Recent Advances in Understanding the Molecular Mechanisms of SGLT2 Inhibitors in Atrial Remodeling.

Atrial cardiomyopathy and remodeling play pivotal roles in the development of atrial fibrillation (AF) and heart failure (HF), involving complex changes in atrial structure and function. These changes facilitate the progression of AF and HF by creating a dynamic interplay between mechanical stress and electrical disturbances in the heart. Sodium-glucose cotransporter 2 inhibitors (SGLT2is), initially developed for the management of type 2 diabetes, have demonstrated promising cardiovascular benefits, being currently one of the cornerstone treatments in HF management. Despite recent data from randomized clinical trials indicating that SGLT2is may significantly influence atrial remodeling, their overall effectiveness in this context is still under debate. Given the emerging evidence, this review examines the molecular mechanisms through which SGLT2is exert their effects on atrial remodeling, aiming to clarify their potential benefits and limitations. By exploring these mechanisms, this review aims to provide insights into how SGLT2is can be integrated into strategies for preventing the progression of atrial remodeling and HF, as well as the development of AF.

General Anesthesia Improves Efficiency of High-Power Short-Duration Catheter Ablation for Atrial Fibrillation: Comparison with Mild Conscious Sedation.

BACKGROUND: Atrial fibrillation (AF) is the most common cardiac arrhythmia globally. High-power, short-duration radiofrequency (RF) catheter ablation (CA) for AF has recently emerged, reducing ablation times and enhancing patient tolerability with comparable efficacy and safety. While the benefits of general anesthesia (GA) for standard-power, standard-duration CA are well-established, data comparing GA to mild conscious sedation (MCS) for high-power, short-duration CA are limited. METHODS: We included patients undergoing high-power, short-duration CA for AF under GA (group 1) or MCS (group 2). Procedural characteristics, success rates, and mid-term outcomes were compared. RESULTS: In total, 131 patients, 47 in the GA group and 84 in the MCS group, were included. CA was performed for paroxysmal AF in 34 patients in group 1 (72.3%) and 68 patients in group 2 (80.9%). We found lower a mean total procedure time (100 [90-120] vs. 160 [130-180] min, p < 0.0001), lower radiation exposure (932.5 [625-1716] vs. 2445 [1228-4791] µGy, p < 0.0001 and 4.5 [3-7.1] 7.3 [4.2-13.5] min, p = 0.0003) and fewer RF applications (71 [54.8-83.8] vs. 103 [88.5-120.5], p < 0.0001) in the GA group. No major complications occurred. The 6-month AF recurrence rate was comparable between the groups (21.2% vs. 33.3%, p = 0.15). CONCLUSION: In patients undergoing high-power, short-duration RFCA for AF, the use of GA is associated with better procedural efficiency while simultaneously associated with an early recurrence rate comparable to MCS.

Updates on the Renin-Angiotensin-Aldosterone System and the Cardiovascular Continuum.

The cardiovascular continuum describes how several cardiovascular risk factors contribute to the development of atherothrombosis, ischemic heart disease, and peripheral arteriopathy, leading to cardiac and renal failure and ultimately death. Due to its multiple valences, the renin-angiotensin-aldosterone system plays an important role in all stages of the cardiovascular continuum, starting from a cluster of cardiovascular risk factors, and continuing with the development of atherosclerosis thorough various mechanisms, and culminating with heart failure. Therefore, this article aims to analyze how certain components of the renin-angiotensin-aldosterone system (converting enzymes, angiotensin, angiotensin receptors, and aldosterone) are involved in the underlying pathophysiology of the cardiovascular continuum and the possible arrest of its progression.

Exploring Periodontal Conditions, Salivary Markers, and Systemic Inflammation in Patients with Cardiovascular Diseases.

