CI: 1.07-2.18). There was a statistically significant difference for all variables studied (FMBA, plasma ADMA, and plasma Adiponectin concentrations), while simultaneous confidence interval measurements indicated that the value of FMBA and the concentration of plasma adiponectin were significantly lower, respectively p<0.001, 95% CI: -4.409-(-2.114), and p=0.015, 95% CI: -1.083-(-0.082) in LBW compared to NBW subjects. The correlation between plasma adiponectin concentration and plasma ADMA concentration in LBW subjects was not significant. CONCLUSION: there is an effect of LBW on endothelial function. LBW compared to NBW subjects have lower VR and plasma adiponectin concentration. There may be a small role of plasma adiponectin in endothelial dysfunction of young adults with LBW.

Adherence to penicillin treatment is essential for effective secondary prevention of rheumatic heart disease: a systematic review and meta-analysis.

Background: Penicillin is essential for secondary prevention of acute rheumatic fever (ARF) and rheumatic heart disease (RHD). However, the incidences of ARF recurrence and RHD progression remain high, particularly in endemic countries. This meta-analysis evaluated the effectiveness of penicillin adherence in secondary prevention of ARF recurrence and RHD progression. Methods: The authors included original articles employing an observational study design in which the study population included patients with ARF or RHD and documented adherence to secondary prophylaxis with penicillin for secondary prevention. Systematic searches of the PubMed, Scopus, and Cochrane databases were performed. Moreover, the authors also conducted a snowballing literature search from Europe PMC to expand the included studies. The quality of each study was assessed using the National Institute of Health Quality Assessment Tool. The statistical analyses were conducted using Review Manager 5.4.1 software developed by Cochrane. In addition, the authors utilized pooled odds ratios (ORs) to compare the adherence techniques. Results: A total of 310 studies were identified, of which 57 full-text articles were assessed for eligibility. The authors included six studies with 1364 patients for the qualitative synthesis and meta-analysis. Good adherence to penicillin for the secondary prophylaxis of ARF and RHD, significantly reduced the odds of ARF recurrence or RHD progression by up to 71% compared to that associated with poor adherence [pooled OR 0.29 (0.21-0.40); I²=0% (p=0.56); Z=7.64 (p <0.00001)]. Conclusion: Good adherence to penicillin for secondary prophylaxis in patients with ARF or RHD is essential for reducing the risk of ARF recurrence or RHD progression.

Proactive method for identification and handling of patient complaints with root cause analysis in Surabaya Islamic Hospital.

Background: Errors or cases that occur in health care organizations are very fatal because they can reduce the quality of life of patients and the worst is cause the death of the patient. One of the appropriate tools to be applied in analyzing cases/problems that occur in Surabaya Islamic Hospitals is root cause analysis. The complaints were addressed to the medical services, medical support, general, administration and verification, information systems and management, and finance sections. Design and methods: This research uses secondary data on hospital patient complaints in 2022 and is supported by the results of online interviews with the head of marketing public relations. Secondary data was processed through a six stages of root cause analysis and analyzed with the help of a fishbone diagram to determine the root cause of the problem in the health care sector. Results: There were 261 complaints received by customer service addressed to the medical services, medical support, general, administration and verification, information systems and management, and finance departments. There are eight root causes found in Surabaya Islamic Hospital inpatient complaints. This proves that there must be improvements/ interventions made by the Surabaya Islamic Hospital to overcome inpatient complaints. Conclusions: Inpatient complaints at Surabaya Islamic Hospital prove the need for a number of interventions/improvements, especially in the field of human resources, namely the level of discipline, skills, empathy, communication, limited medical, and financial staff.

Identification of Pacemaker Lead Position Using Fluoroscopy to Avoid Significant Tricuspid Regurgitation.

Permanent pacemaker implantation improves survival but can cause tricuspid valve dysfunction in the form of tricuspid regurgitation (TR). The dominant mechanism of pacemaker-mediated TR is lead impingement. This study evaluated the association between the location of the pacemaker leads crossing the tricuspid valve and the incidence of worsening TR and lead impingement using fluoroscopy. Lead positions were evaluated using perpendicular right anterior oblique (RAO) and parallel left anterior oblique (LAO) fluoroscopic angulation views of the tricuspid annulus. A two-dimensional transthoracic echocardiogram (TTE) was performed to evaluate the maximum TR jet area-to-right atrium ratio and define regurgitation severity. A three-dimensional TTE was performed to evaluate lead impingement. A worsening of TR was observed in 23 of 82 subjects. Most leads had an inferior position in the RAO view and a septal position in the LAO view. The mid position in the RAO view and septal position in the LAO view were risk factors for lead impingement. Mid and septal positions were associated with higher risks of significant TR and lead impingement. Lead impingement was associated with a high risk of significant TR. Pacemaker-mediated TR remains a significant problem after lead implantation.

