Atherosclerotic Plaque Erosion: Mechanisms, Clinical Implications, and Potential Therapeutic Strategies-A Review.

ABSTRACT: Atherosclerosis is an insidious and progressive inflammatory disease characterized by the formation of lipid-laden plaques within the intima of arterial walls with potentially devastating consequences. While rupture of vulnerable plaques has been extensively studied, a distinct mechanism known as plaque erosion (PE) has gained recognition and attention in recent years. PE, characterized by the loss of endothelial cell lining in the presence of intact fibrous cap, contributes to a significant and growing proportion of acute coronary events. However, despite a heterogeneous substrate underlying coronary thrombosis, treatment remains identical. This article provides an overview of atherosclerotic PE characteristics and its underlying mechanisms, highlights its clinical implications, and discusses potential therapeutic strategies.

Nonagenarians admission and prognosis in a tertiary center intensive coronary care unit - a prospective study.

BACKGROUND: With increasing life expectancy, the prevalence of nonagenarians with cardiovascular disease is steadily growing. However, this population is underrepresented in randomized trials and thus poorly defined, with little quality evidence to support and guide optimal management. The aim of the present study was to evaluate the clinical management, therapeutic approach, and outcomes of nonagenarians admitted to a tertiary care center intensive coronary care unit (ICCU). METHODS: We prospectively collected all patients admitted to a tertiary care center ICCU between July 2019 - July 2022 and compared nonagenarians to all other patients. The primary outcome was in-hospital mortality. RESULTS: A total of 3807 patients were included in the study. Of them 178 (4.7%) were nonagenarians and 93 (52%) females. Each year the prevalence of nonagenarians has increased from 4.0% to 2019, to 4.2% in 2020, 4.6% in 2021 and 5.3% in 2022. Admission causes differed between groups, including a lower rate of acute coronary syndromes (27% vs. 48.6%, p < 0.001) and a higher rate of septic shock (4.5% vs. 1.2%, p < 0.001) in nonagenarians. Nonagenarians had more comorbidities, such as hypertension, renal failure, and atrial fibrillation (82% vs. 59.6%, 23% vs. 12.9%, 30.3% vs. 14.4% p < 0.001, respectively). Coronary intervention was the main treatment approach, although an invasive strategy was less frequent in nonagenarians in comparison to younger subjects. In-hospital mortality rate was 2-fold higher in the nonagenarians (5.6% vs. 2.5%, p = 0.025). CONCLUSION: With increasing life expectancy, the prevalence of nonagenarians in ICCU's is expected to increase. Although nonagenarian patients had more comorbidities and higher in-hospital mortality, they generally have good outcomes after admission to the ICCU. Hence, further studies to create evidence-based practices and to support and guide optimal management in these patients are warranted.

Peripheral Arterial Disease in Patients With Acute Coronary Syndrome: Results From a Large Real-World Registry.

BACKGROUND: Limited data exist regarding the significance of peripheral arterial disease (PAD) in patients with acute coronary syndrome (ACS). METHODS: We evaluated 16,922 consecutive ACS patients who were prospectively included in a national ACS registry. The co-primary endpoint included 30 days major adverse cardiovascular event (MACE) (re-infarction, stroke, and/or cardiovascular death) and 1-year mortality. RESULTS: PAD patients were older (70±11 vs 63±13; p<0.01), male predominance (80% vs 77%; p=0.01), and more likely to sustain prior cardiovascular events. PAD patients were less likely to undergo coronary angiography (69% vs 83%; p<0.001) and revascularisation (80% vs 86%; p<0.001). Patients with PAD were more likely to sustain 30-day MACE (22% vs 14%; p<0.001) and mortality (10% vs 4.4%; p<0.001), as well as re-hospitalisation (23% vs 19%; p=0.001). After adjusting for potential confounders, PAD remained an independent predictor of 30-day MACE (odds ratio [OR], 1.6 [95% confidence interval (CI), 1.24-2.06]). Patients with compared to those without PAD had 2.5 times higher 1-year mortality rate (22% vs 9%; p<0.001). Co-existence of PAD remained an independent predictor of 1-year mortality after adjustment for potential confounders by multivariable regression analysis (OR, 1.62; 95% CI, 1.4-1.9). PAD was associated with a significant higher 1-year mortality rate across numerous sub-groups of patients including type of myocardial infarction (ST-elevation myocardial infarction vs non-ST-elevation myocardial infarction), and whether the patient underwent revascularisation. CONCLUSIONS: Acute coronary syndrome with concomitant PAD represents a high-risk subgroup that warrants special attention and a more tailored approach.

Diabetes induces remodeling of the left atrial appendage independently of atrial fibrillation in a rodent model of type-2 diabetes.

BACKGROUND: Diabetic patients have an increased predisposition to thromboembolic events, in most cases originating from thrombi in the left atrial appendage (LAA). Remodeling of the LAA, which predisposes to thrombi formation, has been previously described in diabetic patients with atrial fibrillation, but whether remodeling of the LAA occurs in diabetics also in the absence of atrial fibrillation is unknown. To investigate the contribution of diabetes, as opposed to atrial fibrillation, to remodeling of the LAA, we went from humans to the animal model. METHODS: We studied by echocardiography the structure and function of the heart over multiple time points during the evolution of diabetes in the Cohen diabetic sensitive rat (CDs/y) provided diabetogenic diet over a period of 4 months; CDs/y provided regular diet and the Cohen diabetic resistant (CDr/y), which do not develop diabetes, served as controls. All animals were in sinus rhythm throughout the study period. RESULTS: Compared to controls, CDs/y developed during the evolution of diabetes a greater heart mass, larger left atrial diameter, wider LAA orifice, increased LAA depth, greater end-diastolic and end-systolic diameter, and lower E/A ratio-all indicative of remodeling of the LAA and left atrium (LA), as well as the development of left ventricular diastolic dysfunction. To investigate the pathophysiology involved, we studied the histology of the hearts at the end of the study. We found in diabetic CDs/y, but not in any of the other groups, abundance of glycogen granules in the atrial appendages , atria  and ventricles, which may be of significance as glycogen granules have previously been associated with cell and organ dysfunction in the diabetic heart. CONCLUSIONS: We conclude that our rodent model of diabetes, which was in sinus rhythm, reproduced structural and functional alterations previously observed in hearts of human diabetics with atrial fibrillation. Remodeling of the LAA and of the LA in our model was unrelated to atrial fibrillation and associated with accumulation of glycogen granules. We suggest that myocardial accumulation of glycogen granules is related to the development of diabetes and may play a pathophysiological role in remodeling of the LAA and LA, which predisposes to atrial fibrillation, thromboembolic events and left ventricular diastolic dysfunction in the diabetic heart.

Impact in total ischemic time and ST-segment elevation myocardial infarction admissions during COVID-19.

BACKGROUND: Despite the COVID-19 pandemic, cardiovascular disease is still the main cause of death in developed countries. Of these deaths, acute coronary syndromes (ACS) account for a substantial percentage of deaths. Improvement in ACS outcomes, are achieved by reducing the time from symptom onset until reperfusion or total ischemic time (TIT). Nevertheless, due to the overwhelming reality at the beginning of the pandemic, acute coronary syndrome (ACS) care may have been compromised. OBJECTIVES: We evaluated delays in TIT based on the date and timing of admissions in patients with STEMI, by a timeline follow-up form, before and during the current COVID-19 pandemic. METHODS: Between July 2018 and June 2020, two hundred and twelve patients diagnosed with ST-segment elevation myocardial infarction (STEMI) were admitted to our medical center. Upon presentation, cases were assigned a timeline report sheet and each time interval, from onset of symptoms to the catheterization lab, was documented. The information was later evaluated to study potential excessive delays throughout ACS management. RESULTS: Our data evidenced that during the COVID-19 pandemic ACS admissions were reduced by 34.54%, in addition to several in-hospital delays in patient's ACS management including delays in door-to-ECG time (9.43 ± 18.21 vs. 18.41 ± 28.34, p = 0.029), ECG-to-balloon (58.25 ± 22.59 vs. 74.39 ± 50.30, p = 0.004) and door-to-balloon time (57.41 ± 27.52 vs. 69.31 ± 54.14, p = 0.04). CONCLUSIONS: During the pandemic a reduction in ACS admissions occurred in our hospital that accompanied with longer in-hospital TIT due to additional tests, triage, protocols to protect and prevent infection within hospital staff, and maintenance of adequate standards of care. However, door-to-balloon time was maintained under 90 min.

Standards on Digital Echocardiography: An Israel Heart Society Position Paper Presented by the Israel Working Group on Echocardiography.

BACKGROUND: The output settings of echocardiographic systems should be set to the full (original) frame rate and lossless compression (e.g., run-length encoding) in order to transmit echocardiographic videos so that they retain their original quality. In addition, monitors and display cards of echocardiography systems and workstations should be able to support an adaptive refresh rate for displaying video at an arbitrary frame rate, including a high frame rate (90+ fps) without dropping frames and preserving the original frame duration. Currently, the only available option for echocardiography monitors is 144-165 Hz (or higher) based on adaptive frame rate G-Sync or FreeSync technology monitors. These monitors should be accompanied by compatible display cards. Echocardiography systems and workstation video playback software should support G-Sync or FreeSync adaptive frame rate technology to display echocardiography videos at their original frame rates without the effects of jitter and frame drops. Echocardiography systems should support an online display of the videos on the workstations during acquisition with the original quality. The requirements for web-based workstations are the same as for desktops workstations. Hospital digital networks should provide transmission and long-term archiving of the echocardiographic videos in their original acquisition quality.

Safety of nifedipine in threatened preterm labor: Investigation by three-dimensional echocardiography.

OBJECTIVE: To evaluate atrial and ventricular parameters using real time three-dimensional transthoracic echocardiography (RT3DTTE) in women treated with nifedipine in the early third trimester (III-T) of pregnancy. METHODS: A prospective single-subject design study in a university-affiliated hospital, where each participant served as her own control. We studied 25 pregnant women at a gestational age of 25-33 weeks with TPTL prior to vs 48 hours postnifedipine treatment. Two-dimensional transthoracic echocardiography (2DTTE) and RT3DTTE were used to study 3D left atrial (LA) volumes and indexes, emptying fraction, left ventricular and LA cavities, and total vascular resistance (TVR). RESULTS: Two-dimensional transthoracic echocardiography showed a significant increase in LA area (from 15.2 ± 2.62 to 16.16 ± 2.21 mm2 , P = .02) before vs after nifedipine; RT3DTTE showed a significant change in LA end-diastolic volume index (from 23.7 ± 4.2 to 26.75 ± 3.8 mL/m2 , P = .008). LA end-systolic volume and index were not significantly different before vs after nifedipine (from 24.56 ± 8 to 25.3 ± 5.5 mL, from 13.6 ± 5.3 to 14.8 ± 3.4 mL/m2 ); P > .05, respectively. E/a ratio, E-tdi, and E/E-tdi did not change significantly ([from 2.54 ± 4.46 to 2.54 ± 4.1], [from 11.9 ± 1.9 to 11.9 ± 2], [from 7.8 ± 1.4 to 7.6 ± 1.1], respectively, P > .05). Tricuspid annular plane systolic excursion (TAPSE) did not change significantly from 23.77 ± 4.2 to 23.9 ± 3.3, P = .1. There was a significant decrease in pulmonary pressure (from 25.4 ± 4.2 to 23 ± 2.5 mm Hg, P = .02), in mean arterial pressure (from 80 ± 4 to 76 ± 3 mm Hg, P < .001) and in TVR (from 1160 ± 260 to 1050 ± 206 dyne s/cm-5 , P = .04). CONCLUSIONS: According to RT3DTTE measurements, in pregnant women treated with nifedipine for tocolysis, there were no detrimental cardiovascular effects detected 48 hours postnifedipine treatment. RT3DTTE could show accurately the compensatory response of the left heart to the cardiovascular changes induced by treatment with nifedipine.

Safety, efficacy, and clinical applicability of pulmonary vein isolation with circular multi-electrode ablation systems: PVAC® vs. nMARQ™ for atrial fibrillation ablation.

AIMS: We compare our experience with available circular multi-electrode catheters for atrial fibrillation (AF) ablation: PVAC(®), a phased radiofrequency system, and nMARQ™, an irrigated tip-CARTO-based technology. METHODS AND RESULTS: Prospective observational study of 175 consecutive patients with follow-up duration of at least 5 months who underwent pulmonary vein isolation (PVI) for symptomatic AF using PVAC(®) (n = 93, age 61.4 ± 9.8 years; 60% male, 13% persistent AF) vs. nMARQ™ (n = 82, age 63.2 ± 10.6 years; 67% male, 24% persistent AF). Procedure and radiation times were 94 ± 27 and 33 ± 13 min for PVAC(®) and 81 ± 18 and 30 ± 8.5 for nMARQ™ (P = 0.0008 and P = 0.18), respectively. The number of applications and the total burning time (min) were 20 ± 7 and 19 ± 6.7 for PVAC(®) and 16 ± 5.6 and 11 ± 4 for nMARQ™ (P < 0.0001 for both), respectively. In two nMARQ™ patients with small atria and pulmonary veins (PVs) and in two PVAC(®) patients with large PVs, the procedure failed; switching to the alternative technology was successful. Acute success rate was 97% for PVAC(®) and 95% for nMARQ™. There was one tamponade in nMARQ™ group and non-significant different minor complications for both techniques. One-year freedom from AF was 79 and 80.7% with PVAC(®) vs. nMARQ™, after one PVI, and 88 vs. 87.7% after two PVIs. CONCLUSION: Both technologies have short procedure and fluoroscopy times, comparable complication rates, and comparable acute and 1-year success rates. The number of applications and total procedure and burning times were shorter with nMARQ™. nMARQ™ was more suitable for larger atria and PVs. Thus, a patient-based pre-ablation anatomy definition is probably warranted for appropriate selection of technology type.

Rotational method simplifies 3-dimensional measurement of left atrial appendage dimensions during transesophageal echocardiography.

BACKGROUND: Not all echo laboratories have the capability of measuring direct online 3D images, but do have the capability of turning 3D images into 2D ones "online" for bedside measurements. Thus, we hypothesized that a simple and rapid rotation of the sagittal view (green box, x-plane) that shows all needed left atrial appendage (LAA) number of lobes, orifice area, maximal and minimal diameters and depth parameters on the 3D transesophageal echocardiography (3DTEE) image and LAA measurements after turning the images into 2D (Rotational 3DTEE/"Yosefy Rotation") is as accurate as the direct measurement on real-time-3D image (RT3DTEE). METHODS: We prospectively studied 41 consecutive patients who underwent a routine TEE exam, using QLAB 10 Application on EPIQ7 and IE33 3D-Echo machine (BORTHEL Phillips) between 01/2013 and 12/2015. All patients underwent 64-slice CT before pulmonary vein isolation or for workup of pulmonary embolism. LAA measurements were compared between RT3DTEE and Rotational 3DTEE versus CT. RESULTS: Rotational 3DTEE measurements of LAA were not statistically different from RT3DTEE and from CT regarding: number of lobes (1.6 ± 0.7, 1.6 ± 0.6, and 1.4 ± 0.6, respectively, p = NS for all); internal area of orifice (3.1 ± 0.6, 3.0 ± 0.7, and 3.3 ± 1.5 cm(2), respectively, p = NS for all); maximal LAA diameter (24.8 ± 4.5, 24.6 ± 5.0, and 24.9 ± 5.8 mm, respectively, p = NS for all); minimal LAA diameter (16.4 ± 3.4, 16.7 ± 3.3, and 17.0 ± 4.4 mm, respectively, p = NS for all), and LAA depth (20.0 ± 2.1, 19.8 ± 2.2, and 21.7 ± 6.9 mm, respectively, p = NS for all). CONCLUSION: Rotational 3DTEE method for assessing LAA is a simple, rapid and feasible method that has accuracy similar to that of RT3DTEE and CT. Thus, rotational 3DTEE ("Yosefy rotation") may facilitate LAA closure procedure by choosing the appropriate device size.

A New Method for Direct Three-Dimensional Measurement of Left Atrial Appendage Dimensions during Transesophageal Echocardiography.

AIMS: Currently, two-dimensional transesophageal echocardiography (2DTEE) at a cut-plane angulation of 135° is the recommended method to size maximal left atrial appendage (LAA) orifice diameter before introducing a percutaneous LAA closure device. We compared real time three-dimensional TEE (RT3DTEE) and 2DTEE for measuring LAA dimensions versus computed tomography (CT) as gold standard. METHODS AND RESULTS: We prospectively studied 30 consecutive patients who underwent a routine TEE examination, using QLAB 10.0 Application on EPIQ7 iE33 3D echo machine between December 2012 and December 2013. All patients underwent 64-slice CT before pulmonary vein isolation or for workup of pulmonary embolism. LAA measurements were compared between 135 2DTEE and RT3DTEE. Results were compared with CT measurements. Using RT3DTEE, larger LAA diameters were measured versus 2DTEE (23.5 ± 3.9 vs. 24.5 ± 4.7 mm). In seven patients (23.3%), the measurements in 135° 2DTEE were smaller than the cut-plane angulation with maximal orifice diameter. RT3DTEE measurements of LAA were not different from CT regarding number of lobes, area of orifice, and maximal diameter. LAA volume could not be measured directly using RT3DTEE. No difference was found between LAA depth using RT3DTEE (19.5 ± 2.3 mm) vs. CT (19.6 ± 2.3, P = NS) and 2DTEE (19.4 ± 2.2 mm) vs. CT (P = NS). However, RT3DTEE (24.5 ± 4.7 mm) vs. CT (24.6 ± 5, P = NS) was more accurate in measuring maximal LAA diameter compared to 2DTEE (23.5 ± 3.9 mm) vs. CT (P < 0.01). CONCLUSION: RT3DTEE method is more accurate than 2DTEE for assessment of maximal LAA orifice diameter. Bedsides, RT3DTEE LAA measurements are not statistically different from CT. Thus, RT3DTEE may facilitate LAA closure procedure by choosing the appropriate device size.

[THE IMPACT OF A COMMUNITY INTERVENTION PROGRAM IN ISRAELI WORKSITES TO REDUCE THE RISK OF CARDIOVASCULAR DISEASES].

INTRODUCTION: Atherosclerosis is the main cause of cardiovascular (CV) morbidity and mortality in the western world. Detection and treatment of risk factors (such as hypertension, dyslipidemia and diabetes mellitus) reduce CV events. We have shown cost utility in reducing these CV risk factors in community clinics and community centers. AIMS: In this paper we focused on community workplaces. METHODS: We included 1011 workers in 15 worksites in the study. All workers were analyzed for CV risk factors and included in 6 months of intervention in their worksite in order to reduce the burden of CV risk factors. RESULTS: Significant reduction was noted in the percentage of high risk patients from 43.7% to 27.8% to 24.7% after 3 and 6 months respectively (p<0.05), in the percentage of workers with high weight circumference, high blood pressure, smokers, and in high body mass index (>30g/m2 ). CONCLUSIONS: Interventions in community workplaces can improve the CV risk factors profile and thus should be implemented as broadly as possible.

Late repair of ischemic mitral regurgitation does not prevent left ventricular remodeling: importance of timing for beneficial repair.

BACKGROUND: Ischemic mitral regurgitation (MR) is a frequent complication of myocardial infarction associated with left ventricular (LV) dilatation and dysfunction, which doubles mortality. At the molecular level, moderate ischemic MR is characterized by a biphasic response, with initial compensatory rise in prohypertrophic and antiapoptotic signals, followed by their exhaustion. We have shown that early MR repair 30 days after myocardial infarction is associated with LV reverse remodeling. It is not known whether MR repair performed after the exhaustion of compensatory mechanisms is also beneficial. We hypothesized that late repair will not result in LV reverse remodeling. METHODS AND RESULTS: Twelve sheep underwent distal left anterior descending coronary artery ligation to create apical myocardial infarction and implantation of an LV-to-left atrium shunt to create standardized moderate volume overload. At 90 days, animals were randomized to shunt closure (late repair) versus sham (no repair). LV remodeling was assessed by 3-dimensional echocardiography, dP/dt, preload-recruitable stroke work, and myocardial biopsies. At 90 days, animals had moderate volume overload, LV dilatation, and reduced ejection fraction (all P<0.01 versus baseline, P=NS between groups). Shunt closure at 90 days corrected the volume overload (regurgitant fraction 6 ± 5% versus 27 ± 16% for late repair versus sham, P<0.01) but was not associated with changes in LV volumes (end-diastolic volume 106 ± 15 versus 110 ± 22 mL; end-systolic volume 35 ± 6 versus 36 ± 6 mL) or increases in preload-recruitable stroke work (41 ± 7 versus 39 ± 13 mL mm Hg) or dP/dt (803 ± 210 versus 732 ± 194 mm Hg/s) at 135 days (all P=NS). Activated Akt, central in the hypertrophic process, and signal transducer and activator of transcription 3 (STAT3), a critical node in the hypertrophic stimulus by cytokines, were equally depressed in both groups. CONCLUSIONS: Late correction of moderate volume overload after myocardial infarction did not improve LV volume or contractility. Upregulation of prohypertrophic intracellular pathways was not observed. This contrasts with previously reported study in which early repair (30 days) reversed LV remodeling. This suggests a window of opportunity to repair ischemic MR after which no beneficial effect on LV is observed, despite successful repair.

Safety and Outcomes of Peripherally Administered Vasopressor Infusion in Patients Admitted with Shock to an Intensive Cardiac Care Unit-A Single-Center Prospective Study.

BACKGROUND: Vasopressors are frequently utilized for blood pressure stabilization in patients with cardiogenic shock (CS), although with a questionable benefit. Obtaining central venous access is time consuming and may be associated with serious complications. Hence, we thought to evaluate whether the administration of vasopressors through a peripheral venous catheter (PVC) is a safe and effective alternative for the management of patients with CS presenting to the intensive cardiovascular care unit (ICCU). METHODS: A prospective single-center study was conducted to compare the safety and outcomes of vasopressors administered via a PVC vs. a central venous catheter (CVC) in patients presenting with CS over a 12-month period. RESULTS: A total of 1100 patients were included; of them, 139 (12.6%) required a vasopressor treatment due to shock, with 108 (78%) treated via a PVC and 31 (22%) treated via a CVC according to the discretion of the treating physician. The duration of the vasopressor administration was shorter in the PVC group compared with the CVC group (2.5 days vs. 4.2 days, respectively, p < 0.05). Phlebitis and the extravasation of vasopressors occurred at similar rates in the PVC and CVC groups (5.7% vs. 3.3%, respectively, p = 0.33; 0.9% vs. 3.3%, respectively, p = 0.17). Nevertheless, the bleeding rate was higher in the CVC group compared with the PVC group (3% vs. 0%, p = 0.03). CONCLUSIONS: The administration of vasopressor infusions via PVC for the management of patients with CS is feasible and safe in patients with cardiogenic shock. Further studies are needed to establish this method of treatment.

Mitral regurgitation after anteroapical myocardial infarction: new mechanistic insights.

BACKGROUND: Mitral regurgitation (MR) generally accompanies inferobasal myocardial infarction (MI), with leaflet tethering by displaced papillary muscles. Mitral regurgitation is also reported with anteroapical MI without global dilatation or inferior wall motion abnormalities. We hypothesized that anteroapical MI extending to the inferior apex displaces the papillary muscles, tethering the mitral leaflets to cause MR. METHODS AND RESULTS: In the retrospective part of the study, consecutive anteroapical MI patients were studied. Moderate-severe MR occurred in 9% of 234 patients with only anteroapical MI versus 17% of 242 with inferoapical extension (P<0.001). Ejection fraction was only mildly different (41 ± 4% versus 46 ± 5%; P<0.01). In the human mechanistic portion of the study, 60 anteroapical MI patients (20 with only 2 apical segments involved and 40 with involvement of all 4 apical segments; 20 with MR and 20 without MR) were compared with 20 normal controls. Those with MR (≥ moderate) had higher systolic papillary muscle-to-annulus tethering length (P < 0.01). Mitral regurgitation grade correlated most strongly with tethering length (r = 0.70) and its diminished systolic shortening (r = -0.65). In the animal study, 9 sheep with left anterior descending coronary artery ligation were analyzed. Four sheep that developed MR had inferoapical MI extension with tethering length increasing over 1.5 months (2.1 ± 0.4 to 2.9 ± 0.4 cm, P < 0.001) versus no significant increase in 5 sheep without MR (2.0 ± 0.4 to 2.1 ± 0.3 cm, P not statistically significant). In MR sheep, the normal decrease in tethering length from diastole to systole was eliminated (P < 0.01). CONCLUSIONS: Anteroapical MI with inferoapical extension can mechanically displace papillary muscles, causing MR despite the absence of basal and midinferior wall motion abnormalities. This suggests the possibility of repositioning treatments for this condition.

Left atrial function during pregnancy: a three-dimensional echocardiographic study.

BACKGROUND: Alteration of diastolic function is considered a sensitive means for detecting changes in the normal cardiac adaptation to pregnancy. Our aim was to evaluate volumetric and functional atrial parameters, using real time three-dimensional echocardiography (RT3DE) in women in early and late third trimester of pregnancy. METHODS: We studied pregnant women in early third trimester (III-E = gestational age 26-33 weeks), in late third trimester (III-L = gestational age 34-40 weeks), and control nonpregnant women (C). Two-dimensional (2D-Echo) and RT3DE were used to study 3D left atrial (LA) systolic and diastolic stroke volumes and index (LASVI, LAEDVI), emptying fraction, left ventricular and LA cavities. RESULTS: Although the LA end systolic volume index increased significantly (from 19.42 ± 0.1 to 24.7 ± 3.5 mm(2), P < 0.01), the EF did not change significantly. This was mainly achieved by increasing atrial contraction (A-wave), maintaining cardiac output by increasing heart rate. A decrease in diastolic E-wave, increased atrial kick (A-wave) with reduced E/A ratio, was noted as the pregnancy progressed. Pulmonary pressure increased from 16.9 ± 6.6 to 20.5 ± 2.9 mmHg (P < 0.01), Using 2D-Echo revealed no change in LA diameter from control to III-E and III-L, respectively (from 17.1 ± 2.3 to 16.7 ± 2.6, 17.5 ± 2.2 mm) and area (from 11.7 ± 3.1 to 16.5 ± 2.3, 17.6 ± 1.6 cm(2)). However, using RT3DE, a significant increase in the LASVI, LAEDVI, and LA stroke volume index (from 12.02 ± 2.5 to 14.7 ± 3.2, and 15.1 ± 2.7 mL/m(2)) was detected. CONCLUSIONS: Enlargement of the LA volume with unchanged blood pressure values, as found using RT3DE, may be part of the adaptation to increased blood volume during pregnancy.

[Etiology of severe pulmonary hypertension--possible role of metabolic syndrome].

BACKGROUND: In clinical practice the association between obesity and pulmonary hypertension (PH) is not rare. AIM: The aim of this study was to examine the prevalence of obesity and metabolic syndrome in patients with severe PH, especially cases without significant cardiac, pulmonary or vascular causes. METHODS: We retrospectively anaLyzed the records of 91 patients with severe PH in order to establish its causes. RESULTS: A total of 64% of the patients were women. The women were older than the men, 76.5 years vs 74.0. The BMI of the women was higher than the men, 37.0 vs 30.07. The most common causes of severe PH seen in an internal medicine ward are: severe heart failure (45.1%), chronic lung disease (16.5%) or a combination of both (12.1%). Overall, 11% of our study patients were morbidly obese without significant cardiac, pulmonary or vascular causes of PH. This group was characterized by high incidence of diabetes meLLitus, arterial hypertension, hyperlipidemia, atrial fibrillation and left ventricular (LV) diastolic dysfunction. CONCLUSION: Our results point to a possible association between metabolic syndrome and PH.

Effects of nifedipine on endothelial function, assessed by flow-mediated vasodilatation in pregnant patients.

OBJECTIVES: To evaluate the endothelial function, through flow-mediated vasodilation parameters from brachial artery test in women receiving nifedipine for acute tocolysis with threatened preterm delivery. METHODS: In a prospective study in a university-affiliated hospital, each participant served as herself control. We evaluated various parameters of endothelial function in 22 patients between 27 and 33 weeks of gestation with a diagnosis of threatened preterm delivery (TPTD) before and after 48 h of nifedipine treatment. Each patient received 80 mg nifedipine per day. The assessment tool was Brachial artery reactivity test (BART). Primary outcome was flow mediated vasodilation (FMD). RESULTS: The average participant's age was 27 ± 4.5 years, median gestational age of 28.5 weeks, BMI, kg/m2 (mean ± SD) 28.4 ± 3.3. Systolic blood pressure (mmHg) and diastolic blood pressure (mmHg) decreased from 108 ± 6 to 104 ± 5, p < .001 and from 66 ± 4 to 63 ± 4, p < .001, respectively. FMD (%) significantly decrease from 10.8 ± 6.1 to 7.2 ± 4.7, p = .03 prior to and after nifedipine treatment. The basal brachial artery diameter (mm) at rest was (3.19 ± 0.38 versus 3.39 ± 0.49, p = .28) before versus after nifedipine. The largest brachial artery diameter (mm) was (3.54 ± 0.35 versus 3.58 ± 0.44, p = .76) before versus after nifedipine. CONCLUSIONS: Our results suggest unfavorable changes in FMD probably as a result of nifedipine used for acute tocolysis. Future prospective studies should try to evaluate the safety of acute and maintenance tocolytic therapy with nifedipine on endothelial function in pregnant women.

