Diastology in the intensive care unit: Challenges for the assessment and future directions.

Myocardial dysfunction is common in patients admitted to the intensive care unit (ICU). Septic disease frequently results in cardiac dysfunction, and sepsis represents the most common cause of admission and death in the ICU. The association between left ventricular (LV) systolic dysfunction and mortality is not clear for critically ill patients. Conversely, LV diastolic dysfunction (DD) seems increasingly recognized as a factor associated with poor outcomes, not only in sepsis but also more generally in critically ill patients. Despite recent attempts to simplify the diagnosis and grading of DD, this remains relatively complex, with the need to use several echocardiographic parameters. Furthermore, the current guidelines have several intrinsic limitations when applied to the ICU setting. In this manuscript, we discuss the challenges in DD classification when applied to critically ill patients, the importance of left atrial pressure estimates for the management of patients in ICU, and whether the study of cardiac dysfunction spectrum during critical illness may benefit from the integration of left ventricular and left atrial strain data to improve diagnostic accuracy and implications for the treatment and prognosis.

Competency-based cardiac imaging for patient-centred care. A statement of the European Society of Cardiology (ESC). With the contribution of the European Association of Cardiovascular Imaging (EACVI), and the support of the Association of Cardiovascular Nursing & Allied Professions (ACNAP), the Association for Acute CardioVascular Care (ACVC), the European Association of Preventive Cardiology (EAPC), the European Association of Percutaneous Cardiovascular Interventions (EAPCI), the European Heart Rhythm Association (EHRA), and the Heart Failure Association (HFA) of the ESC.

Imaging plays an integral role in all aspects of managing heart disease and cardiac imaging is a core competency of cardiologists. The adequate delivery of cardiac imaging services requires expertise in both imaging methodology-with specific adaptations to imaging of the heart-as well as intricate knowledge of heart disease. The European Society of Cardiology (ESC) and the European Association of Cardiovascular Imaging have developed and implemented a successful education and certification programme for all cardiac imaging modalities. This programme equips cardiologists to provide high quality competency-based cardiac imaging services ensuring they are adequately trained and competent in the entire process of cardiac imaging, from the clinical indication via selecting the best imaging test to answer the clinical question, to image acquisition, analysis, interpretation, storage, repository, and results dissemination. This statement emphasizes the need for competency-based cardiac imaging delivery which is key to optimal, effective and efficient, patient care.

MINOCA and INOCA: Role in Heart Failure.

PURPOSE OF REVIEW: Infarction (MINOCA) and ischaemia (INOCA) with non-obstructive coronary disease are recent non-conventional presentations of coronary syndromes that are increasingly recognised in the clinical arena, particularly with the availability of new cardiovascular imaging techniques. Both are related to heart failure (HF). MINOCA is not associated with benign outcomes, and HF is among the most prevalent events. Regarding INOCA, microvascular dysfunction has also been found to associate with HF, particularly with preserved ejection fraction (HFpEF). RECENT FINDINGS: Regardless of the several aetiologies underlying HF in MINOCA, it is likely related to LV dysfunction, where secondary prevention is not yet clearly established. Regarding INOCA, coronary microvascular ischaemia has been associated to endothelial dysfunction leading ultimately to diastolic dysfunction and HFpEF. MINOCA and INOCA are clearly related to HF. In both, there is a lack of studies on the identification of the risk factors for HF, diagnostic workup and, importantly, the appropriate primary and secondary prevention strategies.

Coronary Artery Calcium Identified on Non-Gated Chest CT Scans: A Wasted Opportunity for Preventive Cardiological Care.

