Two-dimensional speckle-tracking echocardiography in left ventricular systolic function in patients with systemic lupus erythematosus.

OBJECTIVES: To investigate whether two-dimensional speckle-tracking echocardiography (2DSTE) can be considered a criterion for early left ventricular (LV) systolic impairment in patients with systemic lupus erythematosus (SLE) and to further explore the association with each other. METHODS: We included 38 patients with SLE and assessed the degree of disease activity according to the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) 2000 scoring criteria, together with 38 healthy controls who were matched by sex and age. Routine LV systolic function evaluation parameters were obtained by echocardiography as well as 2DSTE measurement of LV strain parameters to obtain global longitudinal strain (GLS) values, respectively. RESULTS: (I) On routine LV function parameters such as ejection fractions (EF) and left ventricular end-diastolic internal diameter (LVIDd), the SLE group and the control group did not reflect differences. In contrast, on the LV strain parameter obtained from 2DSTE measurements, the GLS values in all cardiac planes were lower in the SLE group than in the control group and showed statistically significant differences. (II) Correlation analysis showed that there was a correlation between SLEDAI and GLS, especially a meaningful correlation with GLS Avg and GLS A4C, with correlation coefficients of 0.35 and 0.47, respectively. CONCLUSIONS: The use of 2DSTE can detect early impaired LV systolic function in SLE patients, and GLS is progressively gaining attention as an indicator of subclinical myocardial injury and LV function in SLE patients. The correlation that exists between GLS and SLEDAI might contribute to a better assessment of cardiac involvement in SLE patients. Key Points • Cardiac involvement has become one of the major factors in the poor prognosis of SLE patients, which directly affects the mortality of SLE patients. Traditional echocardiography is difficult to detect early left ventricular function impairment, thus affecting clinicians' judgment and diagnosis. • 2DSTE can recognize subclinical myocardial injury in SLE patients at an early stage, and its derived strain parameters may be used as an indicator to evaluate myocardial involvement and reflect disease activity in SLE patients.

Cardiac biomarkers and left ventricular systolic function in former very preterm infants and term controls at preschool age.

Introduction: Due to improvements in perinatal care, survival rates of preterm infants have improved during the last decades. However, these infants remain at risk of developing cardiovascular sequelae later in life. This study aimed to investigate the cardiac biomarkers and left ventricular systolic function in former preterm infants in comparison with term controls at preschool age. Methods: The study included children aged 5-7 years old born below 32 weeks of gestational age. The control group consisted of same-age children born at term. Basic data of study participants were collected using questionnaires and follow-up databases. During the study visit, we recorded anthropometric data and blood pressure readings, determined high-sensitive cardiac troponin T (hs-cTnT) and N-terminal pro-B-type natriuretic peptide (NT-pro-BNP) concentrations, and calculated fractional shortening (FS) and left ventricular mass (LVM). Results: Term-born (n = 25; median gestational age, 40.1 weeks) compared with preterm-born infants (n = 80; median gestational age 29.6 weeks) showed no significant differences in the median concentration of hs-cTnT [median, 3.5 (IQR 3.5; 3.5) vs. 3.5 (3.5; 3.5) ng/L, p = 0.328] and the median concentration of NT-pro-BNP [median, 91.0 (IQR 40.8; 150.3) vs. 87.5 (50.1; 189.5) ng/L, p = 0.087]. FS and LVM/LVMI were not significantly different between the two groups. Conclusion: At preschool age, we observed no significant differences in cardiac biomarkers and left ventricular systolic function in preterm infants. Further studies are warranted to explore the potential of cardiac biomarkers as a prognostic tool for subclinical cardiac alterations after preterm birth.

Feasibility and prognostic value of tissue motion annular displacement in patients with heart transplantation.