Highlighting Exosomes' Function in Cardiovascular Diseases.

Exosomes, as one of the extracellular vesicles' subgroups, played an important role in the cell to cell communication. The cargos and surface protein of exosomes have been known to affect the cardiovascular system both positively and negatively in chronic heart failure, ischemic heart disease, and atherosclerosis. There have been several exosomes that emerged as potential diagnostic and prognostic markers in cardiovascular patients. However, the conditions affecting the patients and the method of isolation should be considered to create a standardized normal value of the exosomes and the components. CPC-derived exosomes, ADSCs-derived exosomes, and telocyte- derived exosomes have been proven to be capable of acting as a therapeutic agent in myocardial infarction models. Exosomes have the potential to become a diagnostic marker, prognostic marker, and therapeutic agent in cardiovascular diseases.

Understanding Pacemaker-Induced Cardiomyopathy Incidence and Predictors in Patients with Right Ventricular Pacing: A Systematic Review.

This study aimed to figure out the incidence and predictors of pacemaker-induced cardiomyopathy (PICM) in patients with right ventricular (RV) pacing. We systematically searched in PubMed on March 18, 2020, for English language abstract and full-article journals, using the following criteria: pacemaker induced cardiomyopathy AND right ventricular AND pacemaker AND patients AND human NOT implantable cardioverter defibrillator NOT ICD NOT animal. Four studies were included in this review after filtering 35 studies through year of publication and abstract selection. The average PICM incidence from 1,365 patients included from the four studies was 10.7 to 13.7%. One study stated that preimplantation left ventricular ejection fraction (LVEF) was the predictor for the development of PICM. Three studies mentioned that RV pacing burden was the predictor for the development of PICM. However, the percentage differ in three studies: ≥20, >40, and 60%. In addition, one of the studies also included interventricular dyssynchrony as another predictor. The incidence of PICM in patients with RV pacing ranged from 10.7 to 13.7%. Preimplantation LVEF, interventricular dyssynchrony, and burden of RV pacing are reported as the predictors for the development of PICM in patients with RV pacing.

Determinants and Prediction Equations of Six-Minute Walk Test Distance Immediately After Cardiac Surgery.

Background: To date, there is no reference for a 6-min walk test distance (6-MWD) immediately after cardiac surgery. Therefore, this study aimed to identify the determinants and to generate equations for prediction reference for 6-MWD in patients immediately after cardiac surgery. Methods: This is a cross-sectional study of the 6-min walk test (6-MWT) prior to participation in the cardiac rehabilitation (CR) program of patients after coronary artery bypass surgery (CABG) or valve surgery. The 6-MWT were carried out in a gymnasium prior to the CR program immediately after the cardiac surgery. Available demographic and clinical data of patients were analyzed to identify the clinical determinants of 6-MWD. Results: This study obtained and analyzed the data of 1,509 patients after CABG and 632 patients after valve surgery. The 6-MWD of all patients was 321.5 ± 73.2 m (60-577). The distance was longer in the valve surgery group than that of patients in the CABG group (327.75 ± 70.5 vs. 313.59 ± 75.8 m, p < 0.001). The determinants which significantly influence the 6-MWD in the CABG group were age, gender, diabetes, atrial fibrillation, and body height, whereas in the valve surgery group these were age, gender, and atrial fibrillation. The multivariable regression models generated two formulas using the identified clinical determinants for patients after CABG: 6-MWD (meter) = 212.57 + 30.47 (if male gender) - 1.62 (age in year) + 1.09 (body height in cm) - 12.68 (if with diabetes) - 28.36 (if with atrial fibrillation), and for patients after valve surgery with the formula: 6-MWD (meter) = 371.05 + 37.98 (if male gender) - 1.36 (age in years) - 10.61 (if atrial with fibrillation). Conclusion: This study identified several determinants for the 6-MWD and successively generated two reference equations for predicting 6-MWD in patients after CABG and valve surgery.

Randomised controlled trial into the role of ramipril in fibrosis reduction in rheumatic heart disease: the RamiRHeD trial protocol.

INTRODUCTION: Rheumatic heart disease (RHD) is a major burden in developing countries and accounts for 80% of all people living with the disease, where it causes most cardiovascular morbidity and mortality in children and young adults. Chronic inflammation and fibrosis of heart valve tissue due to chronic inflammation in RHD will cause calcification and thickening of the impacted heart valves, especially the mitral valve. This fibrogenesis is enhanced by the production of angiotensin II by increased transforming growth factor ß expression and later by the binding of interleukin-33, which is known to have antihypertrophic and antifibrotic effects, to soluble sST2. sST2 binding to this non-natural ligand worsens fibrosis. Therefore, we hypothesise that ACE inhibitors (ACEIs) would improve rheumatic mitral valve stenosis. METHODS AND ANALYSIS: This is a single-centre, double-blind, placebo-controlled, randomised clinical trial with a pre-post test design. Patients with rheumatic mitral stenosis and valve dysfunction will be planned for cardiac valve replacement operation and will be given ramipril 5 mg or placebo for a minimum of 12 weeks before the surgery. The expression of ST2 in the mitral valve is considered to be representative of cardiac fibrosis. Mitral valve tissue will be stained by immunohistochemistry to ST2. Plasma ST2 will be measured by ELISA. This study is conducted in the Department of Cardiology and Vascular Medicine, Universitas Indonesia, National Cardiac Center Harapan Kita Hospital, Jakarta, Indonesia, starting on 27 June 2019. ETHICS AND DISSEMINATION: The performance and dissemination of this study were approved by the ethics committee of National Cardiovascular Center Harapan Kita with ethical code LB.02.01/VII/286/KEP.009/2018. TRIAL REGISTRATION NUMBER: NCT03991910.

Drug-eluting balloon: is it useful?

BACKGROUND: Coronary artery disease is one of the major issues in the medical world around the globe. The prevalence tends to increase. The use of coronary intervention is one of the ways often used in the management of coronary artery disease due to its satisfying result from earlier studies. Nowadays, there are several different techniques in coronary intervention: balloon vs stent. MAIN BODY: The stent-based vascular interventions are increasingly being used over balloon-based coronary intervention. However, revascularization intervention using stent often have undesirable long-term effects compared to balloon. Besides, stent-based interventions are also considered more expensive, use more complicated techniques, and use more drug regimens. On the other hand, percutaneous coronary intervention techniques using balloons coated by anti-proliferation drugs have begun to be glimpsed by many interventionists. Studies have found many benefits that cannot be given by stent-based intervention therapy. CONCLUSIONS: Angioplasty using percutaneous coronary intervention techniques reveals satisfying result compared to conservative medical treatment. The indication and technique of percutaneous coronary intervention is still evolving until now. Currently, percutaneous coronary intervention using stent, either bare-metal stent or drug-eluting stent, is preferred by interventionist. Nevertheless, recent clinical trial favors the using of drug-eluting balloon for percutaneous coronary intervention in terms of both clinical outcome and complication in several scenarios.

A time-to-event analysis on air pollutants with the risk of cardiovascular disease and mortality: A systematic review and meta-analysis of 84 cohort studies.

OBJECTIVE: Air pollution is one of the most substantial problems globally. Aerodynamic toxic of particulate matter with <10 mm in diameter (PM10 ), or <2.5 mm (PM2.5 ), as well as nitric dioxide (NO2 ), have been linked with health issues. We aimed to perform a comprehensive analysis of the time-to-event for different types of air pollutants on cardiovascular disease (CVD) events based on cohort studies. METHODS: A comprehensive search on topics that assesses air pollution and cardiovascular disease with keywords up until July 2019 was performed. RESULTS: There were a total of 28 215 394 subjects from 84 cohorts. Increased PM2.5 was associated with composite CVD [HR 1.10 (1.02, 1.19)], acute coronary events [HR 1.15 (1.12, 1.17)], stroke [HR 1.13 (1.06, 1.19)], and hypertension [HR 1.07 (1.01, 1.14)], all-cause mortality [HR 1.07 (1.04, 1.09)], CVD mortality [HR 1.10 (1.07, 1.12)], and ischemic heart disease (IHD) mortality [HR 1.11 (1.07, 1.16)]. Association with AF became significant after removal of a study. Increased PM10 was associated with heart failure [HR 1.25 (1.04, 1.50)], all-cause mortality [HR 1.16 (1.06, 1.27)], CVD mortality [HR 1.17 (1.04, 1.30)], and IHD mortality [HR 1.03 (1.01, 1.05)]. Increased of NO2 was associated with increased composite CVD [HR 1.15 (1.02, 1.29)], atrial fibrillation [HR 1.01 (1.01, 1.02)], acute coronary events [HR 1.08 (1.02, 1.13)], all-cause mortality [HR 1.23 (1.14, 1.32)], CVD mortality [HR 1.17 (1.10, 1.25)], and IHD mortality [HR 1.05 (1.03, 1.08)]. CONCLUSION: Air pollutants are associated with an increased incidence of cardiovascular diseases, all-cause mortality, and CVD mortality.

Angiotensin Converting Enzyme Inhibitors (ACEIs) Decrease the Progression of Cardiac Fibrosis in Rheumatic Heart Disease Through the Inhibition of IL-33/sST2.

Rheumatic heart disease (RHD) is common in developing countries and poses a big medical challenge and burden. The pathogenesis of RHD is influenced by the triad of host, agent, and environment. Autoantigens generated from Group A Streptococcus (GAS) infection are captured by the resident dendritic cells (DCs) in the heart's valvular endothelium. DCs differentiate into antigen presenting cells (APC) in the valve interstices. APC induces activation of autoreactive T cells, which triggers inflammation and tissue fibrosis. Cardiac fibrosis is promoted through the activation of Mitogen activated protein kinases (MAPKs) and its downstream signaling, including its interaction with transforming growth factor-ß (TGF-ß) and Smad proteins. TGF-ß-induced phosphorylation of Smad2 complexes with Smad3 and Smad4, and translocates into the nucleus. Angiotensin II enhances the migration, maturation, and presentation of DC. In RHD, Angiotensin II induces fibrosis via the stimulation of TGF-ß, which further increases the binding of IL-33 to sST2 but not ST2L, resulting in the upregulation of Angiotensin II and progression of cardiac fibrosis. This cascade of inflammation and valvular fibrosis causes calcification and stiffening of the heart valves in RHD. Angiotensin converting enzyme inhibitors (ACEIs) inhibit Angiotensin II production, which in turn decreases TGF-ß expression and the onset of overt inflammatory response. This condition leads to a reduction in the sST2 as the decoy receptor to "steal" IL-33, and IL-33 binds to ST2L and results in cardioprotection against cardiac fibrosis in the pathogenesis of RHD.

Electrocardiographic early repolarization is associated with future ventricular arrhythmia after acute myocardial infarction-Systematic Review and Meta-Analysis.

BACKGROUND: Early repolarization (ER) has been linked to ventricular arrhythmia (VA) and sudden cardiac death in patients without structural heart disease. We aimed to assess the latest evidence on whether ER is associated with future VA after acute myocardial infarction (AMI). METHODS: We performed a comprehensive search on the topic that assesses ER and VA/adverse cardiovascular events in AMI. We included studies with sufficient details on ER and VA, we also performed a meta-analysis on their morphology. RESULTS: A total of 3350 subjects from 9 studies were included. Five hundred and twenty-one (15.55%) had ER and 2829 (84.45%) did not. On meta-analysis, ER (+) in AMI was associated with VA with a pooled odds ratio (OR) of 3.58 (2.70-4.73), P < 0.001; heterogeneity I 2 34%. Subgroup analysis of patients with ST-segment elevation myocardial infarction (STEMI) showed an OR of 2.79 [1.98-3.93], P < 0.001; heterogeneity I 2 0%. Inferior location of ER (+) was associated with VA OR 3.98 [1.86-8.53], P = 0.008; I 2 67%. Notching had a 5.41 [3.52-8.32], P < 0.001; low heterogeneity I 2 0% of having VA. Pooled OR for J-point elevation was 4.72 [2.63-8.46], P < 0.001; I 2 25%. Horizontal ST-segment was associated with VA with an OR of 4.30 [1.89-975], P < 0.001; I 2 59%. Lateral location and slurred morphology were not associated with VA. Upon sensitivity analysis for inferior location and horizontal ST-segment, removal of a study reduces heterogeneity significantly. CONCLUSION: Early repolarization especially those with the inferior location, notching morphology, an elevated J-point and horizontal ST-segment had a higher likelihood of VA in AMI including STEMI patients.