Arrhythmic and mortality outcomes in patients with dilated cardiomyopathy receiving cardiac resynchronization therapy without defibrillator.

INTRODUCTION: The routine implantation of cardiac resynchronization therapy with defibrillators in all patients who are candidates for this treatment is now being negotiated, mainly in patients with dilated cardiomyopathy. OBJECTIVE: We investigated the arrhythmic and mortality outcomes following CRT implantation in DCM, as well as the necessity for defibrillator capabilities in that particular group of patients. METHODS: we included 67- patients with DCM with EF ≤ 35%, QRS duration >130 msec and NYHA class II-IV, or those with EF ≤ 35% with indications of permanent pacing for implantation of CRT-P. Patients were followed to obtain good CRT response. Improved clinical outcomes were defined as improvement in at least one NYHA class, ≥5% increase in LVEF, and ≥15% reduction in left ventricular end-systolic volume versus baseline. Patients were classified into responder and non-responder. Patients were followed for 36 months regarding all-cause morbidity mainly ventricular tachycardia and all-cause mortality. RESULTS: CRT responder patients had better clinical outcomes than CRT non-responder patients (post NYHA, 1.3 ± 0.5 vs. 2.5 ± 0.6, p < 0.0001; post LVEF 30.0 ± 1.6 vs. 20.3 ± 2.2%, p < 0.0001; LVESV, 151.7 ± 7.6 vs. 190.4 ± 9.0 ml, p < 0.0001), with lower ventricular arrhythmia (p < 0.0001), lower mortality (p = 0.015) and lower all-cause morbidity (p < 0.001). This survival advantage may be related to the response to CRT response determined by clinical and echocardiographic parameters over a 36-month period of follow-up. CONCLUSIONS: Our findings suggest that CRT-P implantation without defibrillation backup is an encouraging treatment option for patients with DCM, principally those who responded to it. It may result in cost savings, a decrease in complications, and an improvement in all-cause morbidity, particularly ventricular arrhythmia and survival.

Functional outcomes in post Covid-19 patients with persistent dyspnea: multidisciplinary approach.

BACKGROUND: Post-acute sequelae of SARS-CoV-2 (PASC) have emerged as a major health issue in patients who have previously been infected with Covid-19 virus. PURPOSE: we aimed at the assessment of functional outcomes in post Covid-19 patients with persistent dyspnea using a multidisciplinary approach including clinical assessment, laboratory investigations, exercise ECG, and different echo-Doppler modalities, including left atrial functions. METHODS: The current observational randomized controlled study conducted on 60- patients one month after recovery from Covid-19 infection presented with persistent dyspnea compared to 30 healthy volunteers. All participants were subjected to evaluation of dyspnea by different scores, laboratory investigations, stress ECG, and echo-Doppler examination to measure LV dimensions, volumes, systolic and diastolic functions by M-mode, 2D, and tissue Doppler imaging in addition to 2-D speckle tacking LA strain. RESULTS: Post Covid-19 patients had persistent elevation of inflammatory markers, low functional capacity (evidenced by a higher NYHA class, m MRC score, PCFS scale) and decreased METs by stress ECG compared to control group. Post Covid-19 patients showed LV diastolic dysfunction and impairment of 2D-STE LA functions compared to control group. We found negative correlations between LA strain with NYHA class, mMRC scale, LAVI, ESR and CRP; meanwhile, there were significant positive correlations between LA strain with exercise duration and METs. CONCLUSION: post Covid patients presented with persistent dyspnea demonstrated low functional capacity evidenced by different scores and stress ECG. Moreover, patients with post Covid syndrome showed elevated inflammatory biomarkers, LV diastolic dysfunction in addition to impaired LA strain functions. Impairment of LA strain was closely correlated to different functional scores, inflammatory biomarkers, exercise duration, and METs suggesting that these could to be the possible etiologies for the persistence of post Covid symptoms.

The Usefulness of 4D Echocardiographic Modality for Assessing RV Affection in Uncontrolled Hypertensive Patients.