BACKGROUND: Tissue motion of mitral annular displacement (TMAD) assessment has proved to be an effective method for several cardiovascular diseases including hypertrophic cardiomyopathy, heart failure, non-ST-elevation myocardial infarction, etc. However, there are no studies exploring the feasibility of TMAD in heart transplantation (HT) recipients, and the predictive value of this parameter for adverse outcomes in these patients remains unknown. Consequently, this study aimed to evaluate the feasibility of TMAD in the evaluation of left ventricular (LV) systolic function in clinically well adult HT patients, and further investigate the prognostic value of TMAD. METHODS: Echocardiography was performed in 155 adult HT patients and 49 healthy subjects. All the subjects were examined by conventional transthoracic two-dimensional echocardiography and two-dimensional speckle tracking echocardiography (2D-STE) with evaluation of the LV end-diastolic diameter, LV end-diastolic volume index, LV end-systolic volume index, interventricular septal thickness, left atrial diameter, mitral annular plane systolic excursion (MAPSE), LV ejection fraction (LVEF), TMAD and LV global longitudinal strain (LVGLS). The end point was defined as all-causes mortality or posttransplant related hospitalization during follow up. Cox proportional hazards regression was performed to evaluate the prognostic value of the parameters for predicting poor outcomes in HT patients. RESULTS: A significant positive correlation was found between the measurements of TMAD and LVGLS (r = .714, p < .001). TMAD obtained by 2D-STE had good reproducibility. The LVGLS and TMAD were significantly lower in HT group than in control group (both p < .001). In HT patients, compared with event free group, adverse outcome group displayed reduced TMAD and LVGLS, and elevated age (p < .001, < .001, = .017, respectively). Patients with higher TMAD (> 9.1 mm) had comparatively better survival when stratified by cutoff value (log-rank p < .001). LVGLS and TMAD were independently associated with adverse outcomes in multivariable analysis (both p < .001). CONCLUSION: Assessment of TMAD is effective for evaluating LV longitudinal systolic function and predicting adverse outcomes in clinically well adult HT patients.

Evaluation of Left Ventricular Function in Patients With Severe Aortic Stenosis Utilizing Automated Cardiac Motion Quantitation Techniques.

OBJECTIVE: The objective of this study is to explore the patterns of alteration in left ventricular systolic function among patients with severe aortic stenosis (SAS) through the application of automatic myocardial motion quantification (aCMQ) techniques. Furthermore, we seek to ascertain dependable quantitative markers for the assessment of impaired left ventricular function in patients with SAS and an ejection fraction (EF) ≥ 60%. METHODS: Seventy patients who underwent echocardiography and received a diagnosis of severe aortic stenosis (SAS) in the hospital from November 2021 to August 2022 were selected for the SAS group and categorized into three subgroups based on ejection fraction (EF)-SAS group with EF ≥ 60%, SAS group with EF ranging from 50% to 59%, and SAS group with EF < 50%. Concurrently, 30 healthy individuals were recruited at the hospital during the same timeframe to serve as the control group. Participants from both groups underwent standard transthoracic echocardiography to assess conventional echocardiographic parameters. Dynamic images were examined using automatic myocardial motion quantification (aCMQ) software to derive longitudinal peak strain (LPS) parameters, which were then subjected to statistical analysis. RESULTS: In comparison to the control group participants, the measurements of ascending aorta diameter (AoD), left atrium diameter (LAD), interventricular septal end diastolic thickness (IVSd), left ventricular posterior wall end diastolic thickness (LVPWd), peak systolic velocity (Vmax), and mean pressure gradient (MPG) were significantly higher in the SAS groups (p < 0.05). When compared to participants in the SAS group with an EF ≥ 60%, the values of IVSd, LVPWd, Vmax, and MPG in the SAS group with EF ranging from 50% to 59% were significantly elevated (p < 0.05). Similarly, left ventricular end-diastolic diameter (LVEDD), the ratio of early diastolic mitral inflow velocity to early diastolic mitral annular velocity (E/e'), and the ratio of early to late diastolic mitral inflow velocities (E/A) in the SAS group with EF < 50% were significantly elevated (p < 0.05). The absolute values of longitudinal peak strain (LPS) in the SAS groups were significantly lower in comparison to those in the control group (p < 0.05). Furthermore, all measurements of left ventricular global longitudinal systolic peak strain (GLPS) showed a positive correlation with MPG, a moderate negative correlation with aortic valve area index (AVAI), and a moderate positive correlation with E/A. CONCLUSIONS: Patients with SAS and an EF < 50% exhibited the most profound impairment in left ventricular myocardial function. Utilizing the aCMQ technique enables the precise and quantitative evaluation of the severity of impaired left ventricular systolic function in patients within the SAS group with an EF ≥ 60%.

Quantitative assessment of left ventricular myocardial work in patients with different types of atrial fibrillation by non-invasive pressure-strain loop technique.

