Arrhythmic Mitral Valve Prolapse Phenotype: An Unsupervised Machine Learning Analysis Using a Multicenter Cardiac MRI Registry.

Purpose To use unsupervised machine learning to identify phenotypic clusters with increased risk of arrhythmic mitral valve prolapse (MVP). Materials and Methods This retrospective study included patients with MVP without hemodynamically significant mitral regurgitation or left ventricular (LV) dysfunction undergoing late gadolinium enhancement (LGE) cardiac MRI between October 2007 and June 2020 in 15 European tertiary centers. The study end point was a composite of sustained ventricular tachycardia, (aborted) sudden cardiac death, or unexplained syncope. Unsupervised data-driven hierarchical k-mean algorithm was utilized to identify phenotypic clusters. The association between clusters and the study end point was assessed by Cox proportional hazards model. Results A total of 474 patients (mean age, 47 years ± 16 [SD]; 244 female, 230 male) with two phenotypic clusters were identified. Patients in cluster 2 (199 of 474, 42%) had more severe mitral valve degeneration (ie, bileaflet MVP and leaflet displacement), left and right heart chamber remodeling, and myocardial fibrosis as assessed with LGE cardiac MRI than those in cluster 1. Demographic and clinical features (ie, symptoms, arrhythmias at Holter monitoring) had negligible contribution in differentiating the two clusters. Compared with cluster 1, the risk of developing the study end point over a median follow-up of 39 months was significantly higher in cluster 2 patients (hazard ratio: 3.79 [95% CI: 1.19, 12.12], P = .02) after adjustment for LGE extent. Conclusion Among patients with MVP without significant mitral regurgitation or LV dysfunction, unsupervised machine learning enabled the identification of two phenotypic clusters with distinct arrhythmic outcomes based primarily on cardiac MRI features. These results encourage the use of in-depth imaging-based phenotyping for implementing arrhythmic risk prediction in MVP. Keywords: MR Imaging, Cardiac, Cardiac MRI, Mitral Valve Prolapse, Cluster Analysis, Ventricular Arrhythmia, Sudden Cardiac Death, Unsupervised Machine Learning Supplemental material is available for this article. © RSNA, 2024.

The outcome of genetic and non-genetic pediatric cardiomyopathies.

BACKGROUND: Pediatric cardiomyopathies (CMP) can be familial or idiopathic with increasing detection of genetic mutations. The study is a retrospective single-center review of cardiomyopathy patients from January 2011 to May 2020. Results of the genetic study, as well as the outcome, were reported. Patients were divided according to the type of CMP, age of presentation, and EF at presentation. Univariate and multivariate analysis and ROC and survival curves were done. RESULTS: We reported 229 patients under 14 years of age with a diagnosis of cardiomyopathy, most commonly DCM (160 patients (70%)) followed by HCM (26.2%). 52% presented at 6 months of age or less and 119 (52%) required ICU admission at presentation. The genetic and or metabolic disorder was confirmed in 21.4% of patients, most commonly VLCAD defect (16, 7%) and ELAC2 gene defect (10, 4.4%). During the disease course, 88 patients (38.4%) died (48 with DCM, 39 with HCM, and 1 with RCM). An EF of 20% or less at presentation and presentation at 6 months of age or less carries a risk for mortality in patients with DCM and HCM, respectively (RR 3.88 and 2.06 and OR of 11.09 and 4.35, respectively). Death was more common among HCM patients especially patients with positive genetic abnormality compared with patients with DCM. CONCLUSIONS: The mortality for CMP in children reaches up to 40%, (30% in DCM and 65% in HCM patients). Mortality was higher in those with HCM, DCM with EF of 20% or less, and HCM presented at 6 months of age or less. Whole-exome and/or whole-genome sequencing is advised for all patients of CMP and at-risk family members.

Methotrexate & rheumatoid arthritis associated atherosclerosis: A narrative review of multidisciplinary approach for risk modification by the international board of experts.