BACKGROUND: In many cardiovascular disorders, the contractile performance of the right ventricle (RV) is the primary determinant of prognosis. For evaluating RV volumes and function, 4 dimensional (4D)-echocardiography has become common. This research used 2D and 4D modalities to assess RV contractile performance in hypertensive patients. METHODS: A total of 150 patients with essential hypertension were enrolled in this study, along with 75 age and sex-matched volunteers. Clinical evaluation and echocardiographic examination (including M-mode, tissue Doppler imaging, and 2D speckle tracking) were conducted on all participants. RV volumes, 4D-ejection fraction (EF), 4D-fractional area change (FAC), 4D-tricuspid annular plane systolic excursion (TAPSE), 4D-septal and free wall (FW) strain were all measured using 4D-echocardiography. RESULTS: Hypertensive patients showed 2D-RV systolic and diastolic dysfunction (including TAPSE, 2D-right ventricular global longitudinal strain, RV-myocardial performance index and average E/EaRV) and 4D-RV impairment (including right ventricular EF, FAC, RV strain and TAPSE, right ventricular end-diastolic volume and right ventricular end-systolic volume) compared to the control group. We verified the prevalence of RV systolic dysfunction in hypertension patients using the following parameters: 1) 15% of them had 2D-TAPSE < 17 mm vs. 40% by 4D-TAPSE; 2) 25% of them had 2D-GLS < 19% vs. 42% by 4D-septal strain and 35% by 4D FW strain; 3) 35% of hypertensive patients had 4D-EF < 45%; and finally; 4) 25% of hypertensive patients had 2D-FAC < 35% compared to 45% by 4D-FAC. CONCLUSIONS: The incidence of RV involvement was greater in 4D than in 2D-modality trans-thoracic echocardiography. We speculated that 4D-echocardiography with 4D-strain imaging would be more beneficial for examining RV morphology and function in hypertensive patients than 2D-echocardiography, since 4D-echocardiography could estimate RV volumes and function without making geometric assumptions.

Evaluation of Cardiac Mechanical Dyssynchrony in Heart Failure Patients Using Current Echo-Doppler Modalities.

BACKGROUND: Current guidelines indicate electrical dyssynchrony as the major criteria for selecting patients for cardiac resynchronization therapy, and 25-35% of patients exhibit unfavorable responses to cardiac resynchronization therapy (CRT). We aimed to evaluate different cardiac mechanical dyssynchrony parameters in heart failure patients using current echo-Doppler modalities and we analyzed their association with electrical dyssynchrony. METHODS: The study included 120 heart failure with reduced ejection fraction (HFrEF) who underwent assessments for left ventricular mechanical dyssynchrony (LVMD) and interventricular mechanical dyssynchrony (IVMD). RESULTS: Patients were classified according to QRS duration: group I with QRS < 120 ms, group II with QRS 120-149 ms, and group III with QRS ≥ 150 ms. Group III had significantly higher IVMD, LVMD indices, TS-SD speckle-tracking echocardiography (STE) 12 segments (standard deviation of time to peak longitudinal strain speckle tracking echocardiography in 12 LV-segments), and LVMD score compared with group I and group II. Group II and group III were classified according to QRS morphology into left bundle branch block (LBBB) and non-LBBB subgroups. LVMD score, TS-SD 12 TDI, and TS-SD 12 STE had good correlations with QRS duration. CONCLUSIONS: HFrEF patients with wide QRS duration (> 150 ms) had more evident LVMD compared with patients with narrow or intermediate QRS. Those patients with intermediate QRS duration (120-150 ms) had substantial LVMD assessed by both TDI and 2D STE, regardless of QRS morphology. Subsequently, we suggest that LVMD indices might be employed as additive criteria to predict CRT response in that patient subgroup. Electrical and mechanical dyssynchrony were strongly correlated in HFrEF patients.

Evaluation of Heart Rate Variability Parameters During Awake and Sleep in Refractory and Controlled Epileptic Patients.

Background: Alterations of heart rate variability (HRV) in epileptic patients were the field of interest of several studies for many reasons, particularly the contribution toward sudden unexpected death in epilepsy (SUDEP). Aim: We aimed at evaluation of autonomic dysfunction in epileptic patients during awake and sleep in addition to studying the association between SUDEP risk with different Holter parameters. Patients and Methods: The study included eighty epileptic patients (40 controlled epileptic patients and 40 refractory epileptic patients) compared to 30 volunteers as control group. They underwent detailed epileptic history, Chalfont seizure severity scale, sudden unexpected death in epilepsy (SUDEP)-7 risk score and 24 hour Holter monitoring to assess HRV parameters. Results: Patients with refractory epilepsy had longer duration of epilepsy with increased number of used AEDs compared to controlled epileptic group. Both controlled and refractory epileptic patients had significantly higher average heart rate (AV.HR), sympatho-vagal ratio (low-frequency/high-frequency (LF/HF) ratio in 24 hours, daytime, and nighttime), and LF and HF values compared to controls. The rMSSD (the root mean square of difference between successive normal intervals), Tri.Index (triangular index), and pNN50 (percentage of the number of pairs of consecutive beat-to-beat intervals that varied by 50 ms) were significantly reduced in both epileptic groups compared to controls. Among refractory epileptic patients, patients with generalized epilepsy had significantly higher severity epileptic scale, average heart rate, minimum heart rate, and LF/HF night, in addition to lower rMSSD and pNN50 compared to patients with focal epilepsy. We found positive correlation between the following Holter indices (LF/HF 24, LF/HF day, and LF/HF night) and the duration of the epilepsy, while negative correlations between Tri.Index, LF, and HF and the epileptic duration were detected. SUDEP-7 risk was negatively correlated with pNN50 and rMSSD; meanwhile, it was positively correlated with LF/HF 24. The severity of epilepsy among refractory epileptic patients was positively correlated with average heart rate but negatively correlated with pNN50 and rMSSD. Using linear regression analysis, we found that pNN50 and rMSSD could predict SUDEP-7 risk and severity of epilepsy in refractory epileptic patients. Conclusion: Epileptic patients (particularly refractory patients with generalized EEG findings and long duration) had reduced heart rate variability and hence impairment of parasympathetic activity with increased susceptibility for adverse outcomes. Moreover, pNN50 and rMSSD could be used as predictors for SUDEP-7 risk as well as severity of epilepsy in refractory epileptic patients.

A case report of balloon-assisted tracking to overcome coronary sinus competent valve: a novel technique in left ventricular lead implantation.

BACKGROUND: Competent lateral and posterolateral valves showed proximal tortuosity that might hinder left ventricular (LV) lead implantation in cardiac resynchronization therapy (CRT). CASE SUMMARY: A 57-year-old woman was diagnosed as non-ischaemic cardiomyopathy, no other comorbidities, complaining of dyspnoea [New York Heart Association (NYHA) class III], and on optimal medical therapy. Electrocardiogram showed left bundle branch block with QRS duration 150 ms. The patient was candidate for CRT. However, during LV lead implantation, a competent posterolateral vein valve and proximal tortuosity hindered LV lead implantation that was overcome by balloon-assisted tracking technique. At 9 months of follow-up, the patient had NYHA class II, ejection fraction improved to 38%, and all implanted leads were still in place. DISCUSSION: Balloon-assisted tracking technique can be used to cross coronary sinus and smaller veins with competent valves and coronary veins tortuosity.

Evaluation of QT dispersion in epileptic patients and its association with SUDEP risk.

BACKGROUND: Mortality in epileptic patients was attributed to sudden unexpected death in epilepsy (SUDEP). The precise pathophysiology of SUDEP is not fully understood, yet prolongation of ventricular repolarization particularly QTc interval suggested to be one of the contributing risk factor for SUDEP. OBJECTIVES: We aimed at evaluation of QTc and QT dispersion (QTD) in patients with epilepsy (both refractory and well-controlled epilepsy) and their association with the epileptic severity and sudden unexplained death (SUDEP) risk. PATIENTS AND METHODS: The study included eighty epileptic patients (40 controlled epileptic patients and 40 refractory epileptic patients) compared to thirty non-epileptic volunteers as the control group (patients with history of cardiovascular comorbidities or exposure to antiarrhythmic drugs were excluded from the study). All participants were subjected to clinical evaluation including detailed epileptic history with assessment of SUDEP 7 risk, severity scale, 12 leads surface ECG to measure QTc & QTD, 24 h Holter monitoring to assess heart rate variability (HRV) parameters. RESULTS: Controlled and refractory epileptic patients demonstrated increased average QTc and QTD values compared to control group (450.1 ± 18.9 vs. 412.3 ± 12.3 ms, p < 0.0001, 452.1 ± 19.0 vs. 412.3 ± 12.3 ms, p < 0.0001 respectively) (45.6 ± 14.9 vs. 15.4 ± 6.8 ms, p < 0.001, 70.6 ± 18.1 vs. 15.4 ± 6.8 ms, p < 0.0001 respectively). Refractory epileptic patients had a significantly higher incidence of abnormal QTD > 50 ms compared to controlled epileptic patients (32.5% vs. 90%, p < 0.005). Refractory epileptic patients with generalized form had significantly higher severity scale in addition to significantly impaired rMSSD and pNN50 compared to those with focal form (1072.7 ± 722.7 vs. 429.1 ± 180.4, p < 0.03, 17.11 ± 4.6 vs. 26.4 ± 7.9 ms, p < 0.004 and 2.9 ± 1.8 vs. 7.8 ± 4.1%, p < 0.003 respectively). Among refractory epileptic patients, the duration of epilepsy, rMSSD and QTD significantly correlated with SUDEP-7 risk (r2 =0.199, p < 0.005, r2 =0.623, p < 0.0001 and r2=0.44, p < 0.0001 respectively). CONCLUSIONS: The current study stands out the importance of evaluating QTc and QTD in 12-lead ECG recordings in epileptic patients and signifying their association with SUDEP-7 risk among refractory epileptic patients.

Neutrophil-mediated oxidative stress and albumin structural damage predict COVID-19-associated mortality.

Human serum albumin (HSA) is the frontline antioxidant protein in blood with established anti-inflammatory and anticoagulation functions. Here, we report that COVID-19-induced oxidative stress inflicts structural damages to HSA and is linked with mortality outcome in critically ill patients. We recruited 39 patients who were followed up for a median of 12.5 days (1-35 days), among them 23 had died. Analyzing blood samples from patients and healthy individuals (n=11), we provide evidence that neutrophils are major sources of oxidative stress in blood and that hydrogen peroxide is highly accumulated in plasmas of non-survivors. We then analyzed electron paramagnetic resonance spectra of spin-labeled fatty acids (SLFAs) bound with HSA in whole blood of control, survivor, and non-survivor subjects (n=10-11). Non-survivors' HSA showed dramatically reduced protein packing order parameter, faster SLFA correlational rotational time, and smaller S/W ratio (strong-binding/weak-binding sites within HSA), all reflecting remarkably fluid protein microenvironments. Following loading/unloading of 16-DSA, we show that the transport function of HSA may be impaired in severe patients. Stratified at the means, Kaplan-Meier survival analysis indicated that lower values of S/W ratio and accumulated H2O2 in plasma significantly predicted in-hospital mortality (S/W≤0.15, 81.8% (18/22) vs. S/W>0.15, 18.2% (4/22), p=0.023; plasma [H2O2]>8.6 µM, 65.2% (15/23) vs. 34.8% (8/23), p=0.043). When we combined these two parameters as the ratio ((S/W)/[H2O2]) to derive a risk score, the resultant risk score lower than the mean (<0.019) predicted mortality with high fidelity (95.5% (21/22) vs. 4.5% (1/22), log-rank χ2=12.1, p=4.9×10-4). The derived parameters may provide a surrogate marker to assess new candidates for COVID-19 treatments targeting HSA replacements and/or oxidative stress.

Clinical utility of left ventricular strain, wall stress and serum brain natriuretic peptide levels in chronic hemodialysis patients.

BACKGROUND: Left ventricular (LV) global longitudinal strain (GLS) reliably assesses LV systolic function. The precise relation between LV wall stress and serum Brain natriuretic peptide (BNP) concentrations in hemodialysis (HD) patients needs to be clarified. BNP levels are raised in patients with end-stage renal disease (ESRD) and could reflect LV impairment among HD patients. AIM OF THIS WORK: This study sought to evaluate the clinical utility of LV-GLS, wall stress and serum BNP levels in chronic HD patients. The correlations between BNP levels with both LV wall stress and LV-GLS were assessed. PATIENTS AND METHODS: 30 ESRD patients on regular HD {categorized into 15 patients with LV ejection fraction (EF) ≤ 50% and 15 patients with LV EF > 50%} and 15-age matched healthy subjects were included. LV function and structure were assessed by conventional echocardiography including LV meridional wall stress (LVMWS), LV mass index (LVMI) and 2-dimensional speckle tracking echocardiography for determination of LV-GLS. Serum BNP levels were evaluated after HD session. RESULTS: There were significant increase of LVMSW (189.2 ±â€¯81 vs. 72.2 ±â€¯20.6 dynes/cm2 × 1000, P < 0.0001), higher levels of BNP (1238 ±â€¯1085.5 vs. 71 ±â€¯23.4 pg/ml, P < 0.0001) while LV-GLS was significantly reduced (15.1 ±â€¯3.1 vs. 20.8 ±â€¯1.7%, P < 0.0001) in HD patients compared to controls. Higher values of LVMWS (246.9 ±â€¯67.5 vs. 131.5 ±â€¯43.6 dynes/cm2 × 1000, P < 0.0001) and BNP (1925.4 ±â€¯1087 vs. 550.5 ±â€¯496.5 pg/ml, P < 0.0005) with further impairment of LV-GLS (13.8 ±â€¯2.5 vs. 16.4 ±â€¯5.4%, P < 0.05) were found in patients with LV EF ≤ 50% than those with LV EF > 50%. Serum levels of BNP were positively correlated with LVMI (r = 0.896, P < 0.0001) and LVMWS (r = 0.697, P < 0.0001) but negatively correlated with LV-GLS (r = -0.587, P < 0.0001). CONCLUSION: LV-GLS and LVMWS are useful imaging markers for detection of LV dysfunction in HD patients. Serum BNP level is influenced by LV structural abnormalities and suggested to be a crucial hemodynamic biomarker in those patients.

Cationic starch: Safe and economic harvesting flocculant for microalgal biomass and inhibiting E. coli growth.

Cationized starch-based flocculation processes are the subject of increasing attention because of their non-toxicity, biodegradability and relatively low price synthesized. The study aimed to evaluate the flocculability of different cationic starches using different concentrations of glycidyltrimethylammonium chloride (GTAC) with different degree of substitution (DS) ranged from 0.13 to 0.57. Cationized starch were characterized using Fourier Transform Infrared (FTIR), scanning electron microscopy (SEM) and toxicity checked using experimental animal procedure. They were used in comparison with aluminum sulphate for harvesting microalgal biomass collected from high rate algal pond (HRAP) at Zenin wastewater treatment plant (WWTP), Giza, Egypt. Jar test showed that gradual increase of aluminum sulphate doses (50-400 mg/L) has reduced algal suspension consequently turbidity with accompanied pH decrease from 8.6 to 6.6. Cationic starch with low DS has shown efficiency as flocculants by reducing turbidity of algal suspension from 110 to ≈2 NTU by gradual increase from 10 to 60 mg/L without change in pH value. Fecal coliforms and E. coli were inhibited from 9.6 × 102 and 8.4 × 10 CFU/ml to non-detectable count. Cationic starch with high DS (0.57) has the least effect of algae harvesting and turbidity reduction that 40 NTU after increase the dose to 60 mg/L. Results showed that 10 mg of cationic starch (DS = 0.13) has achieved the same flocculation efficiency of 100 mg of aluminum sulphate. In conclusion, further investigation is required to increase the degree of substitution of cationic starch, consequently the flocculation efficiency might be improved.

Predictive value of osteocalcin and beta-CrossLaps in metastatic breast cancer.

OBJECTIVES: Assessment of the diagnostic value of serum CEA, CA 15.3, osteocalcin (OC) and beta-CrossLaps (beta-CTX) in the detection of metastatic breast cancer. DESIGN AND METHODS: This study included 47 patients with breast cancer (20 non-metastatic breast cancer, 11 bone metastasis, 11 soft tissue metastasis, 5 bone plus soft tissue metastasis), 10 patients with benign breast lesions and 13 healthy volunteers. CEA and CA 15.3 were determined using microparticle enzyme immunoassay; while OC and beta-CTX were measured by electrochemiluminescence immunoassay. RESULTS: CEA, CA 15.3, OC and beta-CTX median levels were higher in breast cancer patients compared to controls (p=0.006, 0.001, 0.004 and 0.038, respectively). Increased levels of OC and beta-CTX were demonstrated in bone metastatic patients compared to non-metastatic or soft tissue metastatic patients (p=0.000). CONCLUSIONS: Combined use of OC and beta-CTX could be useful in early detection of bone metastatic breast cancer which might improve the outcome of the disease.