Conduction system pacing and atrioventricular node ablation in heart failure: The PACE-FIB study design.

AIMS: Atrial fibrillation (AF) worsens the prognosis of patients with heart failure (HF). Successful treatments are still very scarce for those with permanent AF and preserved (HFpEF) or mildly reduced (HFmrEF) ejection fraction. In this study, the long-term benefits and safety profile of heart rate regularization through left-bundle branch pacing (LBBP) and atrioventricular node ablation (AVNA) will be explored in comparison with pharmacological rate-control strategy. METHODS AND RESULTS: The PACE-FIB trial is a multicentre, prospective, open-label, randomized (1:1) clinical study that will take place between March 2022 and February 2027. A total of 334 patients with HFpEF/HFmrEF and permanent AF will receive either LBBP followed by AVNA (intervention arm) or optimal pharmacological treatment for heart rate control according to European guideline recommendations (control arm). All patients will be followed up for a minimum of 36 months. The primary outcome measure will be the composite of all-cause mortality, HF hospitalization, and worsening HF at 36 months. Other secondary efficacy and safety outcome measures such as echocardiographic parameters, functional status, and treatment-related adverse events, among others, will be analysed too. CONCLUSION: LBBP is a promising stimulation mode that may foster the clinical benefit of heart rate regularization through AV node ablation compared with pharmacological rate control. This is the first randomized trial specifically addressing the long-term efficacy and safety of this pace-and-ablate strategy in patients with HFpEF/HFmrEF and permanent AF.

Case Series of Ventricular Tachycardia Ablation With Pulsed-Field Ablation: Pushing Technology Further (Into the Ventricle).

Three cases of ventricular tachycardia ablation with pulsed-field ablation technology performed at 2 separate centers are reported, highlighting the advantages and disadvantages of this tool inside the ventricle: its dependence on proximity rather than contact makes it useful in sites with poor stability, while the speed of application and large scope of action provided by commercially available catheters could help with ablating large diseased areas of endocardium in a fast and hemodynamically well-tolerated fashion. However, lesion depth could be insufficient for guaranteeing efficacy in preventing ventricular tachycardias originating at an epicardial site, even in the right ventricle.

Value of advanced interatrial block in the diagnosis of the ischemic stroke's aetiology: A cohort study

Introduction and objectives: Advanced interatrial block has been linked with atrial fibrillation (AF) (Bayes syndrome). On the other hand, the aetiology of the stroke remains unknown in approximately 20–25% of patients admitted due to ischaemic stroke. The aim of this study was to evaluate whether advanced interatrial block and CHADS2-VASC scale is linked to AF in patients admitted due to ischaemic stroke without previous AF history.MethodsA prospective analysis of consecutive in-hospital patients admitted with ischemic stroke between January/2018 and April/2019 in a stroke hospital was performed. Patients had to be in sinus rhythm at admission and without previous history of AF/atrial flutter. During follow up patients receive the usual care.ResultsA total of 236 patients were included. The median follow-up was 540 days (407–695). 19 patients (8.1%) had advanced interatrial block at admission. Advanced interatrial block was associated with the diagnosis of AF during follow up (5 (26.3%) Vs 21 (9.7%) p=0.027). A CHADS2-VASC score>4 at admission was also associated with AF diagnosis during follow up (23(14.6%) vs 3(3.9%) p=0.009).ConclusionThis study confirms the association of advanced interatrial block and CHADS2-VASC>4 at admission with the diagnosis of AF during follow up in patients with ischemic stroke. This association could have important implications in patients with ischemic stroke who present advanced interatrial block and without previous history of AF. (AU)

Introducción y objetivos: El bloqueo interauricular (BIA) completo se relaciona con el desarrollo de arritmias supraventriculares, especialmente de fibrilación auricular (FA) (síndrome de Bayés). En este trabajo evaluamos la utilidad de este fenómeno para discernir la etiología cardioembólica en los pacientes ingresados por ictus isquémico. También se estudió la relación entre la puntuación en la escala CHADS 2-VA 2 Sc y el desarrollo de FA durante el seguimiento.MétodosAnálisis prospectivo de pacientes consecutivos ingresados por ictus isquémico entre enero del 2018 y abril del 2019 en un hospital terciario centro de referencia de ictus. Los pacientes incluidos debían de estar en ritmo sinusal en el momento del ingreso y no tener historia previa de FA/flutter auricular. Se realizó el seguimiento mediante las consultas y estudios de rutina, sin intervenir en su manejo habitual.ResultadosSe incluyó a 236 pacientes. La mediana de seguimiento fue de 540 días (407-695); 19 pacientes (8,1%) presentaron BIA en el electrocardiograma al ingreso. El BIA completo al ingreso se relacionó con el desarrollo posterior de FA (5 [26,3%) vs. 21 [9,7%]; p=0,027). También se observó que un CHADS 2-VA 2 Sc>4 al ingreso se relacionaba con presentar FA durante el seguimiento (23 [14,6%] vs. 3 [3,9%]; p=0,009).ConclusiónCon este estudio se demuestra por primera vez en pacientes con ictus isquémico que tanto el BIA completo como un CHADS 2-VA 2 Sc>4 se asocian con el desarrollo de FA en el seguimiento. Esta asociación puede tener importantes implicaciones prácticas en el manejo de pacientes ingresados por ictus que presenten BIA completo. (AU)

Role of sex on the efficacy of pharmacological and non-pharmacological treatment of heart failure with reduced ejection fraction: A systematic review.

Background: Heart Failure (HF) is a growing epidemic with a similar prevalence in men and women. However, women have historically been underrepresented in clinical trials, leading to uneven evidence regarding the benefit of guideline-directed medical therapy (GDMT). This review aims to outline the sex differences in the efficacy of pharmacological and non-pharmacological treatment of HF with reduced ejection fraction (HFrEF). Methods and results: We conducted a systematic review via Medline from inception to 31 January 2022, including all randomized clinical trials published in English including adult patients suffering HFrEF that reported data on the efficacy of each drug. Baseline clinical characteristics, primary outcomes, and sex-specific effects are summarized in tables. The systemic review has been conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. In total, 29 articles were included in the systematic review. We observed that the proportion of women enrolled in clinical trials was generally low, the absence of a prespecified analysis of efficacy by sex was frequent, and the level of quality of evidence on the efficacy of GDMT and implantable cardioverter defibrillator (ICD) or cardiac resynchronization therapy (CRT-) in women was relatively poor. Conclusions: Sex influences the response to treatment of patients suffering from HFrEF. All the results from the landmark randomized clinical trials are based on study populations composed mainly of men. Further studies specifically designed considering sex differences are warranted to elucidate if GDMT and new devices are equally effective in both sexes.

Optimal surgical timing after post-infarction ventricular septal rupture.

BACKGROUND: Ventricular septal rupture (VSR) following acute myocardial infarction (AMI) is a dangerous condition. Surgical VSR closure is the definitive therapy, but there is controversy regarding the surgical timing and the bridging therapy between diagnosis and intervention. The objective of this study is to analyze the ideal time of surgical repair and to establish the contribution of mechanical circulatory support (MCS) devices on the prognosis. METHODS: We designed an observational, retrospective, multicenter study, selecting all consecutive patients with post-AMI VSR between January 1, 2008 and December 31, 2018, with non-exclusion criteria. The main objective of this study was to analyze the optimal timing for surgical repair of post-AMI VSR. Secondary endpoints were to determine which factors could influence mortality in the patients of the surgical group. RESULTS: A total of 141 patients were included. We identified lower mortality rates with an odds ratio of 0.3 (0.1-0.9) in patients operated on from day 4 compared with the surgical mortality in the first 24 hours after VSR diagnosis. The use of MCS was more frequent in patients treated with surgery, particularly for intra-aortic balloon pump (IABP; 79.6% vs. 37.8%, p < 0.001), but also for veno-arterial extracorporeal membrane oxygenation (VA-ECMO; 18.2% vs. 6.4%, p = 0.134). Total mortality was 91.5% for conservative management and 52.3% with surgical repair (p < 0.001). CONCLUSIONS: In our study, we observed that the lowest mortality rates in patients with surgical repair of post-AMI VSR were observed in patients operated on from day 4 after diagnosis of VSR, compared to earlier interventions.

Impact of power and contact force on index-guided radiofrequency lesions in an ex vivo porcine heart model.

PURPOSE: Lesion size index (LSI) and ablation index (AI) are markers of lesion quality that incorporate power, contact force (CF) and time in a weighted formula to estimate lesion size. Although accurate predicting lesion depth in vitro, their precision in lesion size estimation has not been well established for certain power and CF settings. We conducted an experimental ex vivo study to analyse the effect of power and CF in size and morphology of ablation lesions in a porcine heart model. METHODS: Twenty-four sets of 10 perpendicular epicardial radiofrequency applications were performed with two commercially available catheters (TactiCath, Sensor Enabled; and SmartTouch) on porcine left ventricle submerged in 37 °C saline, combining different power (25, 30, 35, 40, 50 and 60 W) and CF (10 and 20 g) settings, and aiming at a lower (LSI/AI of 5/400) or higher (LSI/AI of 6/550) index. After each application, lesions were cross-sectioned and measured. RESULTS: Four hundred eighty lesions were performed. For a given target index and CF, significant differences in lesion volume and depth with different power were observed with both catheters, generally with smaller lesions using higher power. Lesions performed with CF of 10 g were particularly smaller with TactiCath compared to SmartTouch; lesions with CF of 20 g aiming a low LSI/AI were, however, bigger; lesions with CF of 20 g aiming a high LSI/AI were similar. In general, high-power lesions were wider and shallower than low-power lesions, especially with SmartTouch. CONCLUSION: Size and morphology of index-guided radiofrequency lesions varied significantly with different power and CF settings.

Value of advanced interatrial block in the diagnosis of the ischemic stroke's aetiology: A cohort study.

INTRODUCTION AND OBJECTIVES: Advanced interatrial block has been linked with atrial fibrillation (AF) (Bayes syndrome). On the other hand, the aetiology of the stroke remains unknown in approximately 20-25% of patients admitted due to ischaemic stroke. The aim of this study was to evaluate whether advanced interatrial block and CHADS2-VASC scale is linked to AF in patients admitted due to ischaemic stroke without previous AF history. METHODS: A prospective analysis of consecutive in-hospital patients admitted with ischemic stroke between January/2018 and April/2019 in a stroke hospital was performed. Patients had to be in sinus rhythm at admission and without previous history of AF/atrial flutter. During follow up patients receive the usual care. RESULTS: A total of 236 patients were included. The median follow-up was 540 days (407-695). 19 patients (8.1%) had advanced interatrial block at admission. Advanced interatrial block was associated with the diagnosis of AF during follow up (5 (26.3%) Vs 21 (9.7%) p=0.027). A CHADS2-VASC score>4 at admission was also associated with AF diagnosis during follow up (23(14.6%) vs 3(3.9%) p=0.009). CONCLUSION: This study confirms the association of advanced interatrial block and CHADS2-VASC>4 at admission with the diagnosis of AF during follow up in patients with ischemic stroke. This association could have important implications in patients with ischemic stroke who present advanced interatrial block and without previous history of AF.

Case report: From monkeypox pharyngitis to myopericarditis and atypical skin lesions.

Background: A global outbreak of the human monkeypox virus (HMPXV), first identified in May 2022, was declared a health emergency of international concern on 23 July 2022. Before the global outbreak, monkeypox cases were mostly confined to central and west African countries, where this virus is prevalent. Close contact, mainly sexual contact, is supposed to be the main route of transmission, and it is remarkable that the incidence is higher in men who have sexual relationships with other men. Case summary: A 40-year-old Caucasian man arrived at the emergency department complaining of oppressive epigastric pain extending to the chest after a diagnosis of pharyngitis, which was suspected to be caused by the human monkeypox virus. Based on the clinical symptoms, physical examination, serum cardiac biomarkers, and electrocardiographic findings, he was diagnosed with myopericarditis. The real-time PCR for human monkeypox in skin lesions, urine, plasma, and the oropharyngeal swab was positive. The peak of troponin I was 20.6 ng/ml, and the electrocardiogram showed an upward concavity in the ST segment in diffuse leads, which was in agreement with the previous diagnosis. The presence of edema, subepicardial, and myocardial late gadolinium enhancement, and increased values on T1 mapping in the cardiac MRI were in agreement with the diagnosis of myopericarditis. Antiviral treatment with tecovirimat was started with excellent tolerability. After 6 days, the patient recovered and was discharged. Discussion: To our knowledge, this is one of the first reported cases of myopericarditis due to human monkeypox infection, which was confirmed by a cardiac MRI following modified Lake Louise criteria. The short span between the onset of the mucocutaneous symptoms and the myocardial damage suggests a pathogenic association. Furthermore, the active viral replication in plasma samples and the negative results on real-time PCR for other viruses support this clinical association.

The Role of 2D and 3D Echo in Mitral Stenosis.

Mitral stenosis is an important cause of heart valve disease globally. Echocardiography is the main imaging modality used to diagnose and assess the severity and hemodynamic consequences of mitral stenosis as well as valve morphology. Transthoracic echocardiography (TTE) is sufficient for the management of most patients. The focus of this review is the role of current two-dimensional (2D) and three-dimensional (3D) echocardiographic imaging for the evaluation of mitral stenosis.

Safety and Efficacy of the Combination of Sacubitril/Valsartan and SGLT2i in HFrEF Patients (SECSI Registry).

ABSTRACT: Recent studies have proven benefit of SGLT2i drugs in patients with heart failure with reduced ejection fraction (HFrEF), but their safety when combined with angiotensin-neprilysin inhibitor (ARNI) has not been established. The Safety and Efficacy of the Combination of Sacubitril/Valsartan and SGLT2i in HFrEF Patients registry was conducted to address this issue. SECSI registry is a consecutive, observational, retrospective, multicentre study conducted in 3 Heart Failure Units in Spain. It included 144 HFrEF patients who were treated with ARNI and iSGLT2. Data were collected at baseline, month 2, and month 6. The primary endpoint was the estimated glomerular filtration rate (eGFR), after the initiation of ARNI and sodium-glucose cotransporter-2 inhibitors (SGLT2i). Secondary endpoints included potassium levels and functional class (New York Heart Association class). There were 3 prespecified subgroup analyses: Elderly patients (≥70 years), patients with chronic kidney disease (KDIGO classification G3), and the sequence of drug initiation. Mean age was 69.9 ± 10.1 years, and 110 (76.4%) were men. Left ventricular ejection fraction was 32 ± 7.8%, and most patients were symptomatic [123 (87.2%) New York Heart Association II/III/IV]. eGFR decreased at month 2 and this trend was maintained at month 6 [eGFR baseline 68.5 ± 17.3, month 2 62 ± 19.7 and month 6 64.7 ± 8.6 mL/min/1.73 m2 (P < 0.01 for both)]. In prespecified analysis, elder patients and those who simultaneously initiate both treatments showed the steeper decrease in eGFR. To conclude, co-administration of SGLT2i and ARNI in routine care in HFrEF patients produced a slight decrease in eGFR at 6 months of follow-up. This decrease was especially significant in elder patients and those who initiate both drugs simultaneously.

Cardiovascular Oncology: The Need for a Multidisciplinary Approach.

Improved cancer survivorship has led to an increase in cardiovascular (CV) complications in the oncologic population, mainly associated with therapeutic regimens. Hence, cardio-oncology has grown toward unifying the cancer care process in which the best prevention, early detection, treatment, and CV surveillance are offered to patients. This multidisciplinary approach allows us to optimize and agree upon clinical decisions to enhance clinical outcomes. Atrial fibrillation is one of the hot topics in the field because it is still challenging in cancer patients. The optimal antithrombotic therapy remains unclear. Nevertheless, evidence supports that specific recommendations are needed due to a hemorrhagic/thrombotic disbalance present within this subgroup of patients and a low rate of anticoagulation treatments compared with the general population. Further, cardiotoxicity management is currently transforming. Increasingly, early detection of subclinical alterations is raising awareness. When medical therapy is initiated early, fewer patients progress to ventricular dysfunction and the rate of patients completing cancer therapy gradually increases. New approaches are demonstrating better outcomes and these strategies will expectedly be established in clinical practice. Cardio-oncology enables us to find the best balance between cancer treatment and CV health protection. Nowadays, more and more physicians are being instructed in this discipline, which gradually exhibits a greater presence in conferences and scientific journals. However, given the need for physicians thoroughly trained in cardio-oncology, this subspecialty must be promoted further.

A suicide attempt on a left ventricular assist device patient during COVID-19 pandemic: can we only blame the virus? A case report.

BACKGROUND: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has emerged as a new threat, not only to Health Care systems but also to citizen's freedom of movement in many developed countries. CASE SUMMARY: We report a suicidal attempt in a destination therapy left ventricular assist device patient, potentially triggered by coronavirus disease 2019 (COVID-19) lockdown, highlighting the importance of regular and long-term psychological support for this vulnerable population. DISCUSSION: The psychological consequences of this pandemic, particularly in chronically ill patients, are yet to be defined.