Rheumatoid arthritis (RA) is an idiopathic, autoimmune connective tissue disorder that primarily affects the synovial joints, causing symmetric, erosive-deforming polyarthritis. It is also associated with extra-articular manifestations, particularly cardiovascular (CV) diseases (CVD). CV risk modification in RA remains unsolved despite recent advances in the management of RA. RA is an independent risk factor for atherosclerosis. RA and atherosclerosis share similar pathophysiological features (such as the pro-inflammatory cascade activation including interleukin-6) and risk factors (such as microflora dysbacteriosis and smoking). Patients with RA experience an exacerbation of atherogenesis, with atheromas destabilization, endothelial dysfunction, vasculitis, and hypercytokinemia. Consequently, the inflammatory response associated with RA is the basis for CVD development. The treat-to-target strategy not only improved RA control but also had a favorable effect on the morpho-functional state of the CV system in patients living with RA. Thus, disease-modifying antirheumatic drugs (DMARDs) - in particular methotrexate - may have a beneficial effect on the prevention of CV events in RA. It must be mentioned that RA is a serious multi-system disease, not only because of a window period during which the course of RA can be reversed, but also due to early damage to the heart and blood vessels. For this reason, a thorough cardiological assessment must be performed for all patients with RA, regardless of sex, age, disease stage, and disease activity score.

Diabetic Cardiomyopathy: 2023 Update by the International Multidisciplinary Board of Experts.

Diabetes mellitus (DM) is considered by many the pandemic of the 21st century and is associated with multiple organ damages. Among these, cardiovascular complications are responsible for an incredible burden of mortality and morbidity in Western Countries. The study of the pathological mechanisms responsible for the cardiovascular complications in DM patients is key for the development of new therapeutic strategies. The metabolic disorders caused by hyperglycemia, insulin resistance, and dyslipidemia, results in a cascade of pathomorphological changes favoring the atherosclerotic process and leading to myocardial remodeling. Parallel to this, oxidative stress, calcium overload, mitochondrial dysfunction, activation of protein kinase C signaling pathways, myocardial lipomatosis, and low-grade inflammation of the myocardium - are the main pathways responsible for the diabetic cardiomyopathy development. This review aims to appraise and discuss the pathogenetic mechanisms behind the diabetic cardiomyopathy development.

HIV-Related Atherosclerosis: State-of-the-Art-Review.

The infection caused by the Human Immunodeficiency Virus (HIV) has spread rapidly across the globe, assuming the characteristics of an epidemic in some regions. Thanks to the introduction of antiretroviral therapy into routine clinical practice, there was a considerable breakthrough in the treatment of HIV, that is now HIV is potentially well-controlled even in low-income countries. To date, HIV infection has moved from the group of life-threatening conditions to the group of chronic and well controlled ones and the quality of life and life expectancy of HIV+ people, with an undetectable viral load is closer to that of an HIV- people. However, unsolved issues still persist. For example: people living with HIV are more prone to the age-related diseases, especially atherosclerosis. For this reason, a better understanding of the mechanisms of HIV-associated destabilization of vascular homeostasis seems to be an urgent duty, that may lead to the development of new protocols, bringing the possibilities of pathogenetic therapies to a new level. The purpose of the article was to evaluate the pathological aspects of HIV-induced atherosclerosis.

Prognostic role of pre- and postinterventional myocardial injury in patients undergoing transcatheter aortic valve implantation.