BACKGROUND: Coronary artery calcium (CAC) evaluated on dedicated cardiac computed tomography (CT) is an independent predictor of cardiovascular events. This study aimed to evaluate the correlation between CAC detected on non-gated standard chest CT and coronary lesions on coronary angiography (CAG) and determine its impact on prognosis. METHODS: Consecutive patients who underwent CAG due to acute coronary syndrome and had prior non-contrasted non-gated chest CT were included and retrospectively evaluated. Coronary artery calcium was evaluated by quantitative (Agatston score) and qualitative (visual assessment) assessment. RESULTS: A total of 114 patients were included in this study. The mean time difference between chest CT and CAG was 23 months. Coronary artery calcium was visually classified as mild, moderate, and severe in 31%, 33%, and 16% of patients, respectively. Moderate or severe CAC was an independent predictor of significant lesions on CAG (OR 22; 95% CI 8-61; p<0.001) and all-cause mortality (OR 4; 95% CI 2-9; p=0.001). Quantitative CAC evaluation accurately predicted significant lesions on CAG (AUC 0.81; p<0.001). While significant CAC was identified in 80% of chest CTs, formal reporting was 25%. CONCLUSION: Coronary artery calcium evaluation with chest CT was feasible and strongly associated with severity of coronary disease on CAG and mortality. Although the identification of CAC on chest CT represents a unique opportunity for cardiovascular risk stratification for preventive care, CAC underreporting is frequent.

Cardiovascular and Respiratory Safety of Sedation Strategies Used in Transesophageal Echocardiography: A Systematic Review Incorporating Network Meta-Analysis.

TRANSESOPHAGEAL ECHOCARDIOGRAPHY (TEE) is carried out in various clinical settings, with an increasing importance, and sedation usually is required to perform it. Several sedative agents are available, and the authors aimed to compare the cardiovascular and respiratory safety of the strategies used for sedation in TEE through a systematic review with network meta-analysis (NMA). The MEDLINE, CENTRAL, EMBASE, and PsycInfo databases were searched in December 2020 for randomized clinical trials (RCTs) comparing sedation strategies for patients undergoing TEE. The authors assessed variations in systolic blood pressure (SBP), heart rate (HR), and peripheral oxygen saturation (SpO2), along with the incidences of hypotension, bradycardia, and desaturation. A random-effect meta-analysis was performed. Nine RCTs (N = 881 patients) with 20 active arms (5 dexmedetomidine; 4 propofol; 4 midazolam; 3 midazolam + opioid; 2 ketamine + propofol; 1 midazolam + ondansetron; 1 midazolam + metoclopramide) and 1 placebo arm were included. Dexmedetomidine was associated with decreases in SBP (mean difference [MD] = -18.78 mmHg; 95% CI [-26.27 to -11.28]) and HR (MD = -11.15 beats/min; 95% CI [-16.15 to -6.15]). Dexmedetomidine significantly reduced the HR compared with ketamine + propofol (-16.90 beats/min; 95% CI: -33.21 to -0.58]) and midazolam + opioid (-24.15 beats/min; 95% CI: -42.67 to -5.63). Midazolam was found to reduce SBP (-12.09 mmHg; 95% CI: -20.43 to -3.74) and was shown to reduce SpO2 compared with the placebo (-1.00%; 95% CI -1.74 to -0.26). Based on the NMA, the drugs with a higher likelihood of decreasing both SBP and HR were dexmedetomidine and midazolam. All of the drugs led to a small decrease (only statistically significant for midazolam) in SpO2, with the systematic use of supplemental O2 in some trials. The risks of hypotension, bradycardia, or desaturation were not significantly different among the evaluated drugs.

Sutureless bioprosthesis for aortic valve replacement: Surgical and clinical outcomes.

