Diastolic Component Research Articles

Sacubitril/Valsartan Combination Partially Improves Cardiac Systolic, but Not Diastolic, Function through β-AR Responsiveness in a Rat Model of Type 2 Diabetes

Cardiovascular complications are the major cause of diabetes mellitus-related morbidity and mortality. Increased renin–angiotensin–aldosterone system activity and decreased β-adrenergic receptor (β-AR) responsiveness contribute to diabetic cardiac dysfunction. We evaluated the effect of sacubitril/valsartan (neprilysin inhibitor plus angiotensin receptor antagonist combination) and valsartan treatments on the diabetic cardiac function through β-AR responsiveness and on protein expression of diastolic components. Six-week-old male Sprague Dawley rats were divided into control, diabetic, sacubitril/valsartan (68 mg/kg)-, and valsartan-treated (31 mg/kg) diabetic groups. Diabetes was induced by a high-fat diet plus low-dose streptozotocin (30 mg/kg, intraperitoneal). After 10 weeks of diabetes, rats were treated for 4 weeks. Systolic/diastolic function was assessed by in vivo echocardiography and pressure–volume loop analysis. β-AR-mediated responsiveness was assessed by in vitro papillary muscle and Langendorff heart experiments. Protein expression of sarcoplasmic reticulum calcium ATPase2a, phospholamban, and phosphorylated phospholamban was determined by Western blot. Sacubitril/valsartan improved ejection fraction and fractional shortening to a similar extent as valsartan alone. None of the treatments affected in vivo diastolic parameters or the expression of related proteins. β1-/β2-AR-mediated responsiveness was partially restored in treated animals. β3-AR-mediated cardiac relaxation (an indicator of diastolic function) responses were comparable among groups. The beneficial effect of sacubitril/valsartan on systolic function may be attributed to improved β1-/β2-AR responsiveness.

PEEP trial and effect on hemodynamic in cardiogenic shock

Abstract Funding Acknowledgements None. Introduction Congestion is a paramount pathophysiological driver in patients with cardiogenic shock. Almost half of patients admitted due to cardiogenic shock undertake mechanical ventilation although ventilatory parameter, and their potential hemodynamic effect on the hemodynamic and congestion profile are often neglected. Purpose We sought to evaluate the hemodynamic effect of positive end-expiratory pressure (PEEP) titration on patients admitted to intensive care unit for CS. Methods We perform PEEP titration trial on patients undertaking mechanical ventilation for respiratory failure related to CS. The trial consisted in 3 steps of PEEP increase from 5 to 15 cmH2O. For each step arterial saturation, right atrial -RAP- and systemic blood pressure along with heart rate and respiratory mechanics (tidal volume-TV-, dynamic lung compliance- CLdyn, driving- Δ- and plateau pressure- Ppl) were measured. All the measures were taken at end-expiration; RAP trace was analyzed and systolic, mean and diastolic component collected. The final PEEP was decided based on the best matching between saturation, CLdyn and TV. Descriptive and repeated measures with Bonferroni correction were applied as statistical analysis (IBM SPSS 29). Results Twelve patients were included (10 male, 66 ± 7 years old; 8 acute myocardial infarction and 4 acute heart failure). At baseline the mean RAP was 8.44 (± 2.32) ; SBP 106 (IQR 92-112), HR 94 (IQR 88 - 102) Δ and Ppl pressures respectively 7.42 (± 0.79) and 12.08 (± 0.79, ),VT 427(± 65.42) and CLdyn 58.3 (± 7.1). The right atrial pressure (RAP) differed between AMI and AHDF (8.25 ± 2.25 vs 20.25 ± 1.5; p < 0.001), so HR did (113 ± 3.4 versus 96 ± 3.2 betas per minutes; p 0.015). RAP varied consistently during the PEEP trial (either sRAP, dRAP and mRAP- Table and Figure 1). The TV changed signficnatly between the 1st and 3rd step (p 0.004) and the CLdyn varied consistently throughout the 3 steps of the PEEP trial (p <0.001). A significant difference were observed according to aetiology in RAP (AMI Vs ADHF, eman difference 2.4 versus 4.3 mmHg) and in CLdyn (AMI Vs ADHF mean difference 12.31 vs 8 .65, p < 0.01) but not in the other parameters evaluated (p > 0.05). Conclusion This is the first, small, study evaluating the effect of positive pressure ventilation in CS patients according to etiologies. As previously demonstrated PEEP influences the right side hemodynamic by increasing the RAP, although resulting in better CLdyn. The extent of the effect of PEEP increased may be dependent on the underlying aetiology of CS. Considering that the sample size is extremely limited, these results advocate a wider validation. However, the positive pressures induced by the ventilation in patient with CS should be taken in consideration when the comprehensive evaluation of hemodynamic to define congestion profile and phenotype are performed.Table 1.Hemodynamic parametersGraph PEEP vs RAP

Evaluation of arteriovenous fistula for hemodialysis with a new generation digital stethoscope: a pilot study.