BACKGROUND: Chronic pre-procedural and acute post-procedural myocardial injury are frequently observed in patients with aortic stenosis undergoing transcatheter aortic valve implantation (TAVI). The aim of our study was to investigate the prognostic role of high sensitivity cardiac troponins (hs-cTns) elevation before and after TAVI. METHODS: 106 patients with severe aortic stenosis who underwent TAVI were enrolled. High sensitivity cardiac troponin T (hs-cTnT) was measured before and after TAVI (6, 24, 48, 72 hours). Post-procedural myocardial damage was defined as a 15-fold rise in hs-cTnT upper reference limit (URL) after TAVI. The clinical endpoints were all cause death, cardiovascular death and re-hospitalization at 24 months follow-up. RESULTS: Before TAVI, hs-cTnT median value was 0.03 µg/L (2.3±2.1 fold over URL). After TAVI procedure, myocardial damage (MD), as defined by VARC-2 criteria, was observed in 40 patients (38%) (MD group). In our population, logarithmically transformed hs-cTnTs were independently associated with all-cause mortality at 24 months F/U (pre-TAVI hs-cTnT: Hazard ratio [HR] 2.2, 95% confidence interval [CI]: 1.1 to 4.4, P=0.027). No significant differences were observed between the MD and non-MD groups for the three endpoints of all cause death (p log rank: 0.15), cardiovascular death (p log rank: 0.86) and re-hospitalization (p log rank: 0.87). CONCLUSIONS: Only baseline hs-cTnT levels correlated with outcomes at 24 months of follow-up. Chronic pre-procedural myocardial injury significantly affects prognosis after TAVI.

Behavior of Coronavirus pandemic in Yemen: practical experience review.

COVID-19 is caused by a coronavirus called SARS-CoV-2, which spread, all over the world. The virus is spreading very easily and sustainably between people. Information from the ongoing pandemic disease suggests that this virus is spreading more efficiently than influenza. Older adults and people who have severe underlying medical conditions like heart or lung disease or diabetes seem to be at higher risk for developing more serious complications from COVID-19 illness. Coronavirus constantly changes through mutation. When a virus has one or more new mutation, it has called a variant of concern. There is no data from Yemen to show what type of coronavirus variant is spread in Yemen. We believe it is a unique situation where almost all people have been affected by the coronavirus. We tested the cardiac center workers and we found all of them have positive results. No severe symptoms among our staff were reported and many of them suffered from mild to moderate symptoms, which does not need admission to the hospital. Young age among this worker sample may explain the mild severity of COVID-19 infection detected; another explanation is the frequent exposure to viral infection in Yemen and the type of coronavirus variant in Yemen. We conducted this review to describe the current situation and our experience during the pandemic and further studies are needed to identify the exact variant in Yemen and the immunity response for this coronavirus variant in the Yemeni Society.

Myocardial Fibrosis at Cardiac MRI Helps Predict Adverse Clinical Outcome in Patients with Mitral Valve Prolapse.

Background Patients with mitral valve prolapse (MVP) may develop adverse outcomes even in the absence of mitral regurgitation or left ventricular (LV) dysfunction. Purpose To investigate the prognostic value of mitral annulus disjunction (MAD) and myocardial fibrosis at late gadolinium enhancement (LGE) cardiac MRI in patients with MVP without moderate-to-severe mitral regurgitation or LV dysfunction. Materials and Methods In this longitudinal retrospective study, 118 144 cardiac MRI studies were evaluated between October 2007 and June 2020 at 15 European tertiary medical centers. Follow-up was from the date of cardiac MRI examination to June 2020; the minimum and maximum follow-up intervals were 6 months and 156 months, respectively. Patients were excluded if at least one of the following conditions was present: cardiomyopathy, LV ejection fraction less than 40%, ischemic heart disease, congenital heart disease, inflammatory heart disease, moderate or worse mitral regurgitation, participation in competitive sport, or electrocardiogram suggestive of channelopathies. In the remainder, cardiac MRI studies were reanalyzed, and patients were included if they were aged 18 years or older, MVP was diagnosed at cardiac MRI, and clinical information and electrocardiogram monitoring were available within 3 months from cardiac MRI examination. The end point was a composite of adverse outcomes: sustained ventricular tachycardia (VT), sudden cardiac death (SCD), or unexplained syncope. Multivariable Cox regression analysis was performed. Results A total of 474 patients (mean age, 47 years ± 16 [SD]; 244 women) were included. Over a median follow-up of 3.3 years, 18 patients (4%) reached the study end point. LGE presence (hazard ratio, 4.2 [95% CI: 1.5, 11.9]; P = .006) and extent (hazard ratio, 1.2 per 1% increase [95% CI: 1.1, 1.4]; P = .006), but not MAD presence (P = .89), were associated with clinical outcome. LGE presence had incremental prognostic value over MVP severity and sustained VT and aborted SCD at baseline (area under the receiver operating characteristic curve, 0.70 vs 0.62; P = .03). Conclusion In contrast to mitral annulus disjunction, myocardial fibrosis determined according to late gadolinium enhancement at cardiac MRI was associated with adverse outcome in patients with mitral valve prolapse without moderate-to-severe mitral regurgitation or left ventricular dysfunction. © RSNA, 2022 Online supplemental material is available for this article. See also the editorial by Gerber in this issue.

