Cardiac Catheterization Research Articles

Validation of left ventricular filling pressure evaluation by order of tricuspid and mitral valve opening in patients with atrial fibrillation

Abstract Introduction Accurate assessment of the left ventricular (LV) filling pressure in patients with atrial fibrillation (AF) remains difficult. Novel echocardiographic scoring system, visually assessed time difference between mitral valve (MV) and tricuspid valve (TV) opening (VMT) score based on visual assessment of the time sequence of early-diastolic atrioventricular valves opening, is expected to be applied for these patients. Purpose This study aimed to test the diagnostic accuracy of the VMT score in patients with AF. Methods We analyzed 119 consecutive AF patients who underwent cardiac catheterization and echocardiography within 2 days as a derivation cohort. External validation was performed in 189 AF patients from 4 Japanese tertile hospitals. Elevated LV filling pressure was defined as mean pulmonary arterial wedge pressure (PAWP) ≥15 mmHg. The time sequence of MV / TV opening was visually assessed and scored (0: TV first, 1: simultaneous, 2: MV first). When the inferior vena cava was dilated, 1 point was added and the VMT score was finally graded as 0 to 3. Conventional Doppler parameters recommended by the guidelines to estimate LV filling pressure in AF were also measured. Results PAWP was elevated with increase in the VMT score (0: 10±3, 1: 13±5, 2: 22±7, 3: 27±6 mmHg, P < .001) with a significant increase from VMT 1 to 2. VMT≥2 predicted elevated PAWP with an accuracy of 87%, and the diagnostic accuracy was significantly higher in VMT score than in conventional Doppler parameters (C index: 0.88 vs. 0.54 to 0.69; P < .001). In addition, VMT≥2 showed an incremental predictive value over plasma brain natriuretic peptide levels (C index: 0.79 to 0.93; P < .001). In the external validation cohort, VMT≥2 demonstrated acceptable accuracy (72%) to predict elevated PAWP. Conclusions VMT scoring was useful for prediction of elevated LV filling pressure and had an incremental benefit over the practical biomarker in patients with AF.

Natural shear wave imaging outperforms conventional echocardiographic parameters in detecting elevated left ventricular filling pressures

Abstract Background Current conventional echocardiographic assessment of diastolic function relies on predicting left ventricular (LV) filling pressure as a surrogate of diastolic function. However, the current guidelines algorithm for estimation of LV filling pressures is complex. High frame rate (HFR) Shear wave (SW) imaging is emerging as a novel parameter for assessing myocardial stiffness, a key determinant of diastolic function. Natural SW can be induced, e.g., by mitral valve closure (MVC) and their propagation speed is directly related to myocardial stiffness. Little is known, however, to what extent SW after MVC can reflect diastolic LV filling pressures. Purpose We aimed at investigating the relationship between natural SW and LV diastolic filling pressures in comparison to conventional echocardiographic parameters. Methods Thirty patients (mean age 68.4±9.9 years) scheduled for clinically indicated left heart catheterization were prospectively recruited irrespective of diastolic function status. Conventional as well as HFR echocardiography (ca. 1200 frames/second) was performed immediately after the catheterization. We tracked SW occurring after MVC along the ventricular septum in the parasternal long axis view using an anatomical M-mode from base to apex colour coded for tissue acceleration. SW appeared immediately after as tilted green bands and their propagation velocity was measured semi-automatically (Figure 1). Results In our cohort, the LV mid-diastolic pressure (LVMDP) ranged from 5 to 19 mmHg, while the LV end-diastolic pressure (LVEDP) ranged from 7.5 to 29.5 mmHg. LV filling pressures were considered elevated if exceed 15 mmHg for LVMDP and 16 mmHg for LVEDP. Out of the conventional echocardiographic parameters, only mitral inflow to mitral relaxation velocity ratio (E/e’) correlated moderately with LV filling pressures (r=0.47, p=0.009 for LVMDP; and r=0.49, p=0.006 for LVEDP) (Figure 2 A,B). The accuracy of the conventional E/e’ cut-off value of 14 to predict elevated LV filling pressure is 76% for LVMDP and 70% for LVEDP (Figure 2C). SW velocities after MVC correlated strongly with diastolic LV pressures (r=0.65, p<0.001 for LVMDP; r=0.78, p<0.001 for LVEDP) (Figure 2 D,E). Interestingly, a cut-off value for SW velocity of 5.8 m/s showed an excellent ability to discriminate raised LVMDP (AUC: 0.93; sensitivity: 80%, specificity: 80%, accuracy: 80%) and elevated LVEDP (AUC: 0.96 ; Sensitivity: 89%, specificity: 95%, accuracy: 93%) (Figure 2F). Conclusions Our preliminary data showed that SW velocities at end-diastole are strongly related to LV filling pressures and can predict elevated LV filling pressures more accurately than conventional echocardiographic parameters. This ongoing study shows the potential of natural shear wave imaging as a promising innovative tool for assessment of diastolic function. Figure 1 Figure 2

Pursuing ventricular-arterial coupling: a comparison of cardiac magnetic resonance right ventricular strain analysis and novel echo-derived indexes of right ventricular myocardial work

Abstract Introduction End-systolic to arterial elastance ratio (Ees/Ea) represents right ventricular-arterial coupling (RVAC) and is the gold standard for measuring right ventricular (RV) function However, this method is time-consuming and not always readily available. A simplified approach is using the stroke volume (SV) to end-systolic volume (ESV) ratio, which has shown prognostic relevance in pts with PH, with a cut-off value of 0.5. Cardiac magnetic resonance (CMR) measurements of volumetric data allow the assessment of this ratio. CMR strain analysis has also emerged as a technique to detect subtle changes in RV function, and, recently, right ventricular myocardial work (RVMW) assessed by transthoracic echocardiography (TTE) allows the study of RV pressure-strain loops. The association between indexes of RVMW and CMR derived parameters has not yet been extensively studied, namely in pre-capillary PH population. Objectives To evaluate the relationship between the SV/ESV ratio and CMR-derived RV strain and TTE-derived RVMW in a cohort of pts with group I and group IV PH. Methods Thirteen consecutive precapillary PH pts underwent CMR, TTE and right heart catheterization prospectively. CMR feature-tracking was used to track tissue voxel motion in short and long-axis cine images, in order to derive myocardial strain. In TTE, dedicated software for left ventricle myocardial work was used for the RV. Results 69% of pts included were women, mean age 67. The average of mean PAP was 35 mmHg (± 13.5) and PVR was 4.8 WU (± 4.9). SV/ESV ratio significantly correlated with RV ejection fraction (EF) (r = 0.888, p < 0.001) and circumferential peak systolic (CPS) strain (r = 0.538, p = 0.037), but not with longitudinal peak systolic (LPS) strain (p = 0.571). As for TTE-derived RVMW, SV/ESV ratio demonstrated significant correlations with RVGWI (r = 0.580, p = 0.038) and RVGCW (r = 0.654, p = 0.015) but not with RVGWW (p = 0.780) nor RVGWE (p = 0.364). Significant correlations were found between RVEF and CPS strain (r = 0.690, p = 0.009), RVEF and RVGCW (r = - 0.592, p = 0.033) and between CPS strain and RVGWI (r = 0.620, p = 0.024) and RVGCW (r = 0.718, p = 0.006). 38,5% of pts had SV/ESV ratio < 0.5. These pts had lower RVEF (48 ± 7.1 vs 61 ± 5.5, p = 0.004), lower CPS strain (-10.9 ± 3.0 vs -15.8 ± 2.9, p = 0.015) but higher RVGWI (828 ± 167.4 vs 526 ± 192.0, p = 0.015) and RVGCW (1061 ± 228.5 vs 698 ± 141.0, p = 0.004) compared to pts with SV/ESV > 0.5. LPS strain, RVGWW and RVGWE did not showed statistically differences between groups. Conclusion SV/ESV ratio correlated with both CMR-derived CPS strain and TTE-derived RVMW. Pts with a lower SV/ESV ratio had lower circumferential strain but higher work indices, suggesting potential compensatory mechanisms, where increased work may not translate to efficient pumping. Further studies with larger cohorts are warranted to validate these parameters and establish relation with outcomes. Figure 1 Figure 2

Prognostic predictors in constrictive pericarditis, 19-year experience at a tertiary care hospital

Abstract Introduction Constrictive pericarditis is a chronic inflammatory entity that may progress with thickening and calcification in the pericardial tissue, resulting in decreased pericardial elasticity and subsequent increase in ventricular filling pressures1,2. This rare treatable cause of HFpEF, is associated with various aetiologies, depending on the development level of the countries. Several algorithms have been developed for the diagnosis, whereas studies evaluating the prognostic factors are limited3–6. Our study aimed to examine the clinical, laboratory, electrocardiographic, imaging and catheterization parameters that determine the prognosis of constrictive pericarditis. Methods 60 patients diagnosed with constrictive pericarditis based on echocardiography, computed tomography and right heart catheterization parameters were included retrospectively in the study. Clinical presentation, laboratory, and electrocardiographic findings were assessed. Volumetric measurement, tissue Doppler, mitral inflow velocity analysis, and pericardial evaluation were made via 2D echocardiography. Pericardial thickness, effusion, and calcium score were obtained via thorax CT, while right-sided pressure measurements were acquired via catheterization. The primary clinical outcome was determined as mortality, and the effect of these parameters was evaluated by Cox regression analysis. Results Median follow-up was 3.5 years (0-19) and mean age was 52.7 ±17.5 years. 38 of the patients (63.3%) were male, the most common aetiologies were malignancy (21.4%) and other systemic diseases (21.4%). 7 patients were lost to follow-up and 18 (31.6%) patients died during the process. When different models were evaluated with Cox regression analysis, ascites, hemoglobin and elevated proBNP values were prognostic predictors (HR 10.991 p-value 0.006, HR 0.513 p-value 0.010 and HR 3.904 p-value 0.045, respectively). ROC analysis indicated the highest AUC value for the model that included hemoglobin (AUC 0.953). Conclusion Constrictive pericarditis is one of the treatable causes of HFpEF. While imaging and catheterization parameters play a crucial role in the diagnosis, clinical and laboratory parameters affect the prognosis.

Combining Hyperpolarized 129Xe MR Imaging and Spectroscopy to Non-Invasively Estimate Pulmonary Vascular Resistance.

Hyperpolarized 129Xe MRI/MRS enables quantitative mapping of function in lung airspaces, membrane tissue, and red blood cells (RBCs) within the pulmonary capillaries. The RBC signal also exhibits cardiogenic oscillations that are reduced in pre-capillary pulmonary hypertension (PH). This effect is obscured in patients with concomitant defects in transfer from airspaces to RBCs, which increase RBC oscillation amplitudes. Here, we provide a framework for interpreting RBC oscillations and show their relationship to pulsatile blood flow, capillary blood volume, capillary compliance, and impedance of the capillary and venous circulation. This framework was first applied to characterize RBC oscillations in a cohort of subjects with pulmonary disease but no known PH (n=129). 129Xe MRI of RBC transfer was used to estimate capillary blood volume, and as it decreased, RBC oscillations sharply increased (r2adj=0.53), consistent with model predictions. Model-derived fit parameters were then used to estimate the distribution of pulmonary vascular resistance (PVR) across arterial, capillary, and venous circulation, and to correct oscillations for RBC transfer defects. 70% of PVR was estimated to arise from pulmonary arteries, 11% from capillaries, and 19% from veins. When tested in a second cohort of subjects who underwent 129Xe MRI/MRS and right heart catheterization (n=40), oscillations corrected for capillary blood volume correlated moderately with PVR (r2=0.27, p=0.0014). For every 1.96 WU increase in PVR, corrected oscillations decreased by 1 absolute percentage point. This work demonstrates that, although 129Xe-RBC oscillations are only indirectly sensitive to pre-capillary obstruction, corrected oscillations below 7.5% were 100% specific for elevated PVR.

Modern possibilities of echocardiographic diagnosis in pulmonary arterial hypertension

Pulmonary Hypertension (PH) is a hemodynamic and pathophysiological condition characterized by an increase in mean pulmonary artery (PA) pressure by at least 20 mm Hg at rest, measured during right heart catheterization. One of the fastest and most accessible screening non-invasive diagnostic methods for assessing the likelihood of this condition is echocardiography, which is performed according to the standard transthoracic echocardiography protocol, focusing on visualizing and describing certain parameters that characterize function of heart right chambers. In patients with PH, structural changes in the heart right chambers can be observed, such as enlargement of the right atrium and right ventricle, changes in their geometric shape, thickening right ventricle wall, dilatation of the main PA and its branches, and the appearance of tricuspid regurgitation. Pulmonary artery pressure can be measured using either the velocity of the tricuspid regurgitant jet or the ratio of the time acceleration of flow in the outflow tract of the right ventricle to the ejection time (mean pressure in the PA), or the velocity of the pulmonary regurgitation jet (end-diastolic pressure in the PA). Classic parameters of the functional state of the right ventricle, as well as additional indicators of the evaluation of the right ventricular function, for example, the ratio of the amplitude of movement of the fibrous ring to systolic pressure in the PA, called the right ventriculoarterial coupling, should be evaluated only in expert centers providing care for patients with PH. Correct and timely diagnosis, clear dynamic monitoring of the patient’s condition play a crucial role in prescribing targeted treatment and predicting the disease course.

Virtual 3D reconstruction of complex congenital cardiac anatomy from 3D rotational angiography

BackgroundDespite advancements in imaging technologies, including CT scans and MRI, these modalities may still fail to capture intricate details of congenital heart defects accurately. Virtual 3D models have revolutionized the field of pediatric interventional cardiology by providing clinicians with tangible representations of complex anatomical structures. We examined the feasibility and accuracy of utilizing an automated, Artificial Intelligence (AI) driven, cloud-based platform for virtual 3D visualization of complex congenital heart disease obtained from 3D rotational angiography DICOM images.MethodsFive patients selected at random with 3DRA performed in the pediatric cardiac catheterization suite were selected. 3DRA’s were performed following published institutional protocols and segmentations performed by primary operators. The 3DRA DICOM images were anonymized as per protocol and exported. Images when then processed by Axial3D Artificial Intelligence (AI) driven cloud-based platform for virtual segmentation. Two separate expert operators were selected to subjectively analyze the segmentations and compare them to the operator reconstructions for anatomic accuracy.ResultsComparing results with local reconstructions by expert operators, five different patient anatomies were analyzed, showcasing Axial3D’s ability to produce highly detailed reconstructions with improved visual appeal, including color-coded segments for implanted materials like stents. The reconstructions exhibited superior segmentation of different intrathoracic structures when compared to local models, offering valuable insights for medical professionals and patients.ConclusionsThe use of the AI driven, cloud-based platform for 3D visualization of complex congenital heart lesions presents a promising advancement in pediatric interventional cardiology, facilitating enhanced patient care, procedural planning, and educational opportunities for trainees and patients alike.

Unmasking an Intracardiac Shunt in a Case of Persistent Unexplained Hypoxia: A Case Report

Background and Clinical Significance: Pulmonary hypertension (PH) is characterized by an increase in mean pulmonary arterial pressure and pulmonary vascular resistance. It is frequently encountered in patients with significant intracardiac shunts, often necessitating the implementation of a closure device or surgical correction. Nevertheless, the occurrence of a concomitant atrial septal defect (ASD) with a right-to-left shunt inducing left ventricular dysfunction is a rare phenomenon. Case Presentation: A 69-year-old female patient with a history of heart failure (with preserved ejection fraction) and end-stage renal disease on hemodialysis presented to an outside facility, with syncope and hypoxia. She was recently diagnosed with severe pulmonary hypertension (measuring 86 mmHg). Right heart catheterization (RHC) revealed precapillary pulmonary hypertension (88/37/54 mmHg), prompting the initiation of intravenous epoprostenol. Nevertheless, the patient was persistently hypoxic, raising the possibility of a concomitant diagnosis. Upon review of the prior echocardiogram, which included a bubble study, an intracardiac shunt was identified. It was hypothesized that a combination of right ventricular failure and the right-to-left shunt resulting from the ASD contributed to the persistent hypoxemia. In light of this, prostacyclin therapy was continued alongside adjunctive vasopressors, resulting in clinical stabilization. The patient was eventually discharged with a treatment regimen that included subcutaneous Treprostinil. Conclusions: It is important to recognize that the consequences of PH are extensive, and that a rare yet significant etiology for persistent hypoxemia may be attributed to right-to-left shunting.

Prenatal Diagnosis of Congenital Heart Disease in Liveborn Infants in the New England Region.

Prenatal diagnosis of congenital heart disease requiring early cardiac catheterization or surgical intervention enables optimal delivery planning for appropriate postnatal cardiovascular intervention and care. This allows for improved morbidity and mortality. Prior national data reported prenatal diagnosis rates of 32% for congenital heart disease requiring intervention in infants in the first 6months of life in the New England region. With improved technology, access to care and changes to the obstetrical ultrasound guidelines for mid trimester fetal study, it is expected that diagnostic rates should improve. The New England Congenital Cardiology Association (NECCA) conducted a quality improvement study to determine the rates of prenatal detection in the current era with the hypothesis that there has been improvement in detection rates in this region. Ten of fourteen medical centers delivering pediatric cardiology care in New England contributed prenatal diagnosis data for 286 infants born at the participating centers during a one year period. The overall prenatal detection rate was 68%. Detection rates ranged from 39 to 90%. When fetal echocardiogram was performed at a pediatric cardiology center, the detection rate was 95% with only 7 moderate (7/195; 3.6%) and 3 severe (3/195; 1.5%) diagnostic discrepancies. Prenatal diagnostic rate and accuracy are high among pediatric cardiology centers in the New England region, and much improved over historical data. To improve fetal detection of congenital heart disease further, future work is needed to better determine the etiology of missed prenatal diagnoses and efforts should be focused on increasing appropriate referrals to pediatric cardiology centers for fetal evaluation.

Performance of the FORD Versus Other Available Models for the Noninvasive Prediction of Pulmonary Hypertension in Patients with Interstitial Lung Disease

PurposePulmonary hypertension (PH) is associated with morbidity and mortality in patients with interstitial lung disease (ILD). Several prediction models have been proposed to predict PH in ILD patients. We sought to discern how previously described prediction models perform in predicting PH in patients with ILD.MethodsPatients with ILD who completed a baseline right heart catheterization, from Inova Fairfax Hospital, Northwestern Memorial Hospital, and Asan Medical Center in Korea were enrolled. The performance of various prediction models (FORD model, the FORD calculator, the PH‐ILD Detection tool, and the mean pulmonary artery pressure prediction model) were assessed using receiver operating characteristic (ROC) curves and area under the receiver operating characteristic curve (AUROC). There were four definitions of pulmonary hypertension against which the models were evaluated.ResultsThere were a total of 192 patients with ILD, of whom 32.8% (n = 63/192) met the modified 5th world symposium on PH definition of precapillary PH. Among the models assessed, the FORD calculator had an AUROC (0.733) that was marginally highest. Subgroup analysis revealed that the FORD index had the highest AUROC (0.817) in patients with idiopathic pulmonary fibrosis, while the FORD calculator had the highest AUROC (0.751) in patients with non-IPF ILD.ConclusionThe FORD model can be used to predict group 3 PH in both IPF patients and non-IPF ILD patients. It could serve as a tool for ILD patient selection for right heart catheterization as well as an enrichment tool for clinical trials targeting the pulmonary vasculature.

Glycoprotein 130 Antagonism Counteracts Metabolic and Inflammatory Alterations to Enhance Right Ventricle Function in Pulmonary Artery Banded Pigs.

Right ventricular dysfunction (RVD) is a risk factor for death in multiple cardiovascular diseases, but RV-enhancing therapies are lacking. Inhibition of glycoprotein-130 (GP130) signaling with the small molecule SC144 improves RV function in rodent RVD via anti-inflammatory and metabolic mechanisms. However, SC144's efficacy and molecular effects in a translational large animal model of RVD are unknown. 4-week-old castrated male pigs underwent pulmonary artery banding (PAB). After 3 weeks, PAB pigs were randomized into 2 groups (daily injections of SC144 [2.2 mg/kg, PAB-SC144, n =5] or vehicle [PAB-Veh, n =5] for 3 weeks). Five age-matched pigs served as controls. Cardiac MRI quantified RV size/function. Right heart catheterization evaluated hemodynamics. Single-nucleus RNA sequencing delineated cell-type specific changes between experimental groups. Electron microscopy evaluated RV mitochondrial morphology. Phosphoproteomics identified dysregulated RV kinases. Lipidomics and metabolomics quantified lipid species and metabolites in RV tissue. Quantitative proteomics examined RV mitochondrial protein regulation. SC144 significantly improved RV ejection fraction (Control: 60±4%, PAB-Veh: 22±10%, PAB-SC144: 37±6%) despite similar RV afterload. Single-nucleus RNA sequencing demonstrated PAB-Veh pigs had lower cardiomyocyte and higher macrophage/lymphocyte/pericyte/endothelial cell abundances as compared to control, and many of these changes were blunted by SC144. SC144 combatted the downregulation of cardiomyocyte metabolic genes induced by PAB. Kinome enrichment analysis suggested SC144 counteracted RV mTORC1 activation. Correspondingly, SC144 rebalanced RV autophagy pathway proteins and improved mitochondrial morphology. Integrated lipidomics, metabolomics, and proteomics analyses revealed SC144 restored fatty acid metabolism. Finally, CellChat analysis revealed SC144 restored pericyte-endothelial cell cross-talk. GP130 antagonism blunts elevated immune cell abundance, reduces pro-inflammatory gene transcription in macrophages and lymphocytes, rebalances autophagy and preserves fatty acid metabolism in cardiomyocytes, and restores endothelial cell and pericyte communication to improve RV function.

Mortality Patterns in Pediatric Pulmonary Vein Stenosis: Insights Into Right Ventricular Systolic Pressure Associations.

Pulmonary vein stenosis in children is associated with a poor prognosis. However, the cause and risk factors for mortality remain uncertain. This retrospective, single-center study identified children with primary and secondary pulmonary vein stenosis through a cardiac catheterization database. Kaplan-Meier analysis, log-rank tests, and Cox regression analysis were performed to assess outcome and identify significant predictors of mortality. Among 56 children with pulmonary vein stenosis (33 male children, 59%), 20 (36%) died at a median age of 10 months (interquartile range,4-24 months). All patients underwent cardiac catheterization, with 45 (80%) undergoing at least 1 interventional procedure. Causes of death included multiorgan failure (35%), progressive respiratory failure (20%), and sudden cardiac death (15%). Prematurity, chronic lung disease, a genetic syndrome, or the number of affected pulmonary veins did not significantly correlate with mortality. However, right ventricular (RV) systolic pressure greater than half systemic pressure was associated with mortality (hazard ratio [HR], 5.5 [95% CI, 2.2-14.1]; P<0.001). The final predictive model for mortality included RV systolic pressure greater than half systemic pressure (HR, 4.0 [95% CI, 1.6-10.4]; P=0.004), moderately or severely diminished RV systolic function (HR, 3.6 [95% CI, 1.1-11.5]; P=0.032), and the presence of congenital heart disease (HR, 2.4 [95% CI, 0.9-6.7]; P=0.084). This report is the first to indicate that RV systolic pressure and RV dysfunction are significant independent predictors of mortality in children with pulmonary vein stenosis. A greater understanding of mortality in this population is necessary, particularly in those with RV systolic pressure less than half systemic.

Role of Exercise Stress Echocardiography in Systemic Sclerosis: Pathophysiological and Prognostic Significance of the Systemic Sclerosis with a Heart Failure and Preserved Ejection Fraction Phenotype.

Left ventricular (LV) diastolic dysfunction and heart failure with preserved ejection fraction (HFpEF) are common cardiac complications of patients with systemic sclerosis (SSc). Exercise stress echocardiography is often used in symptomatic patients with SSc to detect abnormal increases in pulmonary pressures during exercise, but the pathophysiologic and prognostic significance of exercise stress echocardiography to assess the presence of HFpEF in these patients is unclear. Patients with SSc (n=140) underwent ergometry exercise stress echocardiography with simultaneous expired gas analysis. The HFA-PEFF score ≥ 5 points was used to diagnose HFpEF. Thirty-five patients met the HFpEF criteria (prevalence 25%). Compared to patients with SSc-non-HFpEF, those with SSc-HFpEF were older and had a higher prevalence of coronary artery disease, more severe LV diastolic dysfunction (by definition), depressed right ventricular systolic function, reduced exercise capacity (lower peak oxygen consumption), and poorer ventilatory efficiency. Exercise right heart catheterization (RHC) was performed in 25 patients and it confirmed elevated pulmonary capillary wedge pressure during peak exercise in patients with SSc-HFpEF. Participants were followed up to assess the primary composite endpoint: all-cause mortality, HF hospitalization, unplanned hospital visits requiring intravenous diuretics, or oral diuretic intensification. Compared to SSc-non-HFpEF, SSc-HFpEF had a 5.3-fold increased risk of the composite outcomes (hazard ratio 5.29, confidence intervals 2.06-13.5, p=0.0005). In addition to pulmonary hemodynamics, exercise stress echocardiography may be useful to identify the HFpEF phenotype that has different pathophysiology and clinical outcomes in patients with SSc.

Predictive Value of the DETECT Algorithm for Pulmonary Arterial Hypertension in Systemic Sclerosis: Findings from an Italian Observational Study.

Background/Objectives: Pulmonary arterial hypertension (PAH) is a complication of systemic sclerosis (SSc), and several screening algorithms have been proposed for the early detection of PAH in SSc. This study aimed to evaluate the predicting values of the DETECT algorithm for SSc-PAH screening in patients with SSc undergoing right heart catheterization (RHC) based on 2015 ESC/ERS echocardiographic criteria in a real-life setting. Methods: Patients fulfilling the 2013 ACR/EULAR classification criteria for SSc and with available data for PAH screening with the DETECT algorithm and the 2015 ESC/ERS echocardiographic criteria were retrospectively enrolled from January to June 2017 and then followed for 5 years. Baseline and annual clinical, laboratory, and instrumental data were collected. Results: A total of 33 out of 131 (25%) patients were selected based upon the ESC/ERS echocardiographic criteria, but 30 (23%) underwent RHC, while 51 (39%) patients with SSc were positive based on the DETECT algorithm. PAH diagnosis was confirmed in 28/30 cases (93.3%). The DETECT algorithm showed lower specificity and positive predictive value (PPV) (p < 0.0001) but higher sensitivity and negative predictive value (NPV) (p < 0.0001) than ESC/ERS criteria. Notably, patients with SSc with a negative DETECT screening at baseline had a low probability of developing PAH during a 5-year follow-up (OR 0.15, 95% CI 0.10-0.60-p < 0.0001). Conclusions: The DETECT algorithm has proven to be an easy, fast, and inexpensive tool for screening PAH in patients with SSc. Overall, a low probability of PAH using DETECT is highly predictive of a good prognosis.