The management of complications of arteriovenous fistula (AVF) for hemodialysis, principally stenosis, remains a major challenge for clinicians with a substantial impact on health resources. Stenosis not infrequently preludes to thrombotic events with the loss of AVF functionality. A functioning AVF, when listened by a stethoscope, has a continuous systolic-diastolic low-frequency murmur, while with stenosis, the frequency of the murmur increases and the duration of diastolic component decreases, disappearing in severe stenosis. These evidences are strictly subjective and dependent from operator skill and experience. New generation digital stethoscopes are able to record sound and subsequently dedicated software allows to extract quantitative variables that characterize the sound in an absolutely objective and repeatable way. The aim of our study was to analyze with an appropriate software sounds from AVFs taken by a commercial digital stethoscope and to investigate the potentiality to develop an objective way to detect stenosis. Between September 2022 and January 2023, 64 chronic hemodialysis (HD) patients were screened by two blinded experienced examiners for recognized criteria for stenosis by Doppler ultrasound (DUS) and, consequently, the sound coming from the AVFs using a 3M™ Littmann® CORE Digital Stethoscope 8570 in standardized sites was recorded. The sound waves were transformed into quantitative variables (amplitude and frequency) using a sound analysis software. The practical usefulness of the core digital stethoscope for a quick identification of an AVF stenosis was further evaluated through a pragmatic trial. Eight young nephrologist trainees underwent a simple auscultatory training consisting of two sessions of sound auscultation focusing two times on a "normal" AVF sound by placing the digital stethoscope on a convenience site of a functional AVF. In 48 patients eligible, all sound components displayed, alone, a remarkable diagnostic capacity. More in detail, the AUC of the average power was 0.872 [95% CI 0.729-0.951], while that of the mean normalized frequency was 0.822 [95% 0.656-0.930]. From a total of 32 auscultations (eight different block sequences, each one comprising four auscultations), the young clinicians were able to identify the correct sound (stenosis/normal AVF) in 25 cases, corresponding to an overall accuracy of 78.12% (95% CI 60.03-90.72%). The analysis of sound waves by a digital stethoscope permitted us to distinguish between stenotic and no stenotic AVFs. The standardization of this technique and the introducing of data in a deep learning algorithm could allow an objective and fast method for a frequent monitoring of AVF.

Relative importance of left atrial reservoir strain compared with components of the HFA-PEFF score: a cross-sectional study.

The relative importance of left atrial reservoir strain (LASr) regarding the Heart Failure Association Pre-test assessment, Echocardiography and natriuretic peptide, Functional testing, Final etiology (HFA-PEFF) score, a diagnostic tool for patients with heart failure with preserved ejection fraction (HFpEF), remains unclear. We aimed to identify the relative importance of LASr compared with variables associated with HFpEF and HFA-PEFF scores. Between August 2021 and July 2022, we obtained retrospective data from the participants visiting a single cardiovascular center with subjective symptoms of heart failure, such as dyspnea or chest discomfort. In total, 2,712 participants with sinus rhythm and ejection fraction of more than 50% were enrolled. Multivariable logistic regression analysis, random forest analysis, and supervised machine learning algorithms were performed to identify the relative importance of LASr to the HFA-PEFF score. The average HFA-PEFF score was 2.4 ± 1.6 points. Two hundred and thirty-eight participants had 5 or 6 points. LASr showed a moderate correlation with the HFA-PEFF score (r = -0.50, p < 0.001). Impaired LASr < 25.2% was an independent variable affecting a high HFA-PEFF score with traditional diastolic function parameters and components of the HFA-PEFF diagnostic algorithm. The odds ratio (OR) [1.74, 95% confidence interval (CI) 1.23-2.47] for LASr was higher compared to that of left ventricular global longitudinal strain (OR 1.59, 95% CI 1.14-2.21), septal E/e' (OR 1.23, 95% CI 0.85-1.77), and relative wall thickness (OR 1.20, 95% CI 0.76-1.89). LASr was also a relatively more important variable in estimating a high HFA-PEFF score than TR-Vmax, septal E/e', septal e', left ventricular mass index, and relative wall thickness, the major echocardiographic components of the HFA-PEFF score. LASr is an important factor with components of the HFA-PEFF score and is a useful tool to assess patients with HFpEF. URL: https://clinicaltrials.org. Unique identifiers: NCT05638230.

Antidiabetic Molecule Efficacy in Patients with Type 2 Diabetes Mellitus-A Real-Life Clinical Practice Study.