BACKGROUND: Aortic valve stenosis is the most common adult valve disease in industrialized countries. The aging population and the increase in comorbidities urge the development of safer alternatives to the current surgical treatment. Sutureless bioprosthesis has shown promising results, especially in complex procedures and in patients requiring concomitant surgeries. OBJECTIVES: Assess the clinical and hemodynamic performance, safety, and durability of the Perceval® prosthetic valve. METHODS: This single-center retrospective longitudinal cohort study collected data from all adult patients with aortic valve disease who underwent aortic valve replacement with a Perceval® prosthetic valve between February 2015 and October 2020. Of the 196 patients included (mean age 77.20 ± 5.08 years; 45.4% female; mean EuroSCORE II 2.91 ± 2.20%), the majority had aortic stenosis. RESULTS: Overall mean cross-clamp and cardiopulmonary bypass times were 33.31 ± 14.09 min and 45.55 ± 19.04 min, respectively. Mean intensive care unit and hospital stay were 3.32 ± 3.24 days and 7.70 ± 5.82 days, respectively. Procedural success was 98.99%, as two explants occurred. Four valves were reimplanted due to intraoperative misplacement. Mean transvalvular gradients were 7.82 ± 3.62 mmHg. Pacemaker implantation occurred in 12.8% of patients, new-onset atrial fibrillation in 21.9% and renal replacement support was necessary for 3.1%. Early mortality was 2.0%. We report no structural valve deterioration, strokes, or endocarditis, and one successfully treated valve thrombosis. CONCLUSIONS: Our study confirms the excellent clinical and hemodynamic performance and safety of a truly sutureless aortic valve, up to a 5-year follow-up. These results were consistent in isolated and concomitant interventions, solidifying this device as a viable option for the treatment of isolated aortic valve disease.

Women Who Have Ischemic Strokes Have a Higher Burden of Left Atrial Fibrosis Than Men.

Background and Purpose- Women with atrial fibrillation (AF) have a higher risk of stroke than men who have AF. Atrial fibrosis is a marker of atrial disease that precedes the appearance of AF increasing the risk of ischemic stroke. We aimed to determine whether female sex is independently associated with left atrial fibrosis in stroke patients. Methods- We prospectively included a consecutive sample of ischemic stroke patients aged over 50 years of age. Late gadolinium enhancement cardiac magnetic resonance imaging was performed to quantify the severity of left atrial fibrosis and the wall pattern of its distribution. A multivariable linear regression analysis was performed to determine whether female sex was independently associated with left atrial fibrosis after adjusting for potential confounders namely AF and age. Results- One hundred twenty-four patients were deemed eligible; 117 patients were included (7 were excluded because of cardiomyopathy identified by cardiac magnetic resonance imaging). All had usable cardiac magnetic resonance imaging data. Fifty-three patients (45.3%) were women. Women were older and were less frequently treated with angiotensin-converting-enzyme inhibitors. Ninety-one patients had any degree of atrial fibrosis. Women had a higher percentage of atrial fibrosis than men-median (interquartile range)-18% (17) versus 10% (20). In a multivariable linear regression model adjusted for demographics, medications, AF, comorbidities, and cardiac parameters, female sex was found to be independently associated with left atrial fibrosis. Women were found to have more 4.70% of left atrial fibrosis than men (95% CI, 0.70-8.71%; P=0.02) after controlling for confounders. Conclusions- Female sex was found to be independently associated with left atrial fibrosis after controlling for confounders such as AF and age. Further studies are needed to understand if this contributes to the increased stroke risk related to AF in women compared with men.

Patients With Undetermined Stroke Have Increased Atrial Fibrosis: A Cardiac Magnetic Resonance Imaging Study.

BACKGROUND AND PURPOSE: Some patients with ischemic strokes that are currently classified as having an undetermined cause may have structural or functional changes of the left atrium (LA) and left atrial appendage, which increase their risk of thromboembolism. We compared the LA and left atrial appendage of patients with different ischemic stroke causes using cardiac magnetic resonance imaging. METHODS: We prospectively included a consecutive sample of ischemic stroke patients. Patients with structural changes on echocardiography currently considered as causal for stroke in the Trial of ORG 10172 in Acute Stroke Treatment (TOAST) classification were excluded. A 3-T cardiac magnetic resonance imaging was performed. RESULTS: One hundred and eleven patients were evaluated. Patients with an undetermined cause had a higher percentage of LA fibrosis (P=0.03) than patients with other stroke causes and lower, although not statistically significant, values of LA ejection fraction. Patients with atrial fibrillation and undetermined stroke cause showed a similar value of atrial fibrosis. CONCLUSIONS: The LA phenotype that was found in patients with undetermined cause supports the hypothesis that an atrial disease may be associated with stroke.