Mechanical Circulatory Support Devices for the Treatment of Cardiogenic Shock Complicating Acute Myocardial Infarction-A Review.

Cardiogenic shock complicating acute myocardial infarction is a complex clinical condition associated with dismal prognosis. Routine early target vessel revascularization remains the most effective treatment to substantially improve outcomes, but mortality remains high. Temporary circulatory support devices have emerged with the aim to enhance cardiac unloading and improve end-organ perfusion. However, quality evidence to guide device selection, optimal installation timing, and post-implantation management are scarce, stressing the importance of multidisciplinary expert care. This review focuses on the contemporary use of short-term support devices in the setting of cardiogenic shock following acute myocardial infarction, including the common challenges associated this practice.

Impact of descent and stay at a Dead Sea resort (low altitude) on patients with systolic congestive heart failure and an implantable cardioverter defibrillator.

BACKGROUND: As the lowest natural site on earth (-415 meters), the Dead Sea is unique for its high pressure and oxygen tension in addition to the unparalleled combination of natural resources. Furthermore, its balneotherapeutic resorts have been reported to be beneficial for patients with various chronic diseases. OBJECTIVES: To evaluate the safety, quality of life (QoL), exercise capacity, heart failure, and arrhythmia parameters in patients with systolic congestive heart failure (SCHF) and implantable cardioverter defibrillator (ICD) following descent and stay at the Dead Sea. METHODS: The study group comprised patients with SCHF, New York Heart Association functional class II-III after ICD implantation. The following parameters were tested at sea level one week prior to the descent, during a 4 day stay at the Dead Sea, and one week after return: blood pressure, 02 saturation, ejection fraction (echocardiography), weight, B-type natriuretic peptide (BNP), arrhythmias, heart rate, heart rate variability (HRV), and QoL assessed by the Minnesota Living with Heart Failure questionnaire. RESULTS: We evaluated 19 patients, age 65.3 +/- 9.6 years, of whom 16 (84%) were males and 18 (95%) had ICD-cardiac resynchronization therapy. The trip to and from and the stay at the Dead Sea were uneventful and well tolerated. The QoL score improved by 11 points, and the 6 minute walk increased by 63 meters (P < 0.001). BNP levels increased slightly with no statistical significance. The HRV decreased (P = 0.018). There were no significant changes in blood pressure, weight, 02 saturation or ejection fraction. CONCLUSIONS: Descent to, ascent from, and stay at a Dead Sea resort are safe and might be beneficial in some aspects for patients with SCHF and an ICD.

The relationship between plasma vitamin D level and heart valves calcification in acute coronary syndrome and non acute coronary syndrome patients.

BACKGROUND: There is conflicting data regarding the association between low levels of plasma vitamin D and ischemic heart disease. We aimed to investigate the relationship between plasma vitamin D levels and heart valve calcification in hospitalized patients with ischemic heart disease versus non-ischemic heart disease controls. METHODS: A prospective case-control study comprising two age and gender-matched groups. The study group included consecutive patients hospitalized due to acute coronary syndrome; the control group included consecutive non-ischemic heart disease patients hospitalized for noncardiac causes. Blood samples for 25-hydroxyvitamin D level were drawn. An echocardiogram was performed during the first 3 days of hospitalization and reviewed for presence and degree of valvular calcification. RESULTS: Forty patients with acute coronary syndrome and 40 controls (age 58 ± 11 years, 64% male in both groups) were included. Mean plasma 25-hydroxyvitamin D vitamin level in the entire cohort was 24.5 ± 8 ng/ml. Valve calcification rates were similar in acute coronary syndrome versus non-acute coronary syndrome group (28 vs. 21 had valvular calcification; 18 vs. 12 had aortic valve calcification; 21 vs. 14 had mitral valve calcification, respectively; P = NS for all). We found no significant relationship between vitamin D level and valvular calcification, aortic valve calcification, or mitral valve calcification rate or degree in the entire cohort and in each group alone (P = NS for all). There was a negative correlation between 25-hydroxyvitamin D levels and age in the acute coronary syndrome group (r = -0.399, P = 0.012). CONCLUSIONS: We did not find a significant relationship between plasma vitamin D levels and the rate or degree of calcification of either aortic/mitral/both valves in hospitalized patients with or without ischemic heart disease.