OBJECTIVE: This study aimed to analyze myocardial work in patients with atrial fibrillation (AF) using a noninvasive pressure strain loop (PSL) technique to provide a basis for the quantitative assessment of left ventricular (LV) systolic function. METHODS: LV myocardial work of 107 AF patients (56 with paroxysmal atrial fibrillation and 51 with persistent atrial fibrillation) and 55 healthy individuals were assessed by the noninvasive PSL and then compared. RESULTS: Global longitudinal strain (GLS) in absolute values, global work index (GWI), global constructive work (GCW), and global work efficiency (GWE) were significantly lower in the AF group than control group, whereas peak strain dispersion (PSD) and global wasted work (GWW) were significantly higher (P < .05). Further subdivision according to the AF type revealed that, compared with the controls, GLS in absolute values and GWE decreased significantly; PSD and GWW increased significantly in the paroxysmal AF group (P < .05). Nevertheless, GWI and GCW were not significantly different between paroxysmal AF and control groups (P > .05). Compared to paroxysmal AF, persistent AF induced a further decrease in absolute GLS and GWE and a further increase in GWW (P < .05), but PSD did not increase further (P > .05). Multiple linear regression analysis showed that GWI and GCW were independently associated with systolic blood pressure. GWW was associated with types of AF and left atrial volume index (LAVI). GWE was correlated with age, types of AF, disease duration, and LAVI. Receiver operating characteristic curve analysis showed that the area under the curve predicting myocardial injury was higher for GWE and GWW than for GLS (area under the curve:  .880,  .846, and  .821, respectively). CONCLUSIONS: Non-invasive PSL can quantitatively assess LV systolic function in patients with different kinds of AF and detect early subclinical myocardial injury in patients with paroxysmal AF. GWE and GWW outperform GLS and LV ejection fraction when assessing myocardial injury. Systolic blood pressure, type of AF, LVAI, disease duration, and age may be associated with myocardial injury in patients with AF.

Early left ventricular systolic function is a more sensitive predictor of adverse events after heart transplant.

BACKGROUND: First-phase ejection fraction (EF1) is a novel measure of early changes in left ventricular systolic function. This study was to investigate the prognostic value of EF1 in heart transplant recipients. METHODS: Heart transplant recipients were prospectively recruited at the Union Hospital, Wuhan, China between January 2015 and December 2019. All patients underwent clinical examination, biochemistry measures [brain natriuretic peptide (BNP) and creatinine] and transthoracic echocardiography. The primary endpoint was a combined event of all-cause mortality and graft rejection. RESULTS: In 277 patients (aged 48.6 ± 12.5 years) followed for a median of 38.7 [26.8-45.0] months, there were 35 (12.6%) patients had adverse events including 20 deaths and 15 rejections. EF1 was negatively associated with BNP (ß = -0.220, p < 0.001) and was significantly lower in patients with events compared to those without. EF1 had the largest area under the curve in ROC analysis compared to other measures. An optimal cut-off value of 25.8% for EF1 had a sensitivity of 96.3% and a specificity of 97.1% for prediction of events. EF1 was the most powerful predictor of events with hazard ratio per 1% change in EF1: 0.628 (95%CI: 0.555-0.710, p < 0.001) after adjustment for left ventricular ejection fraction and global longitudinal strain. CONCLUSIONS: Early left ventricular systolic function as measured by EF1 is a powerful predictor of adverse outcomes after heart transplant. EF1 may be useful in risk stratification and management of heart transplant recipients.

Tissue-Tracking Mitral Annular Displacement in Neonates: A Novel Index of Left Ventricular Systolic Function.

OBJECTIVES: To assess the feasibility, accuracy, and reproducibility of tissue-tracking mitral annular displacement (TMAD) compared with other measures of left ventricular systolic function in healthy preterm and term neonates in the transitional period. METHODS: This was a prospective observational study. Two echocardiograms were performed at 24 and 48 hours of life. TMAD, shortening fraction (SF), ejection fraction (EF), s', and global longitudinal strain (GLS) were measured offline. Accuracy to detect impaired GLS was tested by ROC curve analysis. DeLong test was used to compare AUCs. Intra and interobserver reproducibility of the off-line analysis was calculated. RESULTS: Mean ± SD gestational age and weight were 34.2 ± 3.8 weeks and 2162 ± 833 g, respectively. TMAD was feasible in 168/180 scans (93%). At 24 hours the AUC (95% CI) of SF, EF, s', and TMAD (%) was 0.51 (0.36-0.67), 0.68 (0.54-0.82), 0.63 (0.49-0.77), and 0.89 (0.79-0.99) respectively. At 48 hours the AUC (95% CI) of SF, EF, s', and TMAD (%) was 0.64 (0.51-0.77), 0.59 (0.37-0.80), 0.70 (0.54-0.86), and 0.96 (0.91-1.00), respectively. The AUC of TMAD was superior to the AUC of SF, EF, s', at both timepoints (P < .02). Intraclass correlation coefficients (95% CI) of intra and interobserver reproducibility of TMAD were 0.97 (0.95-0.99) and 0.94 (0.88-0.97), respectively. CONCLUSION: TMAD showed improved accuracy and optimal reproducibility in neonates in the first 48 hours of life.

