The Modern Clinician as an "Argonaut" Guiding Through the "Symplegades" of Evidence for PFO Closure in Patients With Migraine.

Patent foramen ovale (PFO) has been associated with migraine, especially migraine with aura, and 30-50% of individuals with migraine with aura have a PFO, suggesting it could be more than just an "innocent bystander''. Observational data showed a reduction of the frequency and severity of migraine attacks, particularly those with aura, following transcatheter PFO closure for established indications. Three small randomized controlled trials have demonstrated significant benefits of PFO closure in most of their secondary endpoints, such as reductions in the mean number of monthly migraine attacks and migraine days. Since a significant proportion of patients experience important side effects from traditional migraine medications and newer highly effective migraine prevention strategies may need to be instituted. PFO closure could in this regard to be a valuable add-on in the armamentarium of migraine treatment, improving the quality of life by alleviating the need for medications. The effect of percutaneous PFO closure on migraine treatment is needed to be clarified. As the underlying pathophysiology remains poorly understood and largely hypothetical, future investigations, focusing on the causal relationship between PFO and migraine, will help to define the subgroup of patients most likely to benefit from PFO closure. More accurate patient recruitment may lead to greater postprocedural benefits and more significant symptom improvement. Additionally, randomized controlled trials need to be reported adequately with more realistic endpoints, sufficient duration of follow-up, and statistical power to detect differences between closure and placebo groups to ensure precise and reliable findings.

Recurrence of an undifferentiated pleomorphic pulmonary artery sarcoma 8 years after initial presentation: a case report.

Background: Primary cardiac tumors remain exceptionally rare, characterized by a poor prognosis. Among them, sarcomas originating in the pulmonary arteries constitute the most infrequent subgroup within primary cardiac sarcomas. Case summary: This report presents the case of a 76-year-old female experiencing a recurrence of an undifferentiated pleomorphic intracardiac pulmonary artery sarcoma located in the right ventricular outflow tract, manifesting 8 years after initial remission. Successful outcomes were attained through a combination of surgical resection, state-of-the-art radiotherapy, and chemotherapy. This comprehensive approach proved essential for optimizing both survival and quality of life. Discussion: The unexpectedly prolonged recurrence-free survival observed in this case underscores the effectiveness of the comprehensive multimodal treatment approach outlined in the existing literature. This highlights the pivotal role of a multidisciplinary strategy in addressing primary cardiac sarcomas, particularly those arising in the pulmonary arteries.

Head-to-Head Comparison and Temporal Trends of Cardiac MRI Recommendations in ESC versus ACC/AHA Guidelines: A Systematic Review and Meta-Analysis.

Purpose To provide a comprehensive head-to-head comparison and temporal analysis of cardiac MRI indications between the European Society of Cardiology (ESC) and American College of Cardiology/American Heart Association (ACC/AHA) guidelines to identify areas of consensus and divergence. Materials and Methods A systematic review and meta-analysis was conducted. ESC and ACC/AHA guidelines published until May 2023 were systematically screened for recommendations related to cardiac MRI. The class of recommendation (COR) and level of evidence (LOE) for cardiac MRI recommendations were compared between the two guidelines and between newer versus older versions of each guideline using χ2 or Fisher exact tests. Results ESC guidelines included 109 recommendations regarding cardiac MRI, and ACC/AHA guidelines included 90 recommendations. The proportion of COR I and LOE B was higher in ACC/AHA versus ESC guidelines (60% [54 of 90] vs 46.8% [51 of 109]; P = .06 and 53% [48 of 90] vs 35.8% [39 of 109], respectively; P = .01). The increase in the number of cardiac MRI recommendations over time was significantly higher in ESC guidelines (from 63 to 109 for ESC vs from 65 to 90 for ACC/AHA; P = .03). The main areas of consensus were found in heart failure and hypertrophic cardiomyopathy, while the main divergences were in valvular heart disease, arrhythmias, and aortic disease. Conclusion ESC guidelines included more recommendations related to cardiac MRI use, whereas the ACC/AHA recommendations had higher COR and LOE. The number of cardiac MRI recommendations increased significantly over time in both guidelines, indicating the increasing role of cardiac MRI evaluation and management of cardiovascular disease. Keywords: Cardiovascular Magnetic Resonance, Guideline, European Society of Cardiology, ESC, American College of Cardiology/American Heart Association, ACC/AHA Supplemental material is available for this article. © RSNA, 2024.