The role of cardiovascular magnetic resonance in takotsubo syndrome.

Takotsubo syndrome (TS) is a transient form of left ventricular dysfunction associated with a distinctive contraction pattern in the absence of significant coronary artery disease triggered by stressful events. Several aspects of its clinical profile have been described but it still remains difficult to quickly establish the diagnosis at admission.Cardiovascular magnetic resonance (CMR) has achieved great improvements in the last years, which in turn has made this imaging technology more attractive in the diagnosis and evaluation of TS. With its superior tissue resolution and dynamic imaging capabilities, CMR is currently the most useful imaging technique in this setting.In this review, we propose to comprehensively define the role of CMR in the evaluation of patients with TS and to summarize a set of criteria suitable for diagnostic decision making in this clinical setting.

Simplifying cardiovascular magnetic resonance pulse sequence terminology.

We propose a set of simplified terms to describe applied Cardiovascular Magnetic Resonance (CMR) pulse sequence techniques in clinical reports, scientific articles and societal guidelines or recommendations. Rather than using various technical details in clinical reports, the description of the technical approach should be based on the purpose of the pulse sequence. In scientific papers or other technical work, this should be followed by a more detailed description of the pulse sequence and settings. The use of a unified set of widely understood terms would facilitate the communication between referring physicians and CMR readers by increasing the clarity of CMR reports and thus improve overall patient care. Applied in research articles, its use would facilitate non-expert readers' understanding of the methodology used and its clinical meaning.

Non-compaction cardiomyopathy: prevalence, prognosis, pathoetiology, genetics, and risk of cardioembolism.

Left ventricular non-compaction (LVNC) is thought to arise from arrest of the normal process of trabecular remodeling or "compaction" that takes place during embryonic life and is characterized by the presence of a two-layered ventricular wall, with a compact epicardial layer and a non-compacted endocardial layer. It is an uncommon condition that can occur isolated or in association with other disorders, including congenital heart anomalies and mitochondrial or musculoskeletal disorders. Both familial and sporadic forms are recognized, and several responsible genes have been identified, although only a minority of patients can be successfully genotyped. The diagnosis is usually made by echocardiography, but cardiac magnetic resonance imaging has been used increasingly. Management is mainly empirical and directed at the major clinical manifestations: heart failure, arrhythmias, and systemic embolic events. This article will review the major features of LVNC and present new trends in the diagnosis and management of this intriguing condition.

Perceptions of cardiology, professional preferences and impact on career choices among Portuguese cardiologists: Results from the Portuguese Society of Cardiology's Women and Cardiology Task Force survey.

INTRODUCTION AND OBJECTIVES: Cardiology has not been seen as an attractive specialty, and women have avoided it for many years. Some surveys have been performed in other countries, but in Portugal, the situation is largely unknown. METHODS: An online survey on perceptions of cardiology and professional preferences was sent to 1371 members of the Portuguese Society of Cardiology, of whom 18.2% completed the survey. RESULTS: We included 219 cardiologists or cardiology trainees, of whom 50.2% were female, with decreasing proportions from younger to older age groups, in which males still predominate. Women are less often married and more frequently childless, particularly those working in an invasive subspecialty, where they represent only 16% of all respondents working in these areas. Men's perception is that women do not choose these areas due to family reasons, radiation concerns and difficult working conditions, but from the female perspective, male dominance, lack of female role models and restricted access are the main barriers. Women consider it is difficult for them to obtain a leadership role, but men do not think the same (75.5% vs. 27.5%). CONCLUSION: In Portugal, females predominate in younger age groups, suggesting a paradigm change. Women are less frequently married and more frequently childless, particularly women working in invasive subspecialties. Women consider that it is more difficult for them to obtain a leadership role. Moreover, the barriers reported by women are substantially different from men regarding the reasons for not choosing an invasive subspecialty.