Prognostic value of systemic inflammatory response syndrome after transcatheter aortic valve implantation.

AIMS: Systemic inflammatory response syndrome (SIRS) could affect mortality after transcatheter aortic valve implantation (TAVI) up to 12 months of follow-up. The aim of this study was to evaluate the prevalence of SIRS after TAVI and its impact on all-cause mortality up to 24 months follow-up. METHODS: We retrospectively enrolled 132 patients with symptomatic severe aortic stenosis undergoing TAVI. SIRS development during the first 72 h after the intervention was evaluated. Other postoperative complications were defined according to the Valve Academic Research Consortium 2 (VARC2). All patients underwent follow-up at 30 days and 24 months. Endpoints were 30-days and 24-months mortality. RESULTS: Post-TAVI SIRS developed in 27 patients (20%). At 30-day follow-up, all-cause death occurred in 10 (8%) patients and SIRS occurred more frequently in patients with adverse short-term outcome (60 vs. 17%; P = 0.001). Twenty-four months all-cause death occurred in 25 (19%) patients. SIRS resulted as an independent predictor of long-term outcome [hazard ratio 3.7; 95% confidence interval (95% CI) 1.5-9; P = 0.004], along with major vascular complications (hazard ratio 4; 95% CI 1.6-9.9; P = 0.003), relevant bleedings (hazard ratio 6.4; 95% CI 1.5-28; P = 0.013) and baseline pulmonary hypertension (hazard ratio 2.4; 95% CI 1.05-5.6; P = 0.039). CONCLUSION: Postoperative SIRS was more frequent in patients who died at 30 days follow-up. Moreover, SIRS resulted as a predictor of 24-month mortality along with vascular complications, relevant bleedings and baseline pulmonary hypertension.

Cardiac and Vascular Remodeling After 6 Months of Therapy With Sacubitril/Valsartan: Mechanistic Insights From Advanced Echocardiographic Analysis.

Background: Effects of Sacubitril/Valsartan (S/V) on left ventricular (LV) mechanics and ventricular-arterial coupling in patients with heart failure with reduced ejection fraction (HFrEF) are not completely understood. The aim of this study was to evaluate both cardiac and vascular remodeling in a group of HFrEF patients undergoing S/V therapy. Methods: Fifty HFrEF patients eligible to start a therapy with S/V were enrolled. Echocardiographic evaluation was performed at baseline and after 6 months of follow-up (FU). Beside standard evaluation, including global longitudinal strain (GLS), estimated hemodynamic forces (HDFs) and non-invasive pressure-volume curves (PV loop) were assessed using dedicated softwares. HDFs were evaluated over the entire cardiac cycle, in systole and diastole, both in apex to base (A-B) and latero-septal (L-S) directions. The distribution of LV HDFs was evaluated by L-S over A-B HDFs ratio (L-S/A-B HDFs ratio). Parameters derived from estimated PV loop curves were left ventricular end-systolic elastance (Ees), arterial elastance (Ea), and ventricular-arterial coupling (VAC). Results: At 6 months of FU indexed left ventricular end-diastolic and end-systolic volumes decreased (EDVi: 101 ± 28 mL vs. 86 ± 30 mL, p < 0.001; ESVi: 72 ± 23 mL vs. 55 ± 24 mL, p < 0.001), ejection fraction and GLS significantly improved (EF: 29 ± 6% vs. 37 ± 7%, p < 0.001; GLS: -9 ± 3% vs. -13 ± 4%, p < 0.001). A reduction of Ea (2.11 ± 0.91 mmHg/mL vs. 1.72 ± 0.44 mmHg/mL, p = 0.008) and an improvement of Ees (1.01 ± 0.37 mmHg/mL vs. 1.35 ± 0.6 mmHg/mL, p < 0.001) and VAC (2.3 ± 1.1 vs. 1.5 ± 0.7, p < 0.001) were observed. Re-alignment of HDFs occurred, with a reduction of diastolic L-S/A-B HDFs ratio [23 (20-35)% vs. 20 (11-28) %, p < 0.001]. Conclusion: S/V therapy leads to a complex phenomenon of reverse remodeling involving increased myocardial contractility, HDFs distribution improvement, and afterload reduction.

Protective Value of Aspirin Loading Dose on Left Ventricular Remodeling After ST-Elevation Myocardial Infarction.

Aims: Left ventricular (LV) remodeling after ST-elevation myocardial infarction (STEMI) is a complex process, defined as changes of LV volumes over time. CMR feature tracking analysis (CMR-FT) offers an accurate quantitative assessment of LV wall deformation and myocardial contractile function. This study aimed to evaluate the role of myocardial strain parameters in predicting LV remodeling and to investigate the effect of Aspirin (ASA) dose before primary coronary angioplasty (pPCI) on myocardial injury and early LV remodeling. Methods and Results: Seventy-eight patients undergoing CMR, within 9 days from symptom onset and after 6 months, were enrolled in this cohort retrospective study. We divided the study population into three groups based on a revised Bullock's classification and we evaluated the role of baseline CMR features in predicting early LV remodeling. Regarding CMR strain analysis, worse global circumferential and longitudinal strain (GCS and GLS) values were associated with adverse LV remodeling. Patients were also divided based on pre-pPCI ASA dosage. Significant differences were detected in patients receiving ASA 500 mg dose before pPCI, which showed lower infarct size extent and better strain values compared to those treated with ASA 250 mg. The stepwise multivariate logistic regression analysis, adjusted for covariates, indicated that a 500 mg ASA dose remained an inverse independent predictor of early adverse LV remodeling. Conclusion: GCS and GLS have high specificity to detect early LV adverse remodeling. We first reported a protective effect of ASA loading dose of 500 mg before pPCI on LV myocardial damage and in reducing early LV adverse remodeling.

Hydroxychloroquine cardiotoxicity: a case-control study comparing patients with COVID-19 and patients with systemic lupus erythematosus.

OBJECTIVES: Antimalarials have been associated with QT prolongation in COVID-19 patients but are generally safe in systemic lupus erythematosus (SLE).We compared the prevalence of QTc prolongation between COVID-19 and SLE patients treated with hydroxychloroquine (HCQ). METHODS: We included patients with SARS-CoV-2 infection confirmed by nasopharyngeal swab and patients taking HCQ for SLE. A prolonged QTc was defined as an increase in QTc intervals >60 ms (compared with baseline) or as a QTc of ≥500 ms. We performed the univariate and multivariate logistic regression to investigate the risk factors for QTc prolongation in COVID-19 patients. RESULTS: We enrolled 58 COVID-19 patients (median age 70.5 years, IQR 25), grouped into group A (patients with HCQ) group B (patients with HCQ + azithromycin) and group C (not received either drug). Fifty (26%) COVID-19 patients presented a QTc prolongation (12 QTc≥500 ms, 3 patients ΔQTc>60 ms). We did not find any differences in QTc prolongation among the three treatment groups. Baseline QTc (OR 111.5) and D-dimer (OR 78.3) were independently associated to QTc prolongation. Compared to the 50 SLE patients (median age 38.5 years, IQR 22), chronically treated with HCQ, COVID-19 patients showed significantly longer QTc (p<0.001). CONCLUSIONS: This is the first study demonstrating that, unlike COVID-19 patients, patients with SLE are not susceptible to HCQ-induced long QT syndrome and arrhythmia. The combined arrhythmogenic effect of SARS-CoV-2 infection and HCQ could account for the excess of QTc prolongation and fatal arrhythmias described in patients with COVID-19.