In this paper, we aim to evaluate the efficacy of antidiabetic cardioprotective molecules such as Sodium-Glucose Cotransporter-2 Inhibitors (SGLT-2i) and Glucagon-like Peptide 1 Receptor Agonists (GLP-1 RAs) when used with other glucose-lowering drugs, lipid-lowering, and blood pressure (BP)-lowering drugs in a real-life setting. A retrospective, observational study on 477 patients admitted consecutively in 2019 to the outpatient clinic of a tertiary care unit for Diabetes Mellitus was conducted. Body mass index (BMI), blood pressure (BP) (both systolic and diastolic), and metabolic parameters, as well as A1c hemoglobin, fasting glycaemia and lipid profile, including total cholesterol (C), HDL-C, LDL-C and triglycerides), were evaluated at baseline and two follow-up visits were scheduled (6 months and 12 months) in order to assess the antidiabetic medication efficacy. Both SGLT-2i and GLP-1 RAs were efficient in terms of weight control reflected by BMI; metabolic control suggested by fasting glycaemia and A1c; and the diastolic component of BP control when comparing the data from the 6 and 12-month visits to the baseline, and when comparing the 12-month visit to the 6-month visit. Moreover, when comparing SGLT-2i and GLP-1 RAs with metformin, there are efficacy data for SGLT-2i at baseline in terms of BMI, fasting glycaemia, and HbA1c. In this retrospective study, both classes of cardioprotective molecules, when used in conjunction with other glucose-lowering, antihypertensive, and lipid-lowering medications, appeared to be efficient in a real-life setting for the management of T2DM.

CHANGES IN THE INTENSITY OF UTERINE CIRCULATION IN PREGNANT WOMEN WITH A HISTORY OF CHRONIC ENDOMETRITIS

CHANGES IN THE INTENSITY OF UTERINE CIRCULATION IN PREGNANT WOMEN WITH A HISTORY OF CHRONIC ENDOMETRITIS

Features of Ocular Blood Flow in Malignant Arterial Hypertension of Renal Origin

Color Doppler imaging allows a detailed non-invasive assessment of the state of blood flow in the retrobulbar vessels in patients with various vascular pathologies. Malignant hypertension (MH) is a clinical syndrome characterized by severe diastolic arterial hypertension (140 mm Hg or more), leading to ischemic damage to various organs — kidneys, heart, brain, eyes. Patients with MH often present with thrombotic microangiopathy (TMA), a rare life-threatening condition characterized by multiple systemic thromboses of the microvasculature.Purpose: to assess the state of blood flow in retrobulbar vessels by color Doppler imaging in TMA associated with MH.Methods: 10 patients (20 eyes) (age 43.5 ± 6.2 years) with TMA associated with MH underwent a study of the state of blood flow in the vessels of the retrobulbar space by color Doppler imaging. Qualitative and quantitative analyzes of retinal and choroidal circulation were assessed.Results. Analysis of the Doppler spectrum of blood flow in TMA associated with MH revealed a statistically significant increase in maximum systolic (Vsyst) and finale diastolic blood flow velocity (Vdiast) in the ophthalmic artery (OA), as well as Vsyst in the medial short posterior ciliary arteries (SPCA), compared with the control group (p &lt; 0.05). In 2 patients (20 %) of the study group, a significant bilateral decrease in the diastolic component of the spectrum was found up to the isoline (Vdiast = 0) and a maximum increase in the peripheral resistance index (RI = 1.0). Statistically significant correlations were found between some laboratory parameters of blood serum (hemoglobin, lactate dehydrogenase, creatinine), as well as the estimated glomerular filtration rate and hemodynamic parameters in the central retinal artery (CRA), lateral (SPCA) and OA (p &lt; 0.05).Conclusion. The results of the study of ocular hemodynamics using color Doppler imaging in TMA associated with MH are presented for the first time. TMA associated with MH is characterized by a statistically significant increase in the maximum systolic blood flow velocity in the OA and SPCA with the development of an ischemic state in the retinal and choroidal microcirculation in some patients. An increase in TMA activity in MH leads to a change in the microcirculation of the retina and choroid of an ischemic nature. An increase in blood creatinine in patients with TMA with MH is statistically significantly associated with a decrease in systolic blood flow velocity in the CRA.

