Autonomic Function in Obese Children and Adolescents: Systematic Review and Meta-Analysis.

Background: Obesity is invariably accompanied by autonomic dysfunction, although data in pediatric populations are conflicting. Methods: We conducted a systematic review and meta-analysis of 12 studies (totaling 1102 participants) comparing obese and normal-weight subjects (5-18 years of age), defined as body mass index >95th or <85th percentile, respectively. Using a random-effects model, we report the standardized mean differences (SMD) of sympathetic and vagal indices of heart rate variability. Results: Autonomic dysfunction was present in the obesity group, based on the average SMD in the standard deviation of sinus intervals (at -0.5340), and on the ratio of low (LF)- to high (HF)-frequency spectra (at 0.5735). There was no difference in sympathetic activity, but the heterogeneity among the relevant studies weakens this result. SMD in HF (at 0.5876), in the root mean square of successive differences between intervals (at -0.6333), and in the number of times successive intervals exceeded 50 ms divided by the total number of intervals (at -0.5867) indicated lower vagal activity in the obesity group. Conclusions: Autonomic dysfunction is present in obese children and adolescents, attributed to lower vagal activity. Further studies are needed in various pediatric cohorts, placing emphasis on sympathetic activity.

Virtual Hemodynamic Assessment of Coronary Lesions: The Advent of Functional Angiography and Coronary Imaging.

The fractional flow reserve (FFR) is well recognized as a gold standard measure for the estimation of functional coronary stenosis. Technological progressions in image processing have empowered the reconstruction of three-dimensional models of the coronary arteries via both non-invasive and invasive imaging modalities. The application of computational fluid dynamics (CFD) techniques to coronary 3D anatomical models allows the virtual evaluation of the hemodynamic significance of a coronary lesion with high diagnostic accuracy. METHODS: Search of the bibliographic database for articles published from 2011 to 2023 using the following search terms: invasive FFR and non-invasive FFR. Pooled analysis of the sensitivity and specificity, with the corresponding confidence intervals from 32% to 94%. In addition, the summary processing times were determined. RESULTS: In total, 24 studies published between 2011 and 2023 were included, with a total of 13,591 patients and 3345 vessels. The diagnostic accuracy of the invasive and non-invasive techniques at the per-patient level was 89% (95% CI, 85-92%) and 76% (95% CI, 61-80%), respectively, while on the per-vessel basis, it was 92% (95% CI, 82-88%) and 81% (95% CI, 75-87%), respectively. CONCLUSION: These opportunities providing hemodynamic information based on anatomy have given rise to a new era of functional angiography and coronary imaging. However, further validations are needed to overcome several scientific and computational challenges before these methods are applied in everyday clinical practice.

Autonomic Responses During Acute Anterior Versus Inferior Myocardial Infarction: A Systematic Review and Meta-Analysis.

Autonomic responses elicited by myocardial infarction vary depending on the site of injury, but accurate assessment using heart rate variability during the acute phase is limited. We systematically searched PubMed without language restrictions throughout July 2023. We reviewed studies reporting autonomic indices separately for anterior and inferior infarcts, followed by a meta-analysis of those reporting the standard deviation of the inter-beat interval between normal sinus beats during the initial 24 hours after the onset of symptoms. Six studies were included, comprising 341 patients (165 anterior, 176 inferior infarcts), all with satisfactory scores on the Newcastle-Ottawa quality scale. The estimated average of the standardized mean difference (based on the random-effects model) was -0.722 (95% confidence intervals: -0.943 to -0.501), which differed from zero (z=-6.416, p<0.0001). This finding indicates sympathetic and vagal dominance during acute anterior and inferior infarcts, respectively, with excessive responses likely contributing to early arrhythmogenesis. Despite the amelioration of autonomic dysfunction by revascularization, infarct location should be considered when commencing ß-adrenergic receptor blockade, especially after delayed procedures.