Complex connections: A young man presenting with shortness of breath, hypoxemia, right lumbar pain and left limb swelling.

A 43-year-old Caucasian man was admitted to hospital due to shortness of breath, right lumbar pain and lower left limb swelling. Arterial blood gas sample showed mild hypoxemia and respiratory alkalosis. CT scan confirmed pulmonary embolism, splenic and bilateral renal ischemic lesions. Echocardiography showed right ventricular and coronary sinus (CS) dilatation. Using contrast echocardiography, a superior sinus venous atrial septal defect and persistent left superior vena cava (PLSVC) draining in CS were suspected. Cardiac CT confirmed the diagnosis and showed overriding right superior vena cava (RSVC) draining in both atria. The patient underwent successful surgical correction.

3D Echo Characterization of Proportionate and Disproportionate Functional Mitral Regurgitation before and after Percutaneous Mitral Valve Repair.

BACKGROUND: The impact of percutaneous mitral valve repair (PMVr) on long-term prognosis in patients with functional mitral regurgitation (FMR) is still unclear. Recently, a new conceptual framework classifying FMR as proportionate (P-MR) and disproportionate (D-MR) was proposed, according to the effective regurgitant orifice area/left ventricular end-diastolic volume (EROA/LVEDV) ratio. The aim was to assess its possible influence on PMVr efficacy. METHODS: A total of 56 patients were enrolled. MV annulus, LV volumes and function were assessed. Global longitudinal strain (GLS) was also calculated. Patients were divided into two groups, according to the EROA/LVEDV ratio. Echocardiographic follow-up was performed after 6 months, and adverse events were collected after 12 months. RESULTS: D-MR patients (n = 28, 50%) had a significantly more elliptical MV annulus (p = 0.048), lower tenting volume (p = 0.01), higher LV ejection fraction (LVEF: 32 ± 7 vs. 26 ± 5%, p = 0.003), lower LVEDV, LV end-systolic volume (LVESV) and mass (LVEDV/i: 80 ± 20 vs. 126 ± 27 mL, p = 0.001; LVESV/i: 60 ± 20 vs. 94 ± 23 mL, p < 0.001; LV mass: 249 ± 63 vs. 301 ± 69 gr, p = 0.035). GLS was more impaired in P-MR (p = 0.048). After 6 months, P-MR patients showed a higher rate of MR recurrence. After 12 months, the rate of CV death and rehospitalization due to HF was significantly higher in P-MR patients (46% vs. 7%, p < 0.001). P-MR status was strongly associated with CV death/rehospitalization (HR = 3.4, CI 95% = 1.3-8.6, p = 0.009). CONCLUSIONS: Patients with P-MR seem to have worse outcomes after PVMr than D-MR patients. Our study confirms the importance of the EROA/LVEDV ratio in defining different subsets of FMR based on the anatomical characteristic of MV and LV.

AC-Mode of Chemotherapy as a Trigger of Cardiac Syndrome X: A Case Study.

In the period of dynamic development of pharmacological possibilities in the modern oncology, unfortunately, the issue of cardiotoxicity of chemotherapy did not lost its urgent value. Cardiotoxicity implies structural and functional myocardial alteration, together with an increase in the concentration of highly sensitive markers of myocardial necrosis, in particular T and I troponins, and N-terminal pro-BNP, as well as with a subclinical or clinical decrease in the LVEF. It is noteworthy that cardiotoxicity is manifested not only by the development of anthracycline cardiomyopathy with a high risk of convention into heart failure. It also can cause various cardiovascular pathologies, in particular cardiac syndrome X. This study described chemotherapy-induced microvascular angina in 23-year-old otherwise heathy woman. The diagnosis is challenging for doctors, since microvascular flow may be only detected by using functional test.

Impact of intraventricular haemodynamic forces misalignment on left ventricular remodelling after myocardial infarction.

AIMS: Altered left ventricular (LV) haemodynamic forces (HDFs) have been associated with positive and negative remodelling after pathogenic or therapeutic events. We aimed to identify LV HDFs patterns associated with adverse LV remodelling (aLVr) in reperfused segment elevation myocardial infarction (STEMI) patients. METHODS AND RESULTS: Forty-nine acute STEMI patients underwent cardiac magnetic resonance (CMR) at 1 week (baseline) and after 4 months (follow-up). LV HDFs were computed at baseline from cine CMR long axis data sets, using a novel technique based on endocardial boundary tracking, both in apex-base (A-B) and latero-septal (L-S) directions. HDFs distribution was evaluated by L-S over A-B HDFs ratio (L-S/A-B HDFs ratio %). HDFs parameters were computed over the entire heartbeat, in systole and diastole. At baseline, aLVr patients had lower systolic L-S HDF (2.7 ± 0.9 vs. 3.6 ± 1%; P = 0.027) and higher diastolic L-S/A-B HDF ratio (28 ± 14 vs. 19 ± 6%; P = 0.03). At univariate logistic regression analysis, higher infarct size [odds ratio (OR) 1.05; 95% confidence interval (CI) 1.01-1.1; P = 0.04], higher L-S/A-B HDFs ratio (OR 1.1; 95% CI 1.01-1.2; P = 0.05) and lower L-S HDFs (OR 0.41; 95% CI 0.2-0.9; P = 0.04) were associated with aLVr at follow-up. In the multivariable logistic regression analysis, diastolic L-S/A-B HDF ratio remained the only independent predictor of aLVr (OR 1.1; 95% CI 1.01-1.2; P = 0.04). CONCLUSIONS: Misalignment of diastolic haemodynamic forces after STEMI is associated with aLVr after 4 months.

The evolving role of echocardiography in the assessment of patent foramen ovale in patients with left-side thromboembolism.

Patent foramen ovale (PFO) is the most common congenital cardiac abnormality found approximately in 25% of the adult population The pathophysiological role of paradoxical embolization through the PFO in ischemic stroke is well established. "Self-expanding double disk" and, more recently, suture-based "deviceless" systems are used for PFO closure in the setting of secondary prevention after ischemic stroke likely related to paradoxical embolization. Ultrasound plays a significant role in PFO assessment, indication to treatment, intra-procedural guidance, and follow-up for those undergoing PFO closure. Three different techniques are frequently used for these purposes: transesophageal echocardiography, transthoracic echocardiogram, and transcranial Doppler. In this review, advantages and limits of these techniques are discussed in detail to improve our skills in detection and treatment of this important condition by using ultrasound.

Characteristics and Risk Factors of Yemeni Patients Presenting with Myocardial Infarction with Nonobstructive Coronary Arteries (MINOCA).

Background: Myocardial infarction with non-obstructive coronary artery (MINOCA) is a syndrome, which requires both clinical documentation of ST-elevation myocardial infarction (STEMI) (abnormal cardiac biomarker, ischemic symptoms, and electrocardiography changes) and detection of nonobstructive coronary arteries. The purpose of this study is to determine the incidence of and characteristics of patients with MINOCA in the Yemeni population. Methods: Consecutive patients admitted between January and June 2019 at Al-Thawra Hospital, Sana'a (Yemen), with STEMI diagnosis were enrolled in this study. Demographic, clinical, echocardiographic, and coronary angiography characteristics of patients were noted. Results: MINOCA was identified in 63 patients (25%) out of 249 admitted with STEMI diagnosis at Al-Thawra Hospital. The mean age of MINOCA patients was similar to obstructive coronary group; however, they were more often females and less frequently with diabetes and family history of coronary artery disease. Other risk factors like smoking, arterial hypertension, dyslipidemia, and oral tobacco were similar. Conversely, the percentage of Khat chewers was significantly higher in the MINOCA patients (P < 0.01) as compared to obstructive group. Conclusions: The relatively high incidence of MINOCA in our country and the long list of multiple potential causes of MINOCA should open further working diagnosis after coronary angiography and further efforts for defining the cause of myocardial infarction in each individual patient in Middle East countries.