Cardiac Point-of-Care Ultrasound (P.O.C.U.S.) Utilization for Hospitalists in the Assessment of Patients with Cardiac Complaints: An Educational Overview.

The use of cardiac point-of-care ultrasound (P.O.C.U.S.) is underutilized in the field of internal medicine for the assessment of patients with cardiac complaints. Numerous studies in emergency medicine, anesthesia, and critical care have demonstrated the successful application of cardiac P.O.C.U.S. in resident and attending physicians with limited prior exposure. This article review overviews the practical implementation of cardiac P.O.C.U.S. for hospitalists by discussing proper technique and assessment for common pathology seen in the medical ward setting. We describe how to assess for left ventricular (LV) systolic function, right ventricular (RV) systolic function, suspected acute coronary syndrome (ACS), post-myocardial infarction (MI) complications, suspected pulmonary embolus, and assessment of intravascular volume status. In each section, we overview the pertinent literature to show how cardiac P.O.C.U.S. has been used to directly impact patient care.

Effect of remimazolam vs. propofol on hemodynamics during general anesthesia induction in elderly patients: Single-center, randomized controlled trial.

The current study aimed to compare the effects between remimazolam and propofol on hemodynamic stability during the induction of general anesthesia in elderly patients. We used propofol at a rate of 60 mg/(kg·h) in the propofol group (group P) or remimazolam at a rate of 6 mg/(kg·h) in the remimazolam group (group R) for the induction. A processed electroencephalogram was used to determine whether the induction was successful and when to stop the infusion of the study drug. We measured when patients entered the operating room (T 0), when the induction was successful (T 1), and when before (T 2) and 5 min after successful endotracheal intubation (T 3). We found that mean arterial pressure (MAP) was lower at T 1-3, compared with T 0 in both groups, but higher at T 2 in the group R, while ΔMAP T0-T2 and ΔMAP max were smaller in the group R (ΔMAP T0-T2: the difference between MAP at time point T 0 and T 2, ΔMAP max: the difference between MAP at time point T 0 and the lowest value from T 0 to T 3). Cardiac index and stroke volume index did not differ between groups, whereas systemic vascular resistance index was higher at T 1-3 in the group R. These findings show that remimazolam, compared with propofol, better maintains hemodynamic stability during the induction, which may be attributed to its ability to better maintain systemic vascular resistance levels.

Non-Invasive Risk Assessment and Prediction of Mortality in Patients Undergoing Coronary Artery Bypass Graft Surgery.

Objectives: Heart rate turbulence (HRT) and T-wave alternans (TWA), non-invasive markers of cardiac autonomic dysfunction, and ventricular repolarization abnormality, reportedly, predict the risk of cardiovascular death after myocardial infarction. We investigated whether pre-operative assessment of HRT and/or TWA could predict long-term mortality following coronary artery bypass graft (CABG) surgery. Methods: From May 2010 to December 2017, patients undergoing elective CABG and receiving 24 h ambulatory electrocardiogram monitoring 1 to 5 days prior to CABG surgery were prospectively enrolled. Pre-operative HRT and TWA were measured using a 24 h ambulatory electrocardiogram. The relative risk of cardiac or overall death was assessed according to abnormalities of HRT, TWA, or left ventricular ejection fraction (LV EF). Results: During the mean follow-up period of 4.6 ± 3.9 years, 40 adjudicated overall (5.9%/yr) and 5 cardiac deaths (0.9%/yr) occurred in 146 enrolled patients (64.9 ± 9.3 years; 108 males). Patients with abnormal HRT exhibited significantly higher relative risks of cardiac death (adjusted hazard ratio [HR] 24.9, 95% confidence interval [CI] 1.46-427) and all-cause death (adjusted HR 5.77, 95% CI 2.34-14.2) compared to those with normal HRT. Moreover, abnormal HRT plus abnormal TWA and LV EF < 50% was associated with a greater elevation in cardiac and overall mortality risk. The predictive role of abnormal HRT with/without abnormal TWA for all-cause death was likely more prominent in patients with mildly reduced (35 to 50%) or preserved (≥50%) LV EF. Abnormal HRT plus abnormal TWA and LV EF < 50% showed high negative predictive value in cardiac and overall mortality risk. Conclusions: Assessment of pre-operative HRT and/or TWA predicted mortality risk in patients undergoing elective CABG. Combined analysis of HRT, TWA, and LVEF enhanced the prognostic power. In particular, the predictive value of HRT was enhanced in patients with preserved or mid-range LV EF.

Study on the correlation between cardiac function indices measured by velocity vector imaging and disease severity in patients with Parkinson disease.

AIM: This study aimed to evaluate cardiac function, particularly left ventricular systolic function, in patients with Parkinson disease (PD) using velocity vector imaging (VVI), and to determine whether a correlation exists between left ventricular global systolic function and PD severity. METHODS: A case-control study design was used to select 56 PD patients and 30 healthy controls from January 2019 to December 2019. The characteristics of age, sex, BMI and course of disease were collected. The Hoehn-Yahr (H-Y) score was collected to record the grading of PD. The left ventricular systolic function of all patients was evaluated by variable vapor injection (VVI). The left ventricular systolic function was compared between the case group and the control group, and the correlation between cardiac dysfunction and the severity of PD symptoms was assessed using the modified H-Y scale. RESULTS: Compared with control group, left ventricular global systolic function18.22 (17.08, 19.12) vs 18.88 (18.12, 20.01) was lower in PD patients as indicated by left ventricular global longitudinal strain (GLS), and the difference was statistically significant (P = 0.039). Additionally, H-Y scores (r = -0.404) and PD duration(r = -0.323) were significantly correlated with reduced left ventricular ejection fraction (P < 0.01), GLS (P < 0.001), left ventricular global radial strain (GRS; P < 0.001), and left ventricular global circumferential strain (GCS; P < 0.001), along with their associated peak strain rates (GLSr, GRSr, and GCSr; P < 0.001). CONCLUSION: Subclinical left ventricular global systolic dysfunction in patients with PD can be detected using VVI, and reduced left ventricular systolic function correlates with the modified H-Y score and duration of the disease.

Asymptomatic people with well-controlled HIV do not have abnormal left ventricular global longitudinal strain.

Background: Previous studies have reported impairment in systolic and diastolic function in people with HIV (PWHIV). Our aim was to determine if echocardiographically measured left ventricular (LV) global longitudinal strain (GLS) is abnormal in asymptomatic PWHIV. Methods: A cross-sectional study of PWHIV (n = 98, 89% male, median age 53 years) and HIV-negative people (n = 50, median age 53 years) without known cardiovascular disease were recruited from a single centre. All participants completed a health/lifestyle questionnaire, provided a fasting blood sample, and underwent a comprehensive echocardiogram for assessment of diastolic and systolic LV function, including measurement of GLS. Results: All PWHIV were receiving antiretroviral therapy (ART) for a median of 12 years (IQR: 6.9, 22.4), the majority with good virological control (87% suppressed) and without immunological compromise (median CD4 598 cells/µl, IQR: 388, 841). Compared with controls of similar age and gender, there was no difference in GLS [mean GLS -20.3% (SD 2.5%) vs. -21.0% (SD 2.5%), p = 0.14] or left ventricular ejection fractions [65.3% (SD 6.3) vs. 64.8% (SD 4.8), p = 0.62]. Following adjustment for covariates (gender, heart rate, systolic and diastolic blood pressure, and fasting glucose), the difference in GLS remained non-significant. There were no differences in LV diastolic function between the groups. Exposure to at least one mitochondrially toxic ART drug (didanosine, stavudine, zidovudine, or zalcitabine) was not associated with impairment of LV systolic function. Conclusion: No clinically significant impairment of myocardial systolic function, as measured by LV GLS, was detected in this predominantly Caucasian male population of PWHIV on long-term ART, with no history of cardiovascular disease.

Association between resting myocardial work indices and stress myocardial perfusion in patients with angina and non-obstructive coronary artery disease.