Transcatheter Aortic Valve Implantation with the Portico Valve: 2-Year Outcomes of a Multicenter, Real-World Registry.

INTRODUCTION: The self-expanding, resheathable, repositionable transcatheter aortic heart valve Portico is being used successfully for transcatheter aortic valve implantation procedures (TAVI) in patients with severe aortic stenosis. The aim of this study was to evaluate outcomes at 2 years after TAVI with the Portico valve. METHODS: Multicenter registry of clinical, echocardiographic and survival data from consecutive patients treated with the Portico TAVI system (Abbott, Chicago, IL, USA) in three cath labs in Northern Greece and Epirus during 2017-2020. The primary end point was all-cause mortality at 24 months. Secondary end points included procedural outcomes (efficacy and safety) and echocardiographic measurements. RESULTS: A total of 90 patients (81 ± 6 years, 50% females, mean age 81 ± 6 years) were included in the registry. The indication for implantation was severe, symptomatic aortic stenosis (NYHA III, IV) in eighty-two (91.1%) and degeneration of a prosthetic aortic valve in eight (8.9%) patients. All patients were categorized as high surgical risk (mean Logistic Euroscore 25.9 ± 10, Euroscore II 7.7 ± 4.4 and STS score 10.8 ± 8.9). The procedure was performed transfemorally in all patients, under general anesthesia in 95.6%, under TOE guidance in 21.1%, with native valve predilatation in 46.7%, and the "resheath" option was used in 31.1% of the cases. The implantation was successful in 97.8% and there was a need for a second valve in 2.2% of the cases. Complications included permanent pacemaker implantation (16.7%), access cite complications (15.6%), arrythmias (23.3%), paravalvular leak (moderate 7.8%, severe 1.1%), acute kidney injury (7.8%), no strokes and one death during the procedure. Aortic valve peak velocity, peak and mean pressure gradients, were significantly reduced after the procedure. All-cause mortality at 1, 12 and 24 months was 4.4%, 6.7% and 7.8%, respectively. CONCLUSIONS: TAVI with the Portico system comprises an effective and safe solution for the management of severe, symptomatic aortic stenosis in high-risk surgical patients.

Renal Complications after Percutaneous Coronary Interventions on Concurrent Metformin Therapy: A Systematic Review with Meta-Analysis.

Objective: Metformin, commonly prescribed in diabetic patients, can cause lactic acidosis. Although generally rare, this side effect remains a source of concern in procedures requiring contrast media, due to the risk of contrast-induced nephropathy. Temporarily withdrawing metformin during the peri-procedural period is often practiced, but clinical decisions are difficult in emergency situations, such as acute coronary syndromes. In this systematic review with meta-analysis, we aimed to further investigate the safety of percutaneous coronary interventions in patients on concurrent metformin therapy.Design, Setting and Participants: We analyzed studies in patients undergoing (elective or emergency) percutaneous coronary interventions with or without concurrent metformin administration, reporting on the incidence of metformin-associated lactic acidosis and peri-procedural renal function.Methods: PubMed, ClinicalTrials.gov, Cochrane Library, and Scopus were systematically searched without language restrictions throughout August 2022. Randomized clinical trials and observational studies were assessed with the Revised Cochrane Collaboration Risk of Bias tool and the Newcastle-Ottawa quality scale, respectively. Data synthesis addressed the mean drop in estimated glomerular filtration rate (eGFR) and the incidence of contrast-induced nephropathy, in addition to lactic acidosis.Results: Nine studies were included, totaling 2235 patients (1076 continuing metformin during the peri-procedural period), mostly with eGFR above 30 mL/min/1.73m2 No cases of lactic acidosis were reported. The mean post-procedural drop in eGFR was 6.81mL/min/1.73m2 (95% confidence interval [CI]: 3.41 to 10.21) in the presence of metformin and 5.34 mL/min/1.73m2 (95% CI: 2.98 to 7.70) in its absence. The incidence of contrast-induced nephropathy was not affected by concurrent metformin, as shown by a (between-groups) standardized mean difference of 0.0007 (95% CI: -0.1007 to 0.1022).Conclusion: Concurrent metformin during percutaneous coronary interventions in patients with relatively preserved renal function is safe, without added risk of lactic acidosis or contrast-induced nephropathy. Thus, emergency revascularization in the context of acute coronary syndromes should not be deferred. More data from clinical trials in patients with severe renal disease are needed.