(1) Background: This cross-sectional investigation appreciated the role of serum C-reactive protein (CRP), several hematologic-cell markers, and salivary inflammation-related molecules [calprotectin (S100A8/A9), interleukin-1ß (IL-1ß), kallikrein] to predict periodontitis in patients with atherosclerotic cardiovascular disease (ACVD), arrhythmia, or both. Also, we appreciated the relationship between the inflammatory burden and periodontal destruction with the type of cardiac pathology. (2) Methods: Demographic, behavioral characteristics, periodontal indicators, blood parameters, and saliva samples were collected. (3) Results: All 148 patients exhibited stage II or III/IV periodontitis. Stage III/IV cases exhibited significantly increased S100A8/A9 levels (p = 0.004). A positive correlation between S100A8/A9 and IL-1ß [0.35 (<0.001)], kallikrein [0.55 (<0.001)], and CRP [0.28 (<0.001)] was observed. Patients with complex cardiac involvement had a significantly higher number of sites with attachment loss ≥ 5 mm [19 (3-30)] compared to individuals with only arrhythmia [9 (3.25-18)] or ACVD [5 (1-12)] [0.048♦ {0.162/0.496/0.14}]. (4) Conclusions: Severe, extensive attachment loss may be indicative of patients with complex cardiac conditions, which underscores the essential role of periodontal status in relation to systemic diseases. The correlations between the rising trends of the inflammatory parameters suggest a potential interconnection between oral and systemic inflammation.

Novel 3D versus traditional transesophageal echocardiography techniques: Defining differences in the diagnosis of infective endocarditis.

BACKGROUND: Despite the availability of current antibiotic and surgical treatment options, infective endocarditis (IE) remains associated with a high mortality rate. Even though two-dimensional (2D) transesophageal echocardiography (TOE) is a major criteria in the diagnosis of IE, it is constrained by the single-plane orientation. Since three-dimensional (3D) TOE provides a comprehensive understanding of the cardiac architecture by allowing for a realistic visualization of the underlying structures in 3D space, it has attracted considerable interest in recent years. AIM: The purpose of this narrative review is to discuss the advantages and pitfalls of 3D TOE in patients with IE, as well as to address emerging photo-realistic 3D techniques that have the potential to enhance the visualization of cardiac structures in this setting. RESULTS: According to recent research, 3D TOE acquisitions outperform 2D acquisitions in terms of vegetation identification accuracy and embolism risk assessment. By reporting a variety of findings that are missed with 2D TOE, but which are validated by surgical examination, 3D TOE further improves the ability to identify endocarditis complications on both native and prosthetic valves. In addition to conventional 3D TOE, future developments in 3D technology led to the development of transillumination and tissue-transparency rendering, which may improve anatomical understanding and depth perception. Due to the use of both conventional and novel 3D techniques, there are more patients who require surgical intervention, indicating that 3D TOE may have a clinical relevance on the surgical management. CONCLUSION: 3D TOE might fill the gaps left by 2D TOE in the diagnosis of IE.

His bundle pacing in nodal versus infranodal atrioventricular block: a mid-term follow-up study.

INTRODUCTION: This study evaluated the feasibility of His bundle pacing (HBP) in consecutive, unselected patients with advanced atrioventricular block (AVB) over a medium-term follow-up period, comparing procedural characteristics between nodal and infranodal sites of the conduction block. MATERIALS AND METHODS: Seventy-five consecutive patients with second-degree or third-degree AVB in which HBP was attempted were prospectively included in this study. The clinical and procedural-related characteristics of the patients were recorded at baseline and over a mid-term follow-up. RESULTS: 72% of the patients had normal QRS duration at baseline. Intracardiac electrograms revealed nodal AVB in 46 patients (61.3%). The permanent HBP procedural success was significantly higher in nodal AVB (84.8%) vs infranodal AVB (31%). There was no statistical difference between paced QRS duration, impedance, pacing and sensing thresholds and fluoroscopy time in the two groups. Infranodal block, baseline QRS duration, left bundle branch block morphology and ejection fraction were significantly associated with HBP procedural failure. The patients were followed for a period of 627.71±160.93 days. There were no significant differences in parameters at follow-up. An increase of >1 V in the His bundle (HB) capture threshold was encountered in one patient with infranodal AVB (11.1 %) and in four patients with nodal AVB (10.25%). CONCLUSION: Permanent HBP is a feasible pacing technique in nodal AVB with a high success rate and stable thresholds in the medium term. Most infranodal blocks are located within the HB, so there is still the possibility to capture the conduction system, although with lower success rates.