Metaverse-based cardiac magnetic resonance imaging simulation application for overcoming claustrophobia: a preliminary feasibility trial.

Introduction: Cardiac magnetic resonance imaging (CMR) is vital, but claustrophobia affects 10% of patients. The metaverse, an immersive virtual and augmented reality environment, has healthcare potential. We present a metaverse-based CMR simulation for claustrophobic patients. Methods: Three cardiomyopathy patients, initially CMR-refusing due to claustrophobia, received training via a virtual reality headset in a metaverse-based virtual hospital. Training efficacy was assessed through questionnaires and anxiety scales. Results: The patients successfully completed metaverse-based training, adapting to the CMR simulation. On CMR day, all entered the machine without issues and with reduced anxiety. Patients found the training useful, suggesting platform familiarization. Discussion: Our study demonstrates the metaverse's potential in alleviating CMR-related claustrophobia. The immersive nature enhances patient preparation, although usability improvements are needed. Further research should compare this approach with alternatives.

Cardiac magnetic resonance imaging (CMR) is a vital tool for diagnosing heart problems, but some patients cannot undergo it due to claustrophobia. To address this, researchers are exploring new methods like hypnosis and simulations. One emerging technology, the metaverse, a 3D virtual reality (VR) environment, is being tested in healthcare. This study created a metaverse-based simulation to help claustrophobic patients prepare for CMR.Three patients with heart issues were given VR headsets to access a virtual hospital in the metaverse. Inside, they were trained for CMR step by step, experiencing the process and sounds realistically. Training was done 1 week, 3 days, and 1 day before the real CMR. Anxiety levels were measured.All patients completed the virtual training without issues. During the first simulations, some could not complete entering the virtual CMR machine due to anxiety. However, by the final simulation, all succeeded. On CMR day, all completed the scan without problems, and their anxiety levels decreased significantly from the initial training.Patients found the training helpful, but the platform's usability needed improvement. The study demonstrates that metaverse-based simulations can help patients overcome claustrophobia to successfully undergo CMR. This technology holds promise for simulating medical situations, easing patient fears, and improving preparation. However, further work is needed to make it user-friendly and accessible without assistance. This study encourages more research to assess the usefulness of the metaverse for broader patient groups, comparing it with other methods like hypnosis or sedation.

Outcomes and Safety of Transcaval Transcatheter Aortic Valve Replacement: A Systematic Review and Meta-analysis.

BACKGROUND: The transcaval (TCv) vascular approach is increasingly used in transcatheter aortic valve replacement (TAVR) in patients unsuitable for the gold-standard transfemoral approach. We aimed to evaluate the efficacy, safety, and clinical outcomes associated with TCv-TAVR. METHODS: A systematic review and meta-analysis was conducted by searching PubMed/Medline, Embase, and the Cochrane Library for all articles assessing the TCv approach published through December 2023. Outcomes included 30-day and 1-year all-cause mortality (ACM), 30-day rehospitalisation, perioperative complications and postoperative complications at 30 days. The meta-analysis was registered on the PROSPERO database with the identifier CRD42024501921. RESULTS: A total of 8 studies with 467 patients were included. TCv-TAVR procedures achieved a success rate of 98.5%. TCv-TAVR was associated with a 30-day ACM rate of 6.1% (95% confidence interval [CI]: 3.9%-8.2%), a 1-year ACM rate of 14.9% (95% CI 2.3%-27.6%) and a 30-day rehospitalisation rate of 4.2% (95% CI -2.2% to 10.6%). Postoperative stroke or transient ischemic attack, major vascular complications, and major or life-threatening bleeding occurred in 3.3%, 8.7%, and 7.5% of cases, respectively. Cumulative meta-analyses showed a temporal trend of decreasing rates of vascular complications. CONCLUSIONS: The TCv approach in TAVR demonstrated a reassuring efficacy and safety profile, with mortality and postoperative complication rates similar to those reported for supra-aortic alternative TAVR access routes. The temporal decrease in vascular complications suggests potential improvements in procedural techniques and device technology. These findings further support the TCv approach as a viable option in patients ineligible for the transfemoral access. PROSPERO: CRD42024501921.