Background: Myocardial work (MW) indices and longitudinal strain (LS) are sensitive markers of early left ventricular systolic dysfunction. Stress computed tomography myocardial perfusion imaging (CT-MPI) can assess early myocardial ischemia. The association between resting MW indices and stress myocardial perfusion remains unclear. This study compares resting MW indices with LS to assess stress myocardial perfusion in angina patients with non-obstructive coronary artery disease (CAD). Methods: Eighty-four patients who underwent resting echocardiography, coronary computed tomography angiography, and stress CT-MPI were reviewed. Seventeen myocardial segments were divided into three regions according to the epicardial coronary arteries. Global indices included global longitudinal strain (GLS), global work index (GWI), global constructive work (GCW), global wasted work (GWW), and global work efficiency (GWE). Regional indices included regional longitudinal strain (RLS), regional work index (RWI), and regional work efficiency (RWE). Reduced global perfusion was defined as an average stress myocardial blood flow (MBF) <116 mL/100 mL/min for the whole heart. Reduced regional perfusion was defined as an average stress MBF <116 mL/100 mL/min for the coronary territories. No patients demonstrated obstructions in the epicardial coronary arteries (stenosis diameter <50%). The MW indices and LS were compared. Receiver operating characteristic curves were constructed and logistic regression analyses were used to investigate the predictors of reduced myocardial perfusion. Results: Patients with reduced stress perfusion demonstrated reduced GLS, GWI, GCW, and GWE (P<0.05) and increased GWW (P<0.05). After adjustment for age and sex, GWE was still independently associated with reduced myocardial perfusion (odds ratio =0.386, 95% confidence interval: 0.214-0.697; P<0.05). Receiver operating characteristic curves reflected the good diagnostic ability of GWE and its superiority to GLS (area under the curve: 0.858 vs. 0.741). The optimal cutoff GWE value was 95% (sensitivity, 70%; specificity, 90%). Regions with lower stress perfusion showed lower RLS, RWI, and RWE (P<0.05). The optimal cutoff value of RWE for predicting reduced regional perfusion was 95%, with an area under the curve of 0.780, a sensitivity of 62%, and a specificity of 83%. Conclusions: Resting MW indices perform well in assessing global and regional stress myocardial perfusion in angina patients with non-obstructive CAD, and GWE is superior to GLS in the global evaluations.

Topographical Association Between Left Ventricular Strain and Brain Lesions in Patients With Acute Ischemic Stroke and Normal Cardiac Function.

Background Although it is well known that the disordered brain provokes cardiac autonomic dysfunction, the detailed location of brain lesions related to cardiac function warrants further investigation. We aimed to elucidate the brain lesions topographically associated with left ventricular (LV) systolic function measured by myocardial strain in patients with acute ischemic stroke without preexisting primary cardiac dysfunction by using support vector regression lesion-symptom mapping. Methods and Results Subjects were those with LV ejection fraction of 50% or more among patients with acute ischemic stroke registered in the Samsung Medical Center stroke registry between 2016 and 2017. To evaluate LV systolic performance and contractility, we measured LV ejection fraction and LV global and regional longitudinal strain using 2-dimensional speckle-tracking echocardiography. The association between stroke lesion location and cardiac strain was assessed using support vector regression lesion-symptom mapping. Of a total of 776 patients, 286 subjects (mean age of 67.0 years, 65.4% men) were finally enrolled in this study. The mean global longitudinal strain was -17.0±3.4%, and the mean LV ejection fraction was 64.7±5.7%. The support vector regression lesion-symptom mapping analysis revealed that the right insula and peri-insular regions and left parietal cortex were associated with impaired LV global longitudinal strain in patients with acute ischemic stroke. In addition, impaired regional longitudinal strain showed topographical associations with these regions. Conclusions This study suggests that brain lesions in the right insula and peri-insular regions and left parietal cortex are topographically associated with impaired LV strain in patients with acute ischemic stroke without preexisting cardiac dysfunction.

Long-Term Outcomes of Women With Peripartum Cardiomyopathy Having Subsequent Pregnancies.

BACKGROUND: Long-term maternal outcomes of subsequent pregnancies (SSPs) in patients with peripartum cardiomyopathy (PPCM) have not been analyzed. OBJECTIVES: The goal of this study was to evaluate the long-term survival of SSPs in women with PPCM. METHODS: We conducted a retrospective review of 137 PPCMs in the registry. The clinical and echocardiographic findings were compared between the recovery group (RG) and nonrecovery group (NRG), defined as left ventricular ejection fraction ≥50% and <50% after an index of pregnancy, respectively. RESULTS: Forty-five patients with SSPs were included with a mean age of 27.0 ± 6.1 years, 80% were of African American descent, and 75.6% from a low socioeconomic background. Thirty (66.7%) women were in the RG. Overall, SSPs were associated with a decrease in mean left ventricular ejection fraction from 45.1% ± 13.7% to 41.2% ± 14.5% (P = 0.009). At 5 years, adverse outcomes were significantly higher in the NRG compared with the RG (53.3% vs 20%; P = 0.04), driven by relapse PPCM (53.3% vs 20.0%; P = 0.03). Five-year all-cause mortality was 13.33% in the NRG compared with 3.33% in the RG (P = 0.25). At a median follow-up of 8 years, adverse outcomes and all-cause mortality rates were similar in the NRG and RG (53.3% vs 33.3% [P = 0.20] and 20% vs 20%, respectively). CONCLUSIONS: Subsequent pregnancies in women with PPCM are associated with adverse events. The normalization of left ventricular function does not guarantee a favorable outcome in the SSPs.

The Effectiveness of Eplerenone vs Spironolactone on Left Ventricular Systolic Function, Hospitalization and Cardiovascular Death in Patients With Chronic Heart Failure-HFrEF.

Background: Heart failure remains one of the most prevalent clinical syndromes associated with significant morbidity and mortality. According to current guidelines, the prescription of a MRA is recommended to reduce the risk of HF hospitalization and death in all patients with symptomatic heart failure and no contraindications for this therapy. Objective: The aim of our study was to determine the efficacy of eplerenone vs. spironolactone on left ventricular systolic function by measuring left ventricle ejection fraction (LVEF) in patients with chronic heart failure, especially their effect on preventing hospitalization, reducing mortality, and improving clinical status among patients with chronic HF. Methods: From June 2021 to June 2022, the study was a randomized, prospective clinical trial single blind study. A total of 142 patients of chronic heart failure with reduced ejection fraction were selected by random sampling. Each patient was randomly allocated into either of the two groups and was continued receiving treatment with either spironolactone (Spiron-HF group) or eplerenone (Epler-HF group). Patients in Epler-HF group were compared with an arm of the same size and matched by age and gender patients in Spiron-HF group for management of chronic HFrEF. Each patient was evaluated clinically, biochemically, and echocardiographically at the beginning of treatment (baseline) after 6 months and at the end of 12th month. Echocardiography was performed to find out change in left ventricular systolic function. Results: After 12 months of treatment, significant improvement of left ventricular ejection fraction was observed in eplerenone treated arm (37.9 ± 3.8 ± 4.6 in Spiron-HF group versus 40.1 ± 5.7 in Epler-HF group; P < 0.05). A significant reduction in left ventricular end-systolic volume (6.3 ± 2.5ml in Spiron-HF versus 17.8± 4.4ml in Epler-HF group; P < 0.05) and left ventricular systolic diameter volume (2.7 ± 0.5ml in Spiron-HF versus 6.7 ± 0.2ml in Epler-HF group; P < 0.05), occurred after 12 months of treatment. Left ventricular global longitudinal strain (LV GLS) was significantly improved in Epler-HF group compared with Spiron-HF group (0.6 ± 0.4 versus 3.4 ± 0.9; P < 0.05). There were no significant differences observed in reduction of left ventricular end-diastolic volume (2.2 ± 0.5 ml versus 4.7 ± 1.1ml; P =0.103) and left ventricular diastolic diameter (1.2 ± 0.6 versus 1.7 ± 0.3; P=0.082) in both arms. The effects of both MRA agents spironolactone and eplerenone on the primary composite outcome, each of the individual mortality and hospital admission outcomes are shown in Figure 1 and 2. Patients of the Epler-HF group showed statistically significant lower cardiovascular mortality (HR 0.53; 95% CI 0.34-0.82; p= 0.007) and all-cause mortality (HR 0.64; 95% CI 0.44-0.93; p= 0.022) than patients of the Spiron-HF group. The statistical analysis did not show a statistically significant difference between Epler -HF and Spiron-HF study groups regarding the risk of the primary composite outcome; cardiovascular death or hospitalization due to HF (Hazard Ratio (HR) eplerenone vs. spironolactone = 0.95; 95% Confidence Interval (CI) 0.73- 1.27; p= 0.675). Conclusion: Our study has demonstrated favorable effects of eplerenone on cardiac remodeling parameters and reduction of cardiovascular mortality and all-cause mortality compared with spironolactone in the treatment of HFrEF. The ability of eplerenone to effectively block the mineralocorticoid receptor while minimizing side effects and a significant reduction in the risk of hospitalization and cardiovascular death confirms its key role in the treatment of patients with chronic HFrEF.

Left bundle branch area pacing prevents pacing induced cardiomyopathy in long-term observation.

BACKGROUND: Left bundle branch area pacing (LBBAP) is one of the methods to deliver conduction system pacing which potentially avoids the negative impact of conventional right ventricular pacing. OBJECTIVE: To assess echocardiographic outcomes in a long-term observation in patients with LBBAP implemented for bradyarrhythmia indications. METHODS AND RESULTS: A total of 151 patients with symptomatic bradycardia and LBBAP pacemaker implanted, were prospectively included in the study. Subjects with left bundle branch block and CRT indications (n = 29), ventricular pacing burden <40% (n = 11), and loss of LBBAP (n = 10) were excluded from further analysis. At baseline and the last follow-up visit, echocardiography with global longitudinal strain (GLS) assessment, 12-lead ECG, pacemaker interrogation, and blood level of NT-proBNP were performed. The median follow-up period was 23 months (15.5-28). None of the analyzed patients fulfilled the criteria for pacing induced cardiomyopathy (PICM). Improvement in left ventricular ejection fraction (LVEF) and GLS was observed in patients with LVEF <50% at baseline (n = 39): 41.4 ± 9.2% versus 45.6 ± 9.9%, and 12.9 ± 3.6% versus 15.5 ± 3.7%, respectively. In the subgroup with preserved EF (n = 62), LVEF and GLS remained stable at follow-up: 59.3 ± 5.5% versus 60 ± 5.5%, and 19 ± 3.9% versus 19.4 ± 3.8%, respectively. CONCLUSION: LBBAP prevents PICM in patients with preserved LVEF and improves left ventricle function in subjects with depressed LVEF. LBBAP might be the preferred pacing modality for bradyarrhythmia indications.

Relationship between coronary blood flow and improvement of cardiac function after catheter ablation for persistent atrial fibrillation.

BACKGROUND: The relationship between coronary blood flow during atrial fibrillation (AF) and improvement of cardiac function after catheter ablation (CA) for persistent AF (PeAF) is not prominent; this study was conducted to evaluate this relationship. METHODS: This was a retrospective case-control study. Eighty-five patients with PeAF (resting heart rate < 100 bpm) and heart failure with reduced ejection fraction (left ventricular ejection fraction (LVEF) < 40%) who had undergone coronary angiography within 1 week before CA were included. All patients could maintain a sinus rhythm for > 6 months after CA. The primary outcome was improvement of cardiac function with an LVEF cutoff value of > 50% during sinus rhythm 6 months after CA. RESULTS: In the LVEF improvement group (N = 57), patients were younger, with a higher baseline diastolic blood pressure and lower baseline brain natriuretic peptide level than the no LVEF improvement group (N = 28). Heart rate at baseline and 6 months after CA and AF duration did not differ between the two groups. Thrombolysis in myocardial infarction frame count parameters was significantly higher in the LVEF improvement (P < 0.001) than in the no LVEF improvement group. Multivariate logistic regression analysis revealed mean thrombolysis in myocardial infarction frame count as an independent factor for LVEF improvement (odds ratio, 1.72 (95% confidence interval 1.17-2.54); P = 0.006). CONCLUSION: Coronary blood flow in patients with PeAF is strongly associated with improved left ventricular systolic function after the restoration of sinus rhythm by CA for PeAF and heart failure with reduced ejection fraction.

Atrial natriuretic peptide stimulates autophagy/mitophagy and improves mitochondrial function in chronic heart failure.

Mitochondrial dysfunction, causing increased reactive oxygen species (ROS) production, is a molecular feature of heart failure (HF). A defective antioxidant response and mitophagic flux were reported in circulating leucocytes of patients with chronic HF and reduced ejection fraction (HFrEF). Atrial natriuretic peptide (ANP) exerts many cardiac beneficial effects, including the ability to protect cardiomyocytes by promoting autophagy. We tested the impact of ANP on autophagy/mitophagy, altered mitochondrial structure and function and increased oxidative stress in HFrEF patients by both ex vivo and in vivo approaches. The ex vivo study included thirteen HFrEF patients whose peripheral blood mononuclear cells (PBMCs) were isolated and treated with αANP (10-11 M) for 4 h. The in vivo study included six HFrEF patients who received sacubitril/valsartan for two months. PBMCs were characterized before and after treatment. Both approaches analyzed mitochondrial structure and functionality. We found that levels of αANP increased upon sacubitril/valsartan, whereas levels of NT-proBNP decreased. Both the ex vivo direct exposure to αANP and the higher αANP level upon in vivo treatment with sacubitril/valsartan caused: (i) improvement of mitochondrial membrane potential; (ii) stimulation of the autophagic process; (iii) significant reduction of mitochondrial mass-index of mitophagy stimulation-and upregulation of mitophagy-related genes; (iv) reduction of mitochondrial damage with increased inner mitochondrial membrane (IMM)/outer mitochondrial membrane (OMM) index and reduced ROS generation. Herein we demonstrate that αANP stimulates both autophagy and mitophagy responses, counteracts mitochondrial dysfunction, and damages ultimately reducing mitochondrial oxidative stress generation in PBMCs from chronic HF patients. These properties were confirmed upon sacubitril/valsartan administration, a pivotal drug in HFrEF treatment.