#4500 IMPLEMENTATION OF A NEW GENERATION DIGITAL STETHOSCOPE FOR ARTERIOVENOUS FISTULA MONITORING IN HEMODIALYSIS PATIENTS

Abstract Background and Aims The management of complications of arteriovenous fistula (AVF) for hemodialysis, principally stenosis, remains a major challenge for clinicians with a substantial impact on health resources. Stenosis not infrequently preludes to thrombotic events with the loss of AVF functionality. A frequent monitoring with physical examination is at the basis for an appropriate clinical care. It includes a regular inspection, palpation and auscultation of the arm. A normally functioning AVF, when listened by a stethoscope, has a continuous systolic-diastolic low-frequency murmur while with stenosis the frequency of the murmur increases and the duration of diastolic component decreases, disappearing in severe stenosis. These evidences are strictly subjective and dependent from operator skill and experience. New generation digital stethoscopes are able to record sound and subsequently dedicated software allows to extract quantitative variables (amplitude and frequency) that characterize the sound in an absolutely objective and repeatable way. The aim of our study was to analyze with an appropriate software listenable sound from AVFs taken by a commercial digital stethoscope and to investigate the potentiality to develop an objective new monitoring system to detect stenosis. Method Between September 2022 and January 2023, we screened forty-eight patients from two hemodialysis centers in Catanzaro (Italy). Patients were screened from two blinded experienced examiners for recognized criteria for stenosis by doppler ultrasound (DUS). We recorded the sound coming from the AVFs using a 3M™ Littmann® CORE Digital Stethoscope 8570 (Figure 1-A), in standardized sites: on the anastomosis chamber, at a distance of 5 and 10 cm from it, on the site of stenosis and immediately after. The sound waves were transformed into quantitative variables (amplitude and frequency) using a sound analysis software. Results Based on doppler evaluation, 14/48 patients (29%) were classified as stenotic of which three were hemodynamically significant. The sounds detected in the stenosis sites had a significant higher average frequency compared to non-stenotic sites (Figure 1-B). Characteristics of sound waves were significant different for stenotic and non-stenotic patients in term of average power, mean amplitude and mean frequency. Analysis of waves permitted us to determine peculiar shape for stenosis and another for normal AVF (Figure 1-C,D). Conclusions The analysis of sound waves by a digital stethoscope permitted us to distinguish between stenotic and no stenotic AVFs. The standardization of this technique and the introducing of data in a deep learning algorithm could allow an objective and fast method for a frequent monitoring of AVF.

Optimal or standard control of systolic and diastolic blood pressure across risk factor categories in patients with chronic coronary syndromes.

Guidelines have lowered blood pressure (BP) targets to <130/80 mmHg. We examined the benefit of intensive control for each BP component, vs. the burden of other modifiable risk factors, in patients with chronic coronary syndromes (CCS). The CLARIFY registry (ISRCTN43070564) enrolled 32 703 patients with CCS, from 2009 to 2010, with a 5-year follow-up. Patients with either BP component below European guideline safety boundaries (120/70 mmHg) were excluded, leaving 19 167 patients (mean age: 63.8 ± 10.1 years, 78% men) in the present analysis. A multivariable-adjusted Cox proportional hazards model showed a gradual increase in cardiovascular risk (cardiovascular death, myocardial infarction, or stroke) when the number of uncontrolled risk factors (active smoking, no physical activity, low-density lipoprotein cholesterol ≥100 mg/dL, and diabetes with glycated haemoglobin ≥7%) increased [adjusted hazard ratio (HR): 1.34; 95% confidence interval (CI): 1.17-1.52, 1.65 (1.40-1.94), and 2.47 (1.90-3.21) for 1, 2, and 3 or 4 uncontrolled risk factors, respectively, vs. 0], without significant interaction with BP. Although uncontrolled systolic (≥140 mmHg) and diastolic (≥90 mmHg) BP were both associated with higher risk than standard BP, standard BP was associated with higher risk than optimal control for only the diastolic component (adjusted HR: 1.08; 95% CI: 0.94-1.25 for systolic BP 130-139 vs. 120-129 mmHg and 1.43; 95% CI: 1.27-1.62 for diastolic BP 80-89 vs. 70-79 mmHg). Our results suggest that the optimal BP target in CCS may be ≤139/79 mmHg and that optimizing the burden of other risk factors should be prioritized over the further reduction of systolic BP.

Study of prevalence of prehypertension and hypertension among urban school-going children in Tripura

Introduction: Prehypertension is defined as an independent category of blood pressure (BP) by the seventh joint national committee on prevention, detection, evaluation, and treatments of BP. Systolic BP (SBP) between 120 and 139 mm Hg or diastolic BP between 80 and 89 mm Hg are considered to have prehypertension. BP ≥140/90 mm Hg is considered hypertension. It is to assess the prevalence of prehypertension and hypertension among urban school-going children. Materials and Methods: A cross-sectional study was conducted among 1011 school-going children of both sexes within 12–17 years of age group and each participant was selected using a simple random sampling technique. Pretested predesigned questionnaire was used for data collection. Results: Prevalence of normotensive, prehypertensive, and hypertensive were 73.6%, 19.4%, and 7%, respectively, when both systolic and diastolic components have been taken into account. Conclusion: This study has showed that more than 19% prehypertensive and 7% hypertensive among the school-going children aged between 12 and 17 years when both systolic and diastolic components have been taken into account.