Comparison of the accuracy of four diagnostic prediction rules for pulmonary embolism in patients admitted to the emergency department.

INTRODUCTION AND OBJECTIVES: Ruling out pulmonary embolism (PE) through a combination of clinical assessment and D-dimer level can potentially avoid excessive use of computed tomography pulmonary angiography (CTPA). We aimed to compare the diagnostic accuracy of the standard approach based on the Wells and Geneva scores combined with a standard D-dimer cut-off (500 ng/ml), with three alternative strategies (age-adjusted and the YEARS and PEGeD algorithms) in patients admitted to the emergency department (ED) with suspected PE. METHODS: Consecutive outpatients admitted to the ED who underwent CTPA due to suspected PE were retrospectively assessed. Sensitivity, specificity, positive and negative predictive values, likelihood ratios and diagnostic odds ratios were calculated and compared between the different diagnostic prediction rules. RESULTS: We included 1402 patients (mean age 69±18 years, 54% female), and PE was confirmed in 25%. Compared to the standard approach (p<0.001), an age-adjusted strategy increased specificity with a non-significant decrease in sensitivity only in patients older than 70 years. Compared to the standard and age-adjusted approaches, the YEARS and PEGeD algorithms had the highest specificity across all ages, but were associated with a significant decrease in sensitivity (p<0.001), particularly in patients aged under 60 years (sensitivity of 81% in patients aged between 51 and 60 years). CONCLUSION: Compared to the standard approach, all algorithms were associated with increased specificity. The age-adjusted strategy was the only one not associated with a significant decrease in sensitivity compared to the standard approach, enabling CTPA requests to be reduced safely.

Association of Left Atrial Stiffness With Risk of Cryptogenic Ischemic Stroke in Young Adults.

Background: Incidence of cryptogenic ischemic stroke (CIS) in young adults is increasing. Early left atrial (LA) myopathy might be 1 of the underlying mechanisms, but this has only been scarcely explored. Objectives: The purpose of this study was to assess the association between increased LA stiffness and CIS in young adults. Methods: In the multicenter SECRETO (Searching for Explanations for Cryptogenic Stroke in the Young: Revealing the Etiology, Triggers, and Outcome) study, LA function was analyzed by speckle tracking echocardiography in 150 CIS patients (aged 18-49 years) and 150 age- and sex-matched controls. Minimum and maximum LA volumes, LA reservoir and contractile strain were measured. LA stiffness was calculated by the ratio: mitral peak E-wave velocity divided by mitral annular e' velocity (E/e')/LA reservoir strain and considered increased if ≥0.22. Increased LA volumes, LA stiffness, and/or reduced LA strain indicated LA myopathy. Logistic regression was used to determine the relation between LA stiffness and CIS and the clinical variables associated with LA stiffness. Results: Increased LA stiffness was found in 36% of patients and in 18% of controls (P < 0.001). Increased LA stiffness was associated with a 2.4-fold (95% CI: 1.1-5.3) higher risk of CIS after adjustment for age, sex, comorbidities, and echocardiographic confounders (P = 0.03). In patients, obesity, pre-CIS antihypertensive treatment, older age, and lower LA contractile strain were all related to increased LA stiffness (all P < 0.05). Conclusions: LA myopathy with increased LA stiffness and impaired LA mechanics more than doubles the risk of CIS in patients under the age of 50 years. This provides new insights into the link between LA dysfunction and CIS at young ages. (Searching for Explanations for Cryptogenic Stroke in the Young: Revealing the Etiology, Triggers, and Outcome [SECRETO]; NCT01934725).