[Cardiac CT in 2024]. / CT cardiaque en 2024.

Coronary Computed Tomography Angiography (CCTA) has now become an established tool in the diagnostic process for patients suspected of coronary artery disease. In light of rapid technological development, CCTA has evolved into an imaging modality providing both anatomical and functional information to guide patient management. In this article, we describe the role of cardiac CT in assessing atherosclerotic plaque, chest pain evaluation, cardiovascular risk stratification, planning and guiding coronary intervention, as well as structural heart diseases.

Le scanner coronarien est actuellement un outil reconnu dans le processus diagnostique des patients chez qui on suspecte une maladie coronarienne. Bénéficiant d'un développement technologique rapide et procurant des informations tant morphologiques que fonctionnelles, le CT cardiaque devient une modalité d'imagerie incontournable pour orienter la prise en charge des patients. Dans cet article, nous décrivons le rôle du CT cardiaque dans l'évaluation de la plaque d'athérosclérose, des douleurs thoraciques, de la stratification du risque cardiovasculaire, de la planification et du guidage de l'intervention coronarienne, ainsi que des maladies cardiaques structurelles.

A study of ChatGPT in facilitating Heart Team decisions on severe aortic stenosis.

BACKGROUND: Multidisciplinary Heart Teams (HTs) play a central role in the management of valvular heart diseases. However, the comprehensive evaluation of patients' data can be hindered by logistical challenges, which in turn may affect the care they receive. AIMS: This study aimed to explore the ability of artificial intelligence (AI), particularly large language models (LLMs), to improve clinical decision-making and enhance the efficiency of HTs. METHODS: Data from patients with severe aortic stenosis presented at HT meetings were retrospectively analysed. A standardised multiple-choice questionnaire, with 14 key variables, was processed by the OpenAI Chat Generative Pre-trained Transformer (GPT)-4. AI-generated decisions were then compared to those made by the HT. RESULTS: This study included 150 patients, with ChatGPT agreeing with the HT's decisions 77% of the time. The agreement rate varied depending on treatment modality: 90% for transcatheter valve implantation, 65% for surgical valve replacement, and 65% for medical treatment. CONCLUSIONS: The use of LLMs offers promising opportunities to improve the HT decision-making process. This study showed that ChatGPT's decisions were consistent with those of the HT in a large proportion of cases. This technology could serve as a failsafe, highlighting potential areas of discrepancy when its decisions diverge from those of the HT. Further research is necessary to solidify our understanding of how AI can be integrated to enhance the decision-making processes of HTs.

Transcaval versus Supra-Aortic Vascular Accesses for Transcatheter Aortic Valve Replacement: A Systematic Review with Meta-Analysis.