Age-Related Changes In Blood Pressure Among Young Adults

Blood pressure is the common name for what is technically known as systemic arterial pressure, which is the pressure inside the major arteries that feed the body's circulatory system. This number delineates the systolic and diastolic components of blood pressure. One of the most closely watched clinical markers, blood pressure, is essential in charting treatment progress. The importance of measuring blood pressure stems from the correlation between present blood pressure and the possibility of future health problems. A person's arteries and heart must work harder when blood pressure is high. In the long run, this stress may make the arteries less elastic, less intense, and thicker, all of which are bad. Monitoring a patient's blood pressure is crucial to ensure it doesn't rise to dangerous levels. High blood pressure, often known as HBP, is a severe health problem. The illness is sometimes called "the silent killer" due to the lack of apparent symptoms. For instance, a medical professional may quickly monitor the patient's blood pressure [1, 2]

Intra-cardiac pressure drop and flow distribution of bicuspid aortic valve disease in preserved ejection fraction.

BackgroundBicuspid aortic valve (BAV) is more than a congenital defect since it is accompanied by several secondary complications that intensify induced impairments. Hence, BAV patients need lifelong evaluations to prevent severe clinical sequelae. We applied 4D-flow magnetic resonance imaging (MRI) for in detail visualization and quantification of in vivo blood flow to verify the reliability of the left ventricular (LV) flow components and pressure drops in the silent BAV subjects with mild regurgitation and preserved ejection fraction (pEF).Materials and methodsA total of 51 BAV patients with mild regurgitation and 24 healthy controls were recruited to undergo routine cardiac MRI followed by 4D-flow MRI using 3T MRI scanners. A dedicated 4D-flow module was utilized to pre-process and then analyze the LV flow components (direct flow, retained inflow, delayed ejection, and residual volume) and left-sided [left atrium (LA) and LV] local pressure drop. To elucidate significant diastolic dysfunction in our population, transmitral early and late diastolic 4D flow peak velocity (E-wave and A-wave, respectively), as well as E/A ratio variable, were acquired.ResultsThe significant means differences of each LV flow component (global measurement) were not observed between the two groups (p > 0.05). In terms of pressure analysis (local measurement), maximum and mean as well as pressure at E-wave and A-wave timepoints at the mitral valve (MV) plane were significantly different between BAV and control groups (p: 0.005, p: 0.02, and p: 0.04 and p: <0.001; respectively). Furthermore, maximum pressure and pressure difference at the A-wave timepoint at left ventricle mid and left ventricle apex planes were significant. Although we could not find any correlation between LV diastolic function and flow components, Low but statistically significant correlations were observed with local pressure at LA mid, MV and LV apex planes at E-wave timepoint (R: −0.324, p: 0.005, R: −0.327, p: 0.004, and R: −0.306, p: 0.008, respectively).ConclusionIn BAV patients with pEF, flow components analysis is not sensitive to differentiate BAV patients with mild regurgitation and healthy control because flow components and EF are global parameters. Inversely, pressure (local measurement) can be a more reliable biomarker to reveal the early stage of diastolic dysfunction.

Significance of abnormal and late ventricular signals in ventricular tachycardia ablation of ischemic and nonischemic cardiomyopathies

Abnormal ventricular signals (AVS) are the cornerstone of substrate-based ventricular tachycardia (VT) ablation in sinus rhythm. Signal characterization of AVS in ischemic and nonischemic cardiomyopathies has never been performed. The purpose of this study was to describe ventricular signal abnormalities in 3 different pathologies and examine their association with the diastolic component of VT circuits. A total of 45 patients (15 ischemic cardiomyopathy [ICM], 15 arrhythmogenic cardiomyopathy [ACM], 15 dilated cardiomyopathy [DCM]) who had undergone VT ablation with >50% of the diastolic pathway of the VT circuit recorded were studied. AVS were classified into late potentials (LPs) and continuous fractionated ventricular signals (CFVS), and their characteristics and correlation with the diastolic pathway of VT circuits were analyzed. Seventy-five VT circuits were analyzed. Bipolar scars were greatest in ICM endocardially (53 cm2 ICM vs 36 cm2 ACM vs 25 cm2 DCM; P = .010) and in ACM epicardially (98 cm2 ACM vs 25 cm2 ICM vs 24 cm2 DCM; P = .005). Location of the VT diastolic interval coincided with AVS location in 54% of VTs in ICM, 89% in ACM, and 72% in DCM (P = .036). There was a trend toward a greater association of diastolic intervals coinciding with LPs than with CFVS (78% vs 57%; P = .052) (69% diastolic intervals in ICM coincided with LPs, 33% with CFVS; P = .063). All patients (100%) with CFVS in ACM hadVTdiastolic components arising from CFVS (33% ICM, 64% DCM; P = .049). Positive predictive value for LPs vs CFVS was 77.8% vs 56.7%, and sensitivity was 67.3% vs 32.7%, respectively. The nature of abnormal signals in different cardiomyopathies reflects underlying pathology. LPs rather than CFVS seem to be more linked to diastolic components of VT circuits, especially in ICM. LPs have greater sensitivity and specificity for VT; however, CFVS may be of more relevance in ACM.

DOPPLER ASSESSMENT OF UTERO-PLACENTAL HEMODYNAMICS IN PREGNANT WOMEN WITH A HISTORY OF CORONAVIRUS DISEASE (COVID-19)

The latest viral disease, which continues to spread today, is caused by a new coronavirus and poses a serious threat to public health around the world. To date, the effects of COVID-19 on pregnant women and infants have not been fully studied and remain a key area of interest. The study aimed to assess utero-placental circulation using Doppler ultrasound for pregnant women with a case history of coronavirus disease (COVID-19). A Doppler screening of utero-placental hemodynamics was performed for 156 pregnant women at 18-22 weeks. Of those, 75 pregnant women with a case history of coronavirus disease COVID-19 were in the first trimester of pregnancy. An abnormal blood flow was observed within the experimental group in 14 cases (18.6%). The analysis of spectrograms revealed the unevenness of the diastolic component with the formation of a dicrotic notch in the early diastolic phase in 5 cases (6.6%). In comparison with the control group, pregnant women with COVID-19 were twice as likely to have impaired blood flow in the uterine arteries. Uterine artery doppler measurement is really important for predicting adverse pregnancy outcomes and perinatal losses. Doppler indices of utero-placental blood flow have clinical value for pregnant women who have recovered from COVID-19.

Left atrial booster-pump function as a predictive parameter for atrial fibrillation in patients with severely dilated left atrium.

Left atrial (LA) dimension ≥50 mm had approximately four times the risk of developing atrial fibrillation (AF). The aim of this study was to investigate whether the application of clinical and echocardiographic parameters could differentiate between the patients having severely dilated left atrium with and without AF. This retrospective cross-sectional study enrolled consecutive patients with LA dimension ≥50 mm and divided them into three groups: no AF (no-AF), paroxysmal AF (PAF) and non-paroxysmal AF (non-PAF) groups. For PAF and non-PAF groups, all patients underwent radiofrequency ablation, and the echocardiographic parameters were obtained on the next day after ablation. Our study population comprised 160 patients, including 80, 53, and 27 patients in the non-AF, PAF and non-PAF groups, respectively. The no-AF group had a significantly higher body mass index (kg/m2) (29.31±6.27, 27.58±4.12 and 26.57±2.81, P=0.01), and a higher prevalence of diabetes mellitus (DM) [31 (38.80%), 13 (25.00%) and 4 (14.80%), P=0.01] and hypertension [67 (83.80%), 34 (65.40%), and 19 (70.40%), P=0.04], but a lower prevalence of rheumatic heart disease (RHD) [3 (3.80%), 6 (11.50%) and 5 (18.50%), P=0.02] and sick sinus syndrome [0 (0.00%), 6 (11.50%) and 4 (14.80%), P=0.045]. Echocardiographic studies showed that the non-AF group had significantly smaller LA minimal volume index (24.89±9.74, 34.06±19.38 and 42.83±17.44 mL/m2, P<0.01), higher LA emptying fraction (51.99%±13.97%, 38.40%±15.96% and 33.89%±10.73%, P<0.01), longitudinal strain (23.87%±7.72%, 17.11%±8.52% and 12.38%±4.28%, P<0.01) and strain rate than the AF groups. The multivariate analysis showed that the late diastolic component of LA strain rate was the only independent factor associated with the presence of AF (odds ratio, 21.69; 95% CI, 9.77-48.13, P<0.01). LA function plays an important role in the absence of AF in patients with LA dimension ≥50 mm; the late diastolic component of LA strain rate was the only independent variable on multivariate analysis.

Zanimljiv slučaj koronarno-kameralne fistule sa anginom pektoris

Introduction: Coronary-cameral fistula (CCF) is an anomalous connection between a coronary artery and a cardiac chamber. Most CCFs are discovered incidentally during angiographic evaluation of coronary vascular disorders. We report a case of CCF with angina pectoris. Case report: A 67-year-old woman presented with chest pain and dyspnea upon exertion. Coronary angiography showed atherosclerotic lesions in the two major coronary arteries, but also communication between three arteries and the cavity of the right ventricle (RV) through many small, diffuse fistulas. Angiography also showed a fistula between the proximal left anterior descending artery (LAD) (first septal branch) and the right ventricle, as well as between the proximal right coronary artery (RCA) (acute marginal branch) and the right ventricle. The patient qualified to undergo coronary artery bypass graft surgery (CABG) and surgical closing of the fistulas, which is why we performed, on a beating heart, double vessel revascularization by autovein graft between the ascending aorta and the RCA and between the ascending aorta and the LAD, as well as closing of the fistulas with hemoclips and polypropylene suture, with a teflon pledget. Conclusion: Hemodynamically insignificant fistulas, which are clinically silent and not associated with other abnormal findings, most commonly do not require further treatment. Large, hemodynamically significant fistulas should be closed by ligation. However, smaller fistulas tend to get larger with age and it is recommended that early elective closure is performed in patients experiencing symptoms or in asymptomatic patients with a continuous murmur or a systolic murmur with an early diastolic component.

Late Gadolinium Enhancement Cardiovascular Magnetic Resonance Assessment of Substrate for Ventricular Tachycardia With Hemodynamic Compromise.

Background: The majority of data regarding tissue substrate for post myocardial infarction (MI) VT has been collected during hemodynamically tolerated VT, which may be distinct from the substrate responsible for VT with hemodynamic compromise (VT-HC). This study aimed to characterize tissue at diastolic locations of VT-HC in a porcine model.Methods: Late Gadolinium Enhancement (LGE) cardiovascular magnetic resonance (CMR) imaging was performed in eight pigs with healed antero-septal infarcts. Seven pigs underwent electrophysiology study with venous arterial-extra corporeal membrane oxygenation (VA-ECMO) support. Tissue thickness, scar and heterogeneous tissue (HT) transmurality were calculated at the location of the diastolic electrograms of mapped VT-HC.Results: Diastolic locations had median scar transmurality of 33.1% and a median HT transmurality 7.6%. Diastolic activation was found within areas of non-transmural scar in 80.1% of cases. Tissue activated during the diastolic component of VT circuits was thinner than healthy tissue (median thickness: 5.5 mm vs. 8.2 mm healthy tissue, p < 0.0001) and closer to HT (median distance diastolic tissue: 2.8 mm vs. 11.4 mm healthy tissue, p < 0.0001). Non-scarred regions with diastolic activation were closer to steep gradients in thickness than non-scarred locations with normal EGMs (diastolic locations distance = 1.19 mm vs. 9.67 mm for non-diastolic locations, p < 0.0001). Sites activated late in diastole were closest to steep gradients in tissue thickness.Conclusions: Non-transmural scar, mildly decreased tissue thickness, and steep gradients in tissue thickness represent the structural characteristics of the diastolic component of reentrant circuits in VT-HC in this porcine model and could form the basis for imaging criteria to define ablation targets in future trials.

Utility of volume-strain loops in diastolic function assessment of patients with hypertrophic cardiomyopathy

Abstract Background Diastolic function assessment in patients with hypertrophic hearts and preserved ejection fraction (EF) is a rather challenging task. Combined plotting of deformation parameters against other indices, especially left ventricular (LV) volume, may reflect diastolic function components of the hypertrophic myocardium. Purpose Aim of this study was i) to apply strain-volume loops (SVLs) in hypertrophic cardiomyopathy (HCM) patients based on simultaneous frame-by-frame strain and volume changes' recordings acquired by means of three-dimensional (3D) speckle tracking imaging and ii) to investigate potential correlations between these loops, traditional diastolic function indices and phenotypic features of HCM (thickness, obstruction and fibrosis) that may also reflect myocardial “stiffness”. Methods We included 40 HCM patients (54.1±14.3 years, 82.5% male, maximum wall thickness 19.3±4.8mm) who have consecutively undergone 3D-speckle tracking echocardiography and cardiovascular magnetic resonance (CMR) with late gadolinium enhancement (LGE). Values of 3D strain were plotted vs. volume for each frame to build an SVL. Peak of radial, longitudinal and circumferential systolic strain (Rsp, Lsp, and Csp, respectively), systolic slopes of the loops (RsSl, LsSl, CsSl), strain to end-diastolic volume (EDV) ratios (Rs/V, Ls/V, Cs/V) as well as the extent of systolic-diastolic uncoupling (difference between systolic and diastolic strain for the same volume) (panel A) were computed for the analysis. Left atrial volume index (LAVI), E/E' and tricuspid regurgitation velocity (TRvel) were measured to define diastolic dysfunction (DD) stage. Burden of fibrosis was evaluated by LGE extent in CMR slices. Results All HCM patients had preserved EF (60.5±5,7%), while 16 (40%) had LV outflow tract obstruction (LVOTO&amp;gt;30 mm Hg at rest). Mean LV mass index was 78.9±14.5 g (evaluated by 3D echocardiography). LGE was observed in 23 patients (57.5%) occupying 5.2±4.5% of LV mass. Concerning SVLs the following values were recorded for radial (Rsp 30.8±9.8%, RsSl 0.4±0.13 and Rs/V 0.25±0.09), longitudinal (Lsp −9.4±3.7%, LsSl 0.12±0.06 and Ls/V 0.08±0.04) and circumferential deformation (Csp −14.2±3.5%, CsSl 0.18±0.05 and Cs/V 0.11±0.03). Traditional isolated diastolic indices (E/E', LAVI, TRvel and DD stage) did not present significant correlations with SVL parameters or HCM phenotypic features. However, potentially “stiffer” hearts (combination of increased LVMI and fibrosis) presented a leftward transition of longitudinal SVLs, which also became wider (greater uncoupling) (panel B). Conclusions Traditional diastolic indices show modest only correlations with SVLs or HCM phenotypic characteristics, necessitating new approaches to DD of HCM patients. SVLs seem to be a promising-innovative tool for indirect assessment of myocardial “stiffness” and diastolic function. Funding Acknowledgement Type of funding sources: None. Figure 1

Peripheral chemoreflex activation and cardiac function during hypoxemia in near-term fetal sheep without placental compromise.

A drop in arterial oxygen content activates fetal chemoreflex including an increase in sympathetic activity leading to peripheral vasoconstriction and redistribution of blood flow to protect the brain, myocardium, and adrenal glands. By using a chronically instrumented fetal sheep model with intact placental circulation at near-term gestation, we investigated the relationship between peripheral chemoreflex activation induced by hypoxemia and central hemodynamics. A total of 17 Åland landrace sheep fetuses at 115-128/145 gestational days were instrumented. Carotid artery was catheterized in 10 fetuses and descending aorta in 7 fetuses. After a 4-day recovery, baseline measurements of fetal arterial blood pressures, blood gas values, and fetal cardiovascular hemodynamics by pulsed Doppler ultrasonography were obtained under isoflurane anesthesia. Comparable data to baseline were collected 10 min (acute hypoxemia) and 60 min (prolonged hypoxemia) after maternal hypo-oxygenation to saturation level of 70%-80% was achieved. During prolonged hypoxemia, pH and base excess (BE) were lower and lactate levels were higher in the descending aorta than in the carotid artery. During hypoxemia mean arterial blood pressure (MAP) in the descending aorta increased, whereas in the carotid artery, MAP decreased. In addition, right pulmonary artery pulsatility index values increased, and the diastolic component in the aortic isthmus blood flow velocity waveform became more retrograde, thus decreasing the aortic isthmus antegrade/retrograde blood flow (AoI Net Flow) ratio. Both fetal ventricular cardiac outputs were maintained even during prolonged hypoxemia when significant fetal metabolic acidemia developed. Fetal chemoreflex activation induced by hypoxemia decreased the perfusion pressure in the cerebral circulation. Fetal weight-indexed left ventricular cardiac output (LVCO) or AoI Net Flow ratio did not correlate with a drop in carotid artery blood pressure.NEW & NOTEWORTHY During fetal hypoxemia with intact placental circulation, peripheral chemoreflex was activated, as demonstrated by an increase in the descending aorta blood pressure, pulmonary vasoconstriction, and an increase in retrograde diastolic AoI blood flow, while both ventricular cardiac outputs remained stable. However, perfusion pressure in the cerebral circulation decreased. These changes were seen even during prolonged hypoxemia when significant metabolic acidosis developed. Weight-indexed LVCO or AoI Net Flow ratio did not correlate with a drop in carotid artery blood pressure.

Preventive effects of Pycnogenol® on cardiovascular risk factors (including endothelial function) and microcirculation in subjects recovering from coronavirus disease 2019 (COVID-19).

The aim of this open supplement study was to evaluate the effects of Pycnogenol® in comparison with controls on symptoms of post-COVID-19 syndrome and in improving endothelial function, microcirculation, inflammatory markers and oxidative stress over 3 months in symptomatic subjects recovering from COVID-19. Sixty subjects recovering from symptomatic COVID-19 were included. One group of 30 followed a standard recovery management while 30 comparable subjects received a supplement of 150 mg Pycnogenol® daily (in 3 doses of 50 mg) in addition to standard management. Two groups of selected subjects were comparable at baseline. The groups progressively improved both with the SM (standard management) and with the SM in combination with the supplement. Patients, supplemented with Pycnogenol® showed significantly better improvement compared to the control group patients. No side effects from the supplementation were observed; tolerability was optimal. The progressive evolution over time was visible in all target measurements. Physiological tests: endothelial function, low in all subjects at inclusion was assessed by flow mediated dilation (FMD) and finger reactive hyperemia in the microcirculation (laser Doppler measurements) after the release of an occluding suprasystolic cuff. It was significantly improved in the Pycnogenol® group after one month and after 3 months (P<0.05 vs. controls). The rate of ankle swelling (RAS) by strain gauge decreased significantly in the supplemented group (P<0.05) in comparison with controls showing an improvement of the capillary filtