Using 2D speckle-tracking echocardiography to localize the accessory pathway and evaluate cardiac function and dyssynchrony in pediatric patients with Wolf-Parkinson-White syndrome.

Wolf-Parkinson-White (WPW) accessory pathway (AP) may be associated with reentry supraventricular tachycardia (SVT) in addition to ventricular dyssynchrony and cardiac dysfunction. Electrophysiological studies (EPS) are the gold standard for the localization of the AP; however, 2D speckle-tracking echocardiography (2D-STE) may help in the localization of the AP noninvasively. Our study aims to evaluate the capability of 2D-STE for AP localization and the identification of AP-related contractile abnormalities and dyssynchrony in pediatric patients with WPW syndrome. This prospective multicenter cohort study involved 18 pediatric patients with ventricular preexcitation from January 2021 to January 2023. Tissue Doppler imaging (TDI), conventional echocardiography, and 2D-STE were done. Myocardial velocities, myocardial performance index (MPI), the global and segmental longitudinal strain of the left ventricle (LV), and time-to-peak longitudinal strain (TPLS) were measured before and after ablation. The longitudinal strain of the LV segments supplied by the AP, or the nearby segments close to the AP, was significantly impaired and improved after ablation (P = 0.0001). The abnormal strain pattern in the affected segments could predict the location of the AP. The TPLS of the affected segments significantly increased after ablation (P = 0.0001), denoting improved dyssynchrony. The ejection time and the LV MPI measured at the basal septum improved significantly after ablation. CONCLUSIONS: 2D STE may be used for noninvasive localization of the AP and to evaluate cardiac function and dyssynchrony in patients with WPW. Further research on more patients is necessary to validate this method for AP localization. WHAT IS KNOWN: • Accessory pathways (AP) associated with the Wolf-Parkinson-White (WPW) syndrome have been linked to supraventricular tachycardia (SVT). Even without SVT, WPW can cause left ventricular dyssynchrony, contractile dysfunction, and cardiomyopathy. • Electrophysiology study is the gold standard for the localization of the AP in WPW syndrome. WHAT IS NEW: • The combination of 2D-speckle-tracking echocardiography (2D-STE) and the modified Arruda algorithm can precisely localize the AP associated with WPW syndrome. • 2D-STE can potentially assess cardiac function and dyssynchrony related to WPW syndrome. Additionally, 2D-STE can be utilized to evaluate the effectiveness of ablation in restoring cardiac function and dyssynchrony.

Comparison of Safety and Effectiveness Between Right Versus Left Radial Arterial Access in Primary Percutaneous Coronary Intervention for Acute ST Segment Elevation Myocardial Infarction.

BACKGROUND: Transradial approach (TRA) is now considered the standard of care in many centres for elective and primary percutaneous intervention (PCI). The use of the radial approach in ST segment elevation myocardial infarction (STEMI) patients has been associated with a significant reduction in major adverse cardiac events. However, it is still unclear if the side of radial access (right vs. left) has impact on safety and effectiveness of TRA in primary PCI. So this study was conducted to compare the safety, feasibility, and outcomes of right radial access (RRA) vs. left radial access (LRA) in the setting of primary PCI. METHODS: We retrospectively analysed the data of 400 consecutive patients presenting to our institution with STEMI for whom primary PCIs were performed via RRA and LRA. RESULTS: Mean age of the whole studied population was 57±12.8 years, with male predominance (77.2%). There were 202 cases in the RRA group and 198 in the LRA group, with no significant difference in demographics and clinical characteristics for patients included in both groups. There was no significant difference in procedure success rate (97.5% for RRA vs. 98.4% for LRA; P=0.77). In addition, no significant difference between both approaches was observed in the contrast volume, number of catheters, fluoroscopy time (FT), needle-to-balloon time, post-procedure vascular complications, in hospital reinfarction, stroke/transient ischaemic attack (TIA) or death. CONCLUSION: Right radial access and LRA are equally safe and effective in the setting of primary PCI. Both approaches have a high success rate and comparable needle-to-balloon time.

Heart failure in low- and middle-income countries: background, rationale, and design of the INTERnational Congestive Heart Failure Study (INTER-CHF).

BACKGROUND: Although heart failure (HF) has been referred to as a global epidemic, most HF information comes from high-income countries, with little information about low-income countries (LIC) and middle-income countries (MIC) in Africa, Asia, the Middle East, and South America, which make up the majority of the world's population. METHODS: The INTERnational Congestive Heart Failure Study is a cohort study of 5,813 HF patients enrolled in 108 centers in 16 LIC and MIC. At baseline, data were recorded on sociodemographic and clinical risk factors, HF etiology, laboratory variables, management, and barriers to evidence-based HF care at the patient, physician, and system levels. We sought to enroll consecutive and consenting patients ≥18 years of age with a clinical diagnosis of HF seen in outpatient clinics (2/3 of patients) or inpatient hospital wards (1/3 of patients). Patients were followed up at 6 and 12 months post-enrollment to record clinical status, treatments, and clinical outcomes such as death and hospitalizations. In the 5,813 enrolled HF patients, the mean age was 59 ± 15 years, 40% were female, 62% had a history of hypertension, 30% had diabetes, 21% had prior myocardial infarction, 64% were recruited from outpatient clinics, 36% lived in rural areas, and 29% had HF with preserved left ventricular ejection fraction. CONCLUSIONS: This unique HF registry aims to systematically gather information on sociodemographic and clinical risk factors, etiologies, treatments, barriers to evidence-based care, and outcomes of HF in LIC and MIC. This information will help improve the management of HF globally.

Evolving interpretation of the athlete's electrocardiogram: from European Society of Cardiology and Stanford criteria, to Seattle criteria and beyond.

Electrocardiographic (ECG) pre-participation screening can prevent sudden cardiac death in the athletes by early diagnosis and disqualification of affected individuals. Interpretation of the athlete's ECG should be based on specific criteria, because ECG changes that would be considered abnormal in the untrained population may develop in trained athletes as a physiologic and benign consequence of the heart's adaptation to exercise. In 2010, a stem document from the Section of Sports Cardiology of the European Society of Cardiology (ESC) proposed to classify the athlete's ECG changes according to the prevalence, relation to exercise training, association with an increased risk of cardiovascular disease and need for further investigations into two groups: "common and training-related" (Group 1) and "uncommon and training-unrelated" (Group 2). Over the last years, several efforts have been made to refine the ESC criteria for interpretation of the athlete's ECG in order to improve specificity maintaining good sensitivity, especially among elite and Afro-Caribbean athletes, which show the highest rate of false positives Group 2 ECG abnormalities. However, the balance between improvement in specificity and loss of sensitivity should be evaluated keeping in mind that the primary aim of the screening program is to save the athlete's lives rather than money.

Electrocardiographic predictors of electroanatomic scar size in arrhythmogenic right ventricular cardiomyopathy: implications for arrhythmic risk stratification.

INTRODUCTION: The extent of right ventricular (RV) electroanatomic scar (EAS) detected by endocardial voltage mapping (EVM) is a powerful invasive predictor of arrhythmic outcome in patients with arrhythmogenic right ventricular cardiomyopathy (ARVC). Electrocardiogram (ECG) and signal-averaged ECG are noninvasive tools of established clinical value for the diagnosis of electrical abnormalities in ARVC. This study was designed to assess the role of ECG and SAECG abnormalities for noninvasive estimation of the extent and regional distribution of RV-EAS and prediction of scar-related arrhythmic risk. METHODS AND RESULTS: The study population included 49 consecutive patients (38 males, median age 35 years) with a definite diagnosis of ARVC and an abnormal EVM by CARTO system. At univariate analysis, the presence of epsilon waves, the degree of RV dilation, the severity of RV dysfunction, and the extent of negative T waves correlated with RV-EAS% area. Normal T-waves were associated with a median RV-EAS% area of 4.9% (4.5-6.4), negative T waves in V1-V3 of 22.0% (8.5-30.6), negative T waves in V1-V3 extending to lateral precordial leads (V4-V6) of 26.8% (11.5-35.2), and negative T waves in both precordial (V2-V6) and inferior leads of 30.2% (24.8-33.0) (P < 0.001). At multivariate analysis, the extent of negative T waves remained the only independent predictor of RV-EAS% area (B = 4.4, 95%CI 1.3-7.4, P = 0.006) and correlated with the arrhythmic event-rate during follow-up (P = 0.03). CONCLUSIONS: In patients with ARVC, the extent of negative T-waves across 12-lead ECG allows noninvasive estimation of the amount of RV-EAS and prediction of EAS-related arrhythmic risk.

Long-term reverse remodeling and clinical improvement by MultiPoint Pacing in a randomized, international, Middle Eastern heart failure study.

PURPOSE: Cardiac resynchronization therapy (CRT) with multipoint left ventricular (LV) pacing (MultiPoint™ Pacing, MPP) has been shown to improve CRT response, although MPP response using automated pacing vector programming has not been demonstrated in the Middle East. The purpose of this study was to compare the impact of MPP to conventional biventricular pacing (BiV) using echocardiographic and clinical changes at 6-month post-implant. METHODS: This prospective, randomized study was conducted at 13 Middle Eastern centers. After de novo CRT-D implant (Abbott Unify Quadra MP™ or Quadra Assura MP™) with quadripolar LV lead (Abbott Quartet™), patients were randomized to either BiV or MPP therapy. In BiV patients, the LV pacing vector was selected per standard practice; in MPP patients, the two LV pacing vectors were selected automatically using VectSelect. CRT response was defined at 6-month post-implant by a reduction in LV end-systolic volume (ESV) ≥ 15%. RESULTS: One hundred and forty-two patients (61 years old, 68% male, NYHA class II/III/IV 19%/75%/6%, 33% ischemic, 57% hypertension, 52% diabetes, 158 ms QRS, 25.8% ejection fraction [EF]) were randomized to either BiV (N = 69) or MPP (N = 73). After 6 months, MPP vs. BiV patients experienced greater ESV reduction (25.0% vs. 15.3%, P = 0.08), greater EF improvement (11.9% vs. 8.6%, P = 0.36), significantly greater ESV response rate (68.5% vs. 50.7%, P = 0.04), and significantly greater NYHA class improvement rate (80.8% vs. 60.3%, P = 0.01). CONCLUSIONS: With MPP and automatic LV vector selection, more CRT patients in the Middle East experienced reverse remodeling and clinical improvement relative to conventional BiV pacing.

Anomalous Left Coronary Artery Arising From Right Coronary Sinus in the Setting of Anterior STEMI.

We present the case of a 55-year-old man who had a diagnosis of an acute anterior ST-segment elevation myocardial infarction. Emergency angiography demonstrated that both coronary systems originated from the right coronary sinus with a culprit proximal left anterior descending artery lesion, which was stented. This is a rare presentation, with only 1 similar case found in published reports. (Level of Difficulty: Intermediate.).

The Egyptian Collaborative Cardiac Genomics (ECCO-GEN) Project: defining a healthy volunteer cohort.

The integration of comprehensive genomic and phenotypic data from diverse ethnic populations offers unprecedented opportunities toward advancements in precision medicine and novel diagnostic technologies. Current reference genomic databases are not representative of the global human population, making variant interpretation challenging, especially in underrepresented populations, such as the North African population. To address this, the Egyptian Collaborative Cardiac Genomics (ECCO-GEN) Project launched a study comprising 1000 individuals free of cardiovascular disease (CVD). Here, we present the first 391 Egyptian healthy volunteers recruited to establish a pilot phenotyped control cohort. All individuals underwent detailed clinical investigation, including cardiac magnetic resonance imaging (MRI), and were sequenced using a targeted panel of 174 genes with reported roles in inherited cardiac conditions. We identified 1262 variants in 27 cardiomyopathy genes of which 15.1% were not captured in current global and regional genetic reference databases (here: gnomAD and Great Middle Eastern Variome). The ECCO-GEN project aims at defining the genetic landscape of an understudied population and providing individual-level genetic and phenotypic data to support future studies in CVD and population genetics.

Global mortality variations in patients with heart failure: results from the International Congestive Heart Failure (INTER-CHF) prospective cohort study.

BACKGROUND: Most data on mortality and prognostic factors in patients with heart failure come from North America and Europe, with little information from other regions. Here, in the International Congestive Heart Failure (INTER-CHF) study, we aimed to measure mortality at 1 year in patients with heart failure in Africa, China, India, the Middle East, southeast Asia and South America; we also explored demographic, clinical, and socioeconomic variables associated with mortality. METHODS: We enrolled consecutive patients with heart failure (3695 [66%] clinic outpatients, 2105 [34%] hospital in patients) from 108 centres in six geographical regions. We recorded baseline demographic and clinical characteristics and followed up patients at 6 months and 1 year from enrolment to record symptoms, medications, and outcomes. Time to death was studied with Cox proportional hazards models adjusted for demographic and clinical variables, medications, socioeconomic variables, and region. We used the explained risk statistic to calculate the relative contribution of each level of adjustment to the risk of death. FINDINGS: We enrolled 5823 patients within 1 year (with 98% follow-up). Overall mortality was 16·5%: highest in Africa (34%) and India (23%), intermediate in southeast Asia (15%), and lowest in China (7%), South America (9%), and the Middle East (9%). Regional differences persisted after multivariable adjustment. Independent predictors of mortality included cardiac variables (New York Heart Association Functional Class III or IV, previous admission for heart failure, and valve disease) and non-cardiac variables (body-mass index, chronic kidney disease, and chronic obstructive pulmonary disease). 46% of mortality risk was explained by multivariable modelling with these variables; however, the remainder was unexplained. INTERPRETATION: Marked regional differences in mortality in patients with heart failure persisted after multivariable adjustment for cardiac and non-cardiac factors. Therefore, variations in mortality between regions could be the result of health-care infrastructure, quality and access, or environmental and genetic factors. Further studies in large, global cohorts are needed. FUNDING: The study was supported by Novartis.

FIRE AND ICE: The quest for the perfect modality in atrial fibrillation ablation.

Atrial fibrillation (AF) is the most common arrhythmia in clinical practice. Catheter ablation of atrial fibrillation plays an important role in the management of AF. Radiofrequency ablation is widely used in practice all over the world. Cryoablation has emerged as an alternative method for AF ablation. The FIRE and ICE trial was a non inferiority, multicentre, randomized trial that compared between the two modalities and proved cryoablation to be non inferior to radiofrequency in terms of efficacy and safety. However, the rate of AF recurrence was markedly high in both arms of the study.

Differential diagnosis at admission between Takotsubo cardiomyopathy and acute apical-anterior myocardial infarction in postmenopausal women.

BACKGROUND: Takotsubo cardiomyopathy (TTC) typically affects postmenopausal women and clinically presents with chest pain, ST-segment elevation, elevated cardiac enzymes and apical left ventricular (LV) wall motion abnormalities that mimic 'apical-anterior' acute myocardial infarction (AMI). This study assessed whether at-admission clinical evaluation helps in differential diagnosis between the two conditions. METHODS: The study compared at-admission clinical, electrocardiographic (ECG) and echocardiographic findings of 31 women (median age 67 years, interquartile range (IQR) 62-76) with typical TTC and 30 women (median age 73 years, IQR 61-81) with apical-anterior AMI due to acute occlusion of the mid/distal left anterior descending coronary artery. RESULTS: Women with TTC significantly more often showed PR-segment depression (62% versus 3%, p<0.001), J-waves (26% versus 3%, p=0.03), maximum ST-segment elevation ⩽2 mm (84% versus 37%, p<0.001) and ST-segment elevation in lead II (42% versus 10%, p=0.01) than those with AMI. At multivariate analysis, PR-segment depression (odds ratio (OR)=37.2, 95% confidence interval (CI)=3.4-424, p=0.002) and maximum ST-segment elevation ⩽2 mm (OR=11.1, 95% CI=1.7-99.4, p=0.01) remained the only independent predictors of TTC and the co-existence of both parameters excluded AMI with a 100% specificity. The two groups did not differ with regard to age, first troponin-I value, echocardiographic LV ejection fraction and distribution of hypo/akinetic LV segments. CONCLUSIONS: At-admission electrocardiogram (but no clinical, laboratory and echocardiographic features) allows differential diagnosis between TTC and apical-anterior AMI in postmenopausal women. The combination of PR-segment depression and mild (⩽2 mm) ST-segment elevation predicted TTC with greater accuracy than traditional parameters such as localisation of ST-segment elevation and reciprocal ST-segment depression.

Heart Failure in Africa, Asia, the Middle East and South America: The INTER-CHF study.

BACKGROUND: There are few data on heart failure (HF) patients from Africa, Asia, the Middle East and South America. METHODS: INTER-CHF is a prospective study that enrolled HF patients in 108 centers in 16 countries from 2012 to 2014. Consecutive ambulatory or hospitalized adult patients with HF were enrolled. Baseline data were recorded on sociodemographics, clinical characteristics, HF etiology and treatments. Age- and sex-adjusted results are reported. RESULTS: We recruited 5813 HF patients: mean(SE) age=59(0.2)years, 39% female, 65% outpatients, 31% from rural areas, 26% with HF with preserved ejection fraction, with 1294 from Africa, 2661 from Asia, 1000 from the Middle-East, and 858 from South America. Participants from Africa-closely followed by Asians-were younger, had lower literacy levels, and were less likely to have health or medication insurance or be on beta-blockers compared with participants from other regions, but were most likely to be in NYHA class IV. Participants from South America were older, had higher insurance and literacy levels, and, along with Middle Eastern participants, were more likely to be on beta-blockers, but had the lowest proportion in NYHA IV. Ischemic heart disease was the most common HF etiology in all regions except Africa where hypertensive heart disease was most common. CONCLUSIONS: INTER-CHF describes significant regional variability in socioeconomic and clinical factors, etiologies and treatments in HF patients from Africa, Asia, the Middle East and South America. Opportunities exist for improvement in health/medication insurance rates and proportions of patients on beta blockers, particularly in Africa and Asia.

ROCKET AF adds more concerns about Digoxin safety in patients with atrial fibrillation.

In a recent article in the Journal, we have reviewed the adverse cardiovascular outcomes observed with digoxin use in the PALLAS study.(1) The PALLAS study was designed to determine if dronedarone would reduce major vascular events in patients with permanent atrial fibrillation (AF).(2) However the study was stopped early because of safety reasons, as a significant number of patients on the dronedarone arm reached the co-primary end point composite of stroke, myocardial infarction, systemic embolism, or cardiovascular death. Data sub-analyses suggested that digoxin-dronedarone interaction was responsible for the higher arrhythmic death rate observed in the trial. These observations are consistent with several other studies that demonstrate the potential hazard of the use of digoxin in heart failure and/or atrial fibrillation. A more recent article published in the Lancet studied the use and outcomes of digoxin in the Rivaroxaban Once Daily Oral Direct Factor Xa Inhibition Compared with Vitamin K Antagonism for Prevention of Stroke and Embolism in Atrial Fibrillation (ROCKET AF) trial.(3) The investigators concluded that digoxin treatment was associated with a significant increase in all-cause mortality, vascular death, and sudden death in patients with AF.

Takotsubo cardiomyopathy: A potentially serious trap (Data from the International Takotsubo Cardiomyopathy Registry).

Takotsubo cardiomyopathy (TTC) is an acute cardiac condition characterized by transient left ventricular dysfunction with wall motion abnormalities, most commonly in the form of apical ballooning. Despite being considered as a generally benign condition, many studies have emphasized potentially sinister outcomes associated with TTC. In this article, we review the most recent results of the International Takotsubo Registry, which investigated the clinical features, prognostic predictors, and outcomes of 1750 patients.

Dronedarone-digoxin interaction in PALLAS: A foxglove connection?

In the Permanent Atrial Fibrillation Outcome Study Using Dronedarone on Top of Standard Therapy (PALLAS) study, dronedarone use was associated with an excess risk of stroke, cardiovascular death and hospitalizations. However, an increased level in the serum digoxin level was observed in the dronedarone arm, as it is a potent inhibitor of the P-glycoprotein transport system. The PALLAS subanalysis suggests that digoxin-dronedarone interaction was responsible for the higher arrhythmic death rate observed in the trial. These data are consistent with several other studies that demonstrate the potential hazard of the use of digoxin in heart failure and/or atrial fibrillation. One must consider other safer alternatives before prescribing digoxin in atrial fibrillation patients.