Past, Present, and Future of Occupational Safety in the Cardiac Catheterization Lab

Past, Present, and Future of Occupational Safety in the Cardiac Catheterization Lab

Left coronary ostial isolation in a young boy caused by a dysplastic aortic valve: a case report

Abstract Background Ischemic cardiac chest pain and coronary artery abnormalities are uncommon in children. The long-term implications of missed or delayed diagnosis are myocardial ischemia and risk of sudden cardiac death. Improvement in non-invasive imaging has made diagnosis and surgical planning possible with multi-modal imaging. Case summary A 12-year-old boy with ischemic chest pain caused by isolation of the left coronary ostium in the context of a dysplastic aortic valve. There was a delay to formal diagnosis. Surgical aortic valve repair resulted in complete resolution of symptoms. Ethics approved (SCHN: CCR2023/5). Discussion Isolation of the left coronary ostium caused by a dysplastic aortic valve (without supravalvar stenosis) is an example of a rare cause of ischemic chest pain in children. To our knowledge, only ten pediatric case reports are published in English. In reported cases, presenting features varied from poor feeding and a murmur in infants to chest pain, syncope or cardiac arrest in adolescents. Historically, angiography during a cardiac catheter procedure was required for diagnosis, however improvements in non-invasive imaging techniques have resulted in the diagnosis being possible on echocardiography (supported by CT angiography or cardiac MRI).

A model of chronic thromboembolic pulmonary hypertension with the use of microencapsulated fibrin particles

Aim. To develop a model of chronic thromboembolic pulmonary hypertension (CTEPH) in rats by embolization of the pulmonary vascular bed with microencapsulated fibrin (MF).Materials and methods. Microencapsulated fibrin (MF) was prepared by encapsulating fibrin particles smaller than 71 μm in sodium alginate. Non-encapsulated fibrin with a particle size of 71–200 µm was used as an alternative embolic particle. Modeling was performed on male Wistar rats. The animals were divided into 4 groups. Intact (INT) animals (n = 7) were administered normal saline intravenously. In the NF8 group (n = 14), non-encapsulated fibrin was injected as embolic particles 8 times every 4 days. In the MF5 group (n = 14), 0.5 ml MF (9,047 ± 430 particles) was administered intravenously 5 times every 5 days. In the MF8 group (n = 14), MF was administered 8 times every 4 days. Six weeks after the last injection of embolic particles, cardiac catheterization with manometry and histologic examination of the lungs were performed.Results. According to cardiac catheterization, right ventricular systolic pressure (RVSP) in the MF8 group was significantly higher compared to rats from the INT and NF8 groups (p &lt; 0.05). The hypertrophy index and the percentage of collagen fibers in the structure of the vascular wall of the pulmonary artery branches were significantly higher in the MF5 and MF8 groups than in the INT and NF8 groups (p &lt; 0.01). There were no significant differences between the MF5 and MF8 groups.Conclusion. A representative CTEPH model in rats was developed, characterized by a stable increase in RVSP and pronounced structural changes in the branches of the pulmonary artery.

Atypical Atrial Flutter: Electrophysiological Characterization and Effective Catheter Ablation.

Atrial flutter (AFL), defined as macro-re-entrant atrial tachycardia, is associated with debilitating symptoms, stroke, heart failure, and increased mortality. AFL is classified into typical, or cavotricuspid isthmus (CTI)-dependent, and atypical, or non-CTI-dependent. Atypical AFL is a heterogenous group of re-entrant atrial tachycardias that most commonly occur in patients with prior heart surgery or catheter ablation. The ECG pattern is poorly predictive of circuit anatomy but may still provide mechanistic insight. AFL is difficult to manage medically and catheter ablation is the preferred treatment for most patients. Recent progress in technology and clinical electrophysiology has led to detailed characterization of re-entry circuits and effective ablation strategies. Combined activation and entrainment mapping are key to identifying the re-entry circuit. The presence of a slow-conducting isthmus, localized re-entry, dual-loop re-entry or bystander loops may lead to misleading activation maps but can be identified by electrogram examination and entrainment mapping. In the occasional patient without inducible AFL, substrate mapping in sinus rhythm may be a viable strategy. Long-term ablation success requires the creation of a transmural continuous lesion across a critical component of the re-entry circuit. Procedural endpoints include bidirectional conduction block across linear lesions and non-inducibility of atrial tachycardia. The present review discusses the epidemiology, mechanisms, ECG characteristics, electrophysiological characterization, and catheter ablation of atypical AFL.

Treatment of vision-threatening branch retinal artery occlusion following coronary angioplasty with surgical displacement of embolus.

To report a successful case of vision restoration and macular reperfusion following branch retinal artery occlusion (BRAO) using pars plana vitrectomy with undermining the artery off the retinal bed. This case report involves a 75-year-old patient who was diagnosed immediately with BRAO following cardiac catheterization procedure. An embolus at the superior retinal artery bifurcation was noted. Initial treatments were ineffective, leading to a pars plana vitrectomy and mechanical elevation of the artery, performed six hours post-occlusion. The surgical intervention successfully dislodged the embolus, resulting in significant visual improvement. Post-operative day 1, 4, and 14 assessments showed visual acuity improvement to counting fingers at 2 meters, 20/40, and 20/20, respectively. Fundoscopic examination and OCT angiography confirmed improved macular perfusion and normalization of the flow signal in the affected artery. This case highlights the efficacy of pars plana vitrectomy and mechanical elevation of the artery for BRAO where the embolus can be visualized. Prompt identification and referral for surgical intervention in BRAO cases with poor prognosis are crucial for favorable visual outcomes. Further research is needed to assess the efficacy of this surgical technique and other interventions for managing BRAO.

The effect of cardiac catheterization on thyroid functions in infants with congenital heart diseases: a prospective observational study

This study aims to determine the incidence, clinical course, and risk factors of hypothyroidism following cardiac catheter (CC) in infants with congenital heart diseases (CHD). This prospective study involved 115 patients with CHD, all aged 3 years or younger, who underwent CC, as well as 100 healthy age- and sex-matched controls. Baseline thyroid function tests (TFTs) were conducted for both the patients and controls. In the CHD cohort, TFTs were reassessed 4 weeks after the CC, and for those with abnormal TFT values at this time, the tests were repeated after 2 weeks. Levothyroxine was started for patients with persistent abnormal TFTs, at 4 weeks and 6 weeks assessments after CC. Four weeks after CC, 12% of the studied group exhibited hypothyroidism. Univariate analysis identified significant predictors of hypothyroidism following CC: aortic stenosis (RR = 10.0 (1.49–66.99), P = 0.018), duration of fluoroscopy during CC (RR = 2.12 (0.99–4.26), P = 0.05), and total iodinated contrast media (iCM) during CC (RR = 2.5 (1.35–3.55), P = 0.019). Multivariate analysis indicated that iCM dose was the sole significant predictor of developing hypothyroidism (RR = 2.10 (1.01–3.23), P = 0.04). ROC curve analysis showed that the cut-off point of iCM dose for prediction of hypothyroidism evolution is 8.7 gm/kg, (sensitivity: 83%, specificity: 65%), while the cut-off point of fluoroscopy duration which predicts the development of hypothyroidism is 24 min (sensitivity: 83%, specificity: 66%). Acquired hypothyroidism after CC persisted in 4% of this cohort for 6 months.Conclusion: Higher doses of iCM and longer duration of fluoroscope during CC are risk factors for the evolution of hypothyroidism post-CC. We recommend assessing thyroid profile 4 weeks after CC, particularly in patients who received an iCM dose greater than 8.7 gm/kg and/or exposed to fluoroscopy for more than 24 min. What is known:• The use of excess iodine leads to transient inhibition of thyroid hormones biosynthesis via the Wolff-Chaikoff effect.• Infants with congenital heart diseases (CHD) are more prone to hypothyroidism due to higher frequency of abnormal thyroid morphology and routine exposure to supraphysiological doses of iodine.What is new:• Exposure to a total dose of iodinated contrast media more than 8.7 gm/kg and a fluoroscopy duration more than 24 min during cardiac catheter are risk factors for the evolution of thyroid hypofunction following cardiac catheter.