A growing body of evidence suggests that extrathoracic vascular accesses for transcatheter aortic valve replacement (TAVR) yield favorable outcomes and can be considered as primary alternatives when the gold-standard transfemoral access is contraindicated. Data comparing the transcaval (TCv) to supra-aortic (SAo) approaches (transcarotid, transsubclavian, and transaxillary) for TAVR are lacking. We aimed to compare the outcomes and safety of TCv and SAo accesses for TAVR as alternatives to transfemoral TAVR. A systematic review with meta-analysis was performed by searching PubMed/MEDLINE and EMBASE databases for all articles comparing TCv-TAVR against SAo-TAVR published until September 2023. Outcomes included in-hospital or 30-day all-cause mortality (ACM) and postoperative complications. A total of three studies with 318 TCv-TAVR and 179 SAo-TAVR patients were included. No statistically significant difference was found regarding in-hospital or 30-day ACM (relative risk [RR] 1.04, 95% confidence interval [CI] 0.47-2.34, p = 0.91), major bleeding, the need for blood transfusions, major vascular complications, and acute kidney injury. TCv-TAVR was associated with a non-statistically significant lower rate of neurovascular complications (RR 0.39, 95%CI 0.14-1.09, p = 0.07). These results suggest that both approaches may be considered as first-line alternatives to transfemoral TAVR, depending on local expertise and patients' anatomy. Additional data from long-term cohort studies are needed.

Head-to-head comparison of two angiography-derived fractional flow reserve techniques in patients with high-risk acute coronary syndrome: A multicenter prospective study.

BACKGROUND: FFRangio and QFR are angiography-based technologies that have been validated in patients with stable coronary artery disease. No head-to-head comparison to invasive fractional flow reserve (FFR) has been reported to date in patients with acute coronary syndromes (ACS). METHODS: This study is a subset of a larger prospective multicenter, single-arm study that involved patients diagnosed with high-risk ACS in whom 30-70% stenosis was evaluated by FFR. FFRangio and QFR - both calculated offline by 2 different and blinded operators - were calculated and compared to FFR. The two co-primary endpoints were the comparison of the Pearson correlation coefficient between FFRangio and QFR with FFR and the comparison of their inter-observer variability. RESULTS: Among 134 high-risk ACS screened patients, 59 patients with 84 vessels underwent FFR measurements and were included in this study. The mean FFR value was 0.82 ± 0.40 with 32 (38%) being ≤0.80. The mean FFRangio was 0.82 ± 0.20 and the mean QFR was 0.82 ± 0.30, with 27 (32%) and 25 (29%) being ≤0.80, respectively. The Pearson correlation coefficient was significantly better for FFRangio compared to QFR, with R values of 0.76 and 0.61, respectively (p = 0.01). The inter-observer agreement was also significantly better for FFRangio compared to QFR (0.86 vs 0.79, p < 0.05). FFRangio had 91% sensitivity, 100% specificity, and 96.8% accuracy, while QFR exhibited 86.4% sensitivity, 98.4% specificity, and 93.7% accuracy. CONCLUSION: In patients with high-risk ACS, FFRangio and QFR demonstrated excellent diagnostic performance. FFRangio seems to have better correlation to invasive FFR compared to QFR but further larger validation studies are required.

Successful closure of transcatheter aortic valve replacement-induced Gerbode defect with valve-in-valve technique: A case report.

We present the first documented case of a successful closure of a transcatheter aortic valve replacement (TAVR)-induced Gerbode defect using a valve-in-valve approach. A 90-year-old female with severe aortic stenosis underwent TAVR. Following post-dilatation, the patient experienced hemodynamic deterioration and collapse due to tamponade and sub-annular rupture leading to hemodynamic deterioration and the development of a Gerbode defect with communication between the left ventricle and right atrium. Hemodynamic stabilization was achieved through pericardiocentesis, followed by the low implantation of a second valve, effectively sealing the rupture. This case showcases a valuable alternative for managing rare challenging complications during TAVR procedures.

Meta-Analysis of the Prognostic Significance of Carotid Artery Stenosis in Patients Who Underwent Transcatheter Aortic Valve Implantation.

Stroke is a known complication of both transcatheter aortic valve implantation (TAVI) and carotid artery stenosis (CAS). Whether CAS is a predictor of worse prognosis after TAVI is unclear. We performed a meta-analysis to assess the impact of CAS on the incidence of neurovascular complications and mortality after TAVI. We searched PubMed/MEDLINE and EMBASE databases from inception to January 2023. CAS was defined by ≥50% stenosis of at least 1 carotid artery. Studies comparing CAS versus non-CAS TAVI populations were included. Patients' baseline characteristics and 30-day clinical outcomes were extracted. End points included the 30-day incidence of neurovascular complications (stroke or transient ischemic attack) and 30-day all-cause mortality. We identified six studies, totaling 6,763 patients in the CAS group and 23,861 patients in the non-CAS group. Patients with CAS had a higher prevalence of hypertension, diabetes mellitus, dyslipidemia, previous myocardial infarction, coronary artery bypass graft, peripheral artery disease, previous neurovascular disease, and chronic kidney disease. There was no significant difference in the rates of 30-day neurovascular complications between CAS and non-CAS groups (relative risk 1.23, 95% confidence interval 0.63 to 2.40, p = 0.54). CAS was associated with a higher risk of 30-day all-cause mortality (relative risk 1.28, 95% confidence interval 1.12 to 1.47, p <0.001), not found in a sensitivity analysis. In conclusion, patients with CAS presented with a significantly higher co-morbidity burden. CAS was not associated with an increased risk of 30-day neurovascular complications. 30-day mortality was higher in the CAS group but that may be a surrogate of the heavy co-morbidity burden of patients with CAS.

ChatGPT takes on the European Exam in Core Cardiology: an artificial intelligence success story?

Chat Generative Pre-trained Transformer (ChatGPT) is currently a trending topic worldwide triggering extensive debate about its predictive power, its potential uses, and its wider implications. Recent publications have demonstrated that ChatGPT can correctly answer questions from undergraduate exams such as the United States Medical Licensing Examination. We challenged it to answer questions from a more demanding, post-graduate exam-the European Exam in Core Cardiology (EECC), the final exam for the completion of specialty training in Cardiology in many countries. Our results demonstrate that ChatGPT succeeds in the EECC.

[State of the art management of patients presenting an ischemia with non-obstructive coronary arteries (ANOCA/INOCA)]. / Prise en charge de l'angine de poitrine et/ou de l'ischémie sans maladie coronarienne obstructive (ANOCA/INOCA).

Angor with non-obstructive coronary arteries or ischemia with non-obstructive coronary arteries (ANOCA/INOCA) is a condition where a patient experiences symptoms and/or signs of myocardial ischemia, without significant coronary artery stenoses. This syndrome is often caused by a direct imbalance between supply and demand, leading to inadequate myocardial perfusion due to microvascular limitations or coronary arteries' spasms. Although previously considered benign, there is increasing evidence that ANOCA/INOCA is associated with a poor quality of life, significant burden on the healthcare system, and major adverse cardiac events. This article reviews the definition of ANOCA/INOCA, epidemiology, risk factors, management, and current knowledge gaps and clinical trials.

La maladie coronarienne se présente classiquement sous forme de sténoses au niveau des artères coronariennes épicardiques. Cependant, un grand nombre de patients présentent des douleurs thoraciques et/ou un test non invasif positif pour une ischémie sans sténose coronarienne significative à l'angiographie. Il s'agit d'une maladie coronarienne non obstructive nommée ANOCA ou INOCA (Angina with Non Obstructive Coronary Arteries ou Ischemia with Non Obstructive Coronary Arteries). La cause peut être une atteinte de la microcirculation coronarienne ou un spasme des artères épicardiques. Longtemps considérée comme bénigne, peu de recherches ont été consacrées à l'ANOCA/INOCA. Cependant, de plus en plus de données montrent un impact sur les événements cardiaques majeurs, la qualité de vie et les coûts du système de santé.