DECAAF: Emphasizing the importance of MRI in AF ablation.

Atrial fibrillation ablation is a complex and challenging procedure. Appropriate patient selection is the most critical step to ensure safe and successful atrial fibrillation ablation procedure. The DECAAF study (Delayed-Enhancement MRI Determinant of Successful Radiofrequency Catheter Ablation of Atrial Fibrillation) showed that atrial tissue fibrosis, as estimated by delayed enhancement magnetic resonance imaging, was independently associated with recurrent arrhythmia post atrial fibrillation ablation. Magnetic resonance imaging also detected left atrial volume and shape. Integrating the data provided by magnetic resonance imaging into the pre-procedural planning is crucial.

STOP-HF: Expanding the role of HF programs into the community.

The St Vincent's Screening TO Prevent Heart Failure (STOP-HF) study is a recently published trial that assessed the use of brain natriuretic peptide (BNP) as a screening tool for HF in an at-risk population in reducing newly-diagnosed heart failure and prevalence of significant left ventricular (LV) systolic and/or diastolic dysfunction. The study provides an excellent model to the global community on how to integrate primary care simple screening with secondary and tertiary level targeted diagnostic and therapeutic system. This integration includes screening of high-risk groups, use of a sensitive screening tool, early diagnostic modalities, early therapeutic interventions, and proper assessment of the hard clinical outcomes. However, more studies are needed across multiple sites around the world with different levels of health care services and variable biomarkers to identify higher-risk groups.

REVERSE 5-year follow up: CRT impact persists.

The role of cardiac resynchronization therapy (CRT) in patients presenting with mild manifestations of heart failure (HF), depressed left ventricular ejection fraction (LV EF), and wide QRS complex, has been addressed in four previous trials: MIRACLE ICD II,(1) MADIT-CRT,(2) RAFT,(3) and REVERSE.(4) The consistent observed benefits in reverse cardiac remodelling and reduction of heart failure adverse events have resulted in guideline recommendations for CRT in NYHA Class II patients. The guidelines also recommend further studies to determine whether survival is increased by CRT in patients with mild symptoms. The 5-year analysis of the REsynchronization reVErses Remodeling Systolic left vEntricular (REVERSE) trial, which was designed prospectively for 5-year follow-up to specifically assess the long term benefits of CRT, were recently published in the European Heart Journal.(5).

The discovery of pulmonary circulation: From Imhotep to William Harvey.

In his quest to comprehend his existence, Man has long been exploring his outer world (macro-cosmos), as well as his inner world (micro-cosmos). In modern times, monmental advances in the fields of physics, chemistry, and other natural sciences have reflected on how we understand the anatomy and physiology of the human body and circulation. Yet, humanity took a long and winding road to reach what we acknowledge today as solid facts of cardiovascular physiology. In this article, we will review some of the milestones along this road.

Heart failure due to 'stress cardiomyopathy': a severe manifestation of the opioid withdrawal syndrome.

Takotsubo cardiomyopathy (TTC) is a transient left ventricular (LV) dysfunction due to akinesia of the LV mid-apical segments ('apical ballooning') in the absence of critical coronary stenoses which can be complicated in the acute phase by heart failure, mitral regurgitation, life-threatening ventricular arrhythmias, or apical LV thrombosis. The syndrome is typically precipitated by intense emotional or physical stress; however, other causes of sympathetic overstimulation including administration of exogenous sympathomimetics or withdrawal of sympathetic antagonists can trigger TTC. We report the case of a patient who unexpectedly developed an 'apical ballooning' with severe reduction in the LV systolic function and heart failure after the withdrawal of methadone. The case supports the concept that increased sympathetic activity secondary to opioids withdrawal can trigger a stress-induced severe LV dysfunction. Physicians should be aware that the abrupt discontinuation of a long-term therapy with opioids may lead to serious cardiac complications. The administration of clonidine may be considered to prevent early clinical manifestations of addictive withdrawal, including TTC.