Feasibility of Permanent His Bundle Pacing in the Elderly vs the Very Elderly. A Single-Center Mid-Term Follow-Up Study.

Purpose: Although feasibility studies have included older patients, specific data for His bundle pacing (HBP) in this population is scarce. The aim of this study was to evaluate the feasibility and mid-term performance of HBP in the elderly (70 to 79 years old) versus the very elderly (80 years old and above) patients with conventional indications for pacing. Patients and Methods: About 105 patients older than 70 years of age with attempted HBP from the 1st of January 2019 to the 31st of December 2021 were reviewed. Clinical and procedural characteristics were recorded at baseline, and after a mid-term follow-up period. Results: The procedural success rate was similar in both age groups (68.49% vs 65.62%). There was no significant difference in pacing or sensing thresholds, impedance, and fluoroscopy times. For both age intervals, patients with a baseline narrow QRS maintained a similar QRS duration after pacing, while in patients with a wide QRS, the paced QRS was significantly shorter. Baseline QRS duration, left bundle branch block morphology, and ejection fraction, were significantly associated with HBP procedural failure. The mean follow-up period was 830.34 days for the elderly and 722.76 days for the very elderly. After the follow-up period, both sensing and pacing thresholds were similar between the groups. Compared to the baseline values, there were no significant changes in both pacing and sensing parameters, irrespective of the age interval. During follow-up, no lead dislodgements were recorded. There were two cases of significant pacing threshold rise in the elderly (4%) and three cases in the very elderly group (14.2%) which were managed conservatively, without lead revision. Conclusion: In elderly and very elderly patients, HBP is a feasible procedure associated with constant pacing and sensing parameters and with low complication rates over mid-term follow-up.

Galectin-3, Inflammation, and the Risk of Atrial High-Rate Episodes in Patients with Dual Chamber Pacemakers.

Atrial high-rate episodes (AHREs) are atrial tachyarrhythmias that are exclusively detected by cardiac implantable electronic devices (CIEDs) with an atrial lead. The objective of this study was to investigate the incidence and predictive factors for AHREs, and to evaluate the ability of inflammation biomarkers to predict the occurrence of AHREs. 102 patients undergoing CIED procedure who received a dual chamber pacemaker were included. CIED interrogation was performed 1 year after the implantation procedure. Patients were divided into groups according to the occurrence of AHREs, which was the primary endpoint of the study. The mean age of the patients was of 73 ± 8.6 years and 48% were male. The incidence of AHREs was 67% at 1 year follow-up. Patients with AHREs were older, had higher left atrial indexed volume (LAVi), higher baseline galectin-3 levels (1007.5 ± 447.3 vs. 790 ± 411.7 pg/mL) and received betablockers more often, along with amiodarone and anticoagulants. Interestingly, the CHADSVASC score did not differ significantly between the two groups. A cut-off value of galectin > 990 pg/mL predicted AHREs with moderate accuracy (AUC of 0.63, 95% CI 0.52 to 0.73, p = 0.04), and this association was confirmed in the univariate regression analysis (OR 1.0012, 95% CI 1.0001 to 1.0023, p = 0.0328). However, based on the multivariate regression analysis, galectin lost its prognostic significance under the effect of LAVi, which remained the only independent predictor of AHREs (OR 1.0883, 95% CI 1.0351 to 1.1441, p = 0.0009). AHREs are common in CIEDs patients. Galectin-3 may bring additional data in the prediction of AHREs.

The Degree of Stent Apposition Measured by Stent Enhancement at the Level of the Side Branch as a Novel Predictor of Procedural Success in Left Main PCI.

BACKGROUND: Stent enhancement techniques allow adequate visualization of stent deformation or incomplete stent expansion at the ostium of the side branch. Measuring the stent enhancement side branch length (SESBL) could reflect procedural success in terms of optimal stent expansion and apposition with better long-term outcomes. A longer SESBL may reflect a better stent apposition at the polygon of confluence and at the side branch (SB) ostium. METHODS: We evaluated 162 patients receiving the left main (LM) provisional one-stent technique and measured the SESBL, dividing them into two groups: SESBL≤ 2.0 mm and SESBL > 2.0 mm. RESULTS: The mean SESBL was 2.0 ± 1.2 mm. More than half of the bifurcations had both main and side branch lesions (Medina 1-1-1) (84 patients, 51.9%) and the length of the SB disease was 5.2 ±1.8 mm. Kissing balloon inflation (KBI) was performed in 49 patients (30.2%). During follow-up (12 months), there was a significantly higher rate of cardiac death in the SESBL ≤ 2.0 mm group (p = 0.02) but no significant difference in all major adverse cardiovascular events (MACEs) (p = 0.7). KBI did not influence the outcomes (p = 0.3). CONCLUSION: Suboptimal SESBL is positively correlated with worse outcomes and SB compromise. This novel sign could aid the LM operator to assess the level of stent expansion at the ostium of the SB in the absence of intracoronary imaging.

Clinical Characteristics and Outcomes following Percutaneous Coronary Intervention in Unprotected Left Main Disease: A Single-Center Study.

Background: Hemodynamically significant unprotected left main (LM) coronary artery disease is a high-risk clinical condition because of the large area of myocardium at risk, and it requires prompt revascularization. Percutaneous coronary intervention (PCI) is an appropriate alternative to coronary artery bypass grafting (CABG) for revascularization of unprotected LM disease in patients with low-to-intermediate anatomic complexity or when the patient refuses CABG after adequate counseling by the heart team. Methods: We retrospectively evaluated 201 patients receiving left main (LM) provisional one-stent or two-stent procedures, and we assessed the clinical characteristics and outcomes of patients undergoing unprotected LM PCI. Results: The mean age was 66.5 ± 9.9 years, and 72% were male. The majority of the subjects presented several cardiovascular risk factors, among which arterial hypertension (179 patients, 89.5%) and dyslipidemia (173 patients, 86.5%) were the most frequent. Out of all patients, 162 (81.8%) underwent revascularization by using the one-stent technique, while the two-stent technique was used in 36 patients (18.2%). The median value of fractional flow reserve (FFR) of the side branch was 0.9 [0.85-0.95], and 135 patients (67.1%) showed a value of FFR > 0.8. One hundred nine patients (54.2%) had a stent enhancement side branch length (SESBL) > 2, with median values of 2.5 mm2 [2.1-3]. Regarding angiographic parameters, the LM area as assessed by intravascular ultrasound (IVUS) or optical coherence tomography (OCT) and the grade of stenosis as assessed by quantitative coronary angiography (QCA) were similar between groups. However, patients who required revascularization by using the two-stent technique presented more frequently with intermediate rather than low SYNTAX scores (69.4% vs. 28.4%, p < 0.0001). Also, the same group required kissing balloon inflation (KBI) more frequently (69.4% vs. 30%, p < 0.001). There were no differences regarding the success of revascularization between the use of the one-stent or two-stent technique. FFR was able to predict a SESBL > 2 mm. The cut-off value for FFR to afford the highest degree of sensitivity (74.5%) and specificity (47%) for a SESBL > 2 was >0.86, indicating a moderate accuracy (AUC = 0.61, 95% CI 0.525-0.690, p = 0.036). Conclusions: Unprotected left main PCI is a safe and effective revascularization option amongst a complex and morbid population. There were no differences regarding the success of revascularization between the use of the one-stent or two-stent technique, and there was no significant impact of KBI on side branch FFR measurements but lower side branch FFR values were correlated with angiographic side branch compromise.