Duplication of the Artery to the Cystic Duct: A Case Report of a Rare Anatomical Variation with Surgical Significance.

Anatomical variations of the cystic artery are frequently documented, but variations of the artery to the cystic duct are extremely uncommon. We report a rare duplication of the artery to the cystic duct, revealed during laparoscopic cholecystectomy on an 18-year-old Caucasian female treated for gallstone disease. Both arterial branches were meticulously and carefully retracted and cauterized to avoid bleeding and subsequent postoperative complications. To our knowledge, this is the first reported case of an artery to the cystic duct duplication. The presence of congenital variations of the artery to the cystic duct encumbers surgical maneuvers and increases the potentiality of intraoperative injury and hemorrhage.

Spontaneous spinal epidural hematoma in an infant presenting with Horner syndrome.

BACKGROUND: Spontaneous spinal epidural hematoma (SSEH) is a rare neurologic entity, especially in infants, that develops in the absence of underlying coagulopathy, bleeding diathesis, infection, vascular malformation, trauma, iatrogenic, or other identifiable cause. In contrast to adults, diagnosis is frequently delayed or missed in infants due to non-specific symptoms and limited clinical examination. CASE ILLUSTRATION: An 11-month-old female demonstrated symptoms of irritability, intermittent diarrhea, lethargy, decreased oral intake, and difficulties crawling before presenting to the emergency room. At time of presentation, she was noted to have minimal spontaneous movement of the lower extremities and anisocoria with ptosis of the right eye. Given her clinical presentation, a magnetic resonance image (MRI) of the spine was obtained which revealed an epidural hematoma with compression extending from C7-T3. She underwent C7-T3 laminoplasty and hematoma evacuation. Following surgical intervention, she demonstrated significant improvements in her lower extremity strength and resolution of Horner syndrome. CONCLUSION: SSEH in infants is a rare neurologic condition, with diagnosis often delayed due to nonspecific symptomatology. Prompt diagnosis and intervention are essential in the treatment of SSEH to prevent permanent neurologic dysfunction. Physicians should have a high index of suspicion for SSEH in these instances, and investigation with spinal MRI imaging is recommended.

Interdisciplinary management of acute ischaemic stroke - current evidence on training requirements for endovascular stroke treatment. Position Paper from the ESC Council on Stroke and the European Association for Percutaneous Cardiovascular Interventions with the support of the European Board of Neurointervention: A step forward.

Stroke, a vascular disease of the brain, is the #1 cause of disability and a major cause of death worldwide. Stroke has a major negative impact on the life of stroke-affected individuals, their families and the society. A significant proportion of stroke victims indicate that would have preferred death over their after-stroke quality of life. Mechanical thrombectomy (MT), opening the occluded artery using mechanical aspiration or a thrombus-entrapment device, is a guideline-mandated (class I, level of evidence A) treatment modality in patients with large vessel occlusion stroke. MT clinical benefit magnitude indicates that a universal access to this treatment strategy should be the standard of care. Today there is a substantial geographic variation in MT deliverability, with large-scale disparities in MT implementation. In many countries effective access to MT remains severely limited. In addition, many of the MT-treated patients are treated too late for a good functional outcome because of logistic delays that include transportations to remotely located, scarce, comprehensive stroke centres. Position Paper from the European Society of Cardiology Council on Stroke and European Association for Percutaneous Cardiovascular Interventions on interdisciplinary management of acute ischaemic stroke, developed with the support of the European Board of Neurointervention fills an important gap in systematically enabling interventional cardiologists to support stroke intervention in the geographic areas of unmet needs in particular. We review strengths and weaknesses of the document, and suggest directions for the next steps that are swiftly needed to deliver MT to stroke patients more effectively.

Autonomic Responses during Labor: Potential Implications for Takotsubo Syndrome.

Takotsubo syndrome is a serious complication of labor. Although the pathophysiologic role of excessive sympathetic activation is established in this process, concurrent vagal responses have not been adequately described. Moreover, it remains unclear whether autonomic activity depends on the mode of delivery. Here, we explored the hypothesis that the different management of cesarean and vaginal delivery may elicit diverse responses affecting both autonomic arms. For this aim, continuous electrocardiographic recording was performed in 20 women during labor, and non-invasive indices of sympathetic and vagal activity were compared between the two modes of delivery. We report sympathetic prevalence during cesarean delivery, caused by marked vagal withdrawal, whereas autonomic activity was rather stable during vaginal delivery. These differences may be attributed to the effects of anesthesia during cesarean delivery, along with the protective effects of oxytocin administration during vaginal delivery. Our results provide further insights on autonomic responses during labor that may prove useful in the prevention of complications, such as takotsubo syndrome.

Should Deferred Stenting Still Be Considered in ST-Elevation Myocardial Infarction with High Thrombus Burden?

Patients with ST-elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI) may demonstrate distal microvascular embolization of thrombotic materials. We retrospectively examined 20 cases displaying extensive thrombus in the infarct-related artery (IRA), treated either with a two-step procedure, with interim tirofiban infusion, or immediate stent implantation. Distal embolization tended to be more common in the latter strategy, but, overall, the outcome was comparable. Thus, a two-staged procedure may be considered in selected cases of primary PCI associated with high thrombus burden.

Sympathetic Activation and Arrhythmogenesis after Myocardial Infarction: Where Do We Stand?

Myocardial infarction often leads to progressive structural and electrophysiologic remodeling of the left ventricle. Despite the widespread use of ß-adrenergic blockade and implantable defibrillators, morbidity and mortality from chronic-phase ventricular tachyarrhythmias remains high, calling for further investigation on the underlying pathophysiology. Histological and functional studies have demonstrated extensive alterations of sympathetic nerve endings at the peri-infarct area and flow-innervation mismatches that create a highly arrhythmogenic milieu. Such accumulated evidence, along with the previously well-documented autonomic dysfunction as an important contributing factor, has stirred intense research interest for pharmacologic and non-pharmacologic neuromodulation in post-infarction heart failure. In this regard, aldosterone inhibitors, sacubitril/valsartan and sodium-glucose cotransporter type 2 inhibitors have shown antiarrhythmic effects. Non-pharmacologic modalities, currently tested in pre-clinical and clinical trials, include transcutaneous vagal stimulation, stellate ganglion modulation and renal sympathetic denervation. In this review, we provide insights on the pathophysiology of ventricular arrhythmogenesis post-myocardial infarction, focusing on sympathetic activation.

Access-site Complications of the Transradial Approach: Rare But Still There.

In the past decade, the Transradial Approach (TRA) has constantly gained ground among interventional cardiologists. TRA's anatomical advantages, in addition to patients' acceptance and financial benefits, due to rapid patient mobilization and shorter hospital stay, made it the default approach in most catheterization laboratories. Access-site complications of TRA are rare and usually of little clinical impact, thus, they are often overlooked and underdiagnosed. Radial Artery Occlusion (RAO) is the most common, followed by radial artery spasm, perforation, hemorrhagic complications, pseudoaneurysm, arterio-venous fistula, and even rarer complications, such as nerve injury, sterile granuloma, eversion endarterectomy or skin necrosis. Most of them are conservatively treated, but rarely, surgical treatment may be needed and late diagnosis may lead to life-threatening situations, such as hand ischemia or compartment syndrome and tissue loss. Additionally, some complications may eventually lead to TRA failure and switch to a different approach. On the other hand, it is the opinion of the authors that non-occlusive radial artery injury, commonly included in TRA's complications in the literature, should be regarded more as an anticipated functional and anatomical cascade, following radial artery puncture and sheath insertion.

Treatment of Mobile Right Heart Thrombi.

Right heart thrombi are detected in approximately 4% of patients with pulmonary embolism. The associated mortality is high, but the optimal strategy remains controversial. We report a case of a large mobile right heart thrombus, complicated by embolism of the right pulmonary artery, which was successfully treated with half-dose alteplase. We briefly review the literature and discuss the therapeutic options, focusing on the advantages of thrombolysis. LEARNING POINTS: Mobile right heart thrombi require rapid therapeutic choices between surgical thrombectomy and thrombolysis.Half-dose alteplase may be effective, even in the presence of an extensive thrombus burden.

Tethered Cord Syndrome in the United States Cluster Analysis of Presenting Anomalies and Associated.

PURPOSE: Tethered cord syndrome (TCS) is an occult spinal dysraphism that includes low lying conus, tight filum terminale, lipomeningomyelocele, split cord malformations, dermal sinus tracts, and dermoids. This congenital disorder has been associated with musculoskeletal, neurological, and gastrointestinal abnormalities. This study presents a retrospective review of the prospectively collected data of TCS patients and their concurrent diagnoses or associated anomalies. METHODS: The National Inpatient Sample (NIS) database from 2003 to 2012 was used for data collection. Hospital- and year-adjusted weights allowed for accurate assessment of the incidence of TCS, as well as cardiac and gastrointestinal (GI) and genitourinary (GU) anomalies. K-means clustering analysis was run to discover patterns of concurrent cardiac, GI, GU, and other system anomalies in TCS patients. RESULTS: A total of 13,470 discharges with a diagnosis of TCS were identified in the NIS database, and at least one additional anomaly was identified in 40.7% of TCS patients. The most common secondary anomalies by system were: spine (24.48%), cardiac (6.27%), and urinary (5.37%). For patients with multiple anomalies, the most common combinations were GI and cardiac (4.55%), urinary and GI (4.26%), and urinary and cardiac (4.19%). The most common spinal association was spina bifida (13.65%). The most common neurological or musculoskeletal anomaly was any VACTERL association (13.45%). The top relation in GI and GU anomalies was cervix and female genitalia anomalies (69.1%). The most common specific anomalies were spina bifida, large intestine atresia, Rubenstein-Taybi syndrome, and atrial and ventral septal defects. CONCLUSION: This study provides a nationwide prospective on congenital anomalies and concurrent conditions present in tethered cord syndrome patients in the United States and demonstrates that 40.7% of TCS patients have at least one associated anomaly. The most common congenital anomalies studied were spina bifida, urogenital with or without cardiac septal defects, and cystourethral anomaly or cystic kidney disease with or without large intestinal atresia.

High Tolerability of Pitavastatin Therapy: A Case Report of Comparison with other Statins.

INTRODUCTION: Myopathy is possibly the most clinically relevant statin-induced side effect. CASE PRESENTATION: We report a case of a 63-year-old healthy male with mixed dyslipidemia. He developed bilateral myalgia of the forearms with fluvastatin 40 mg/day, pravastatin 20 mg/day, and combination of atorvastatin 10 mg and ezetimibe 10 mg/day. The only hypolipidemic treatment that was tolerable was the combination of pitavastatin 1 mg and ezetimibe 10 mg/day. DISCUSSION: Pitavastatin demonstrated less potential for the development of myalgia compared to the so far considered most tolerable statins (i.e., fluvastatin and pravastatin). All the tested statins were used at the lowest approved dose for clinical use. CONCLUSION: The combination of pitavastatin 1 mg and ezetimibe appears to be a promising treatment choice for individuals who are intolerant to statin therapy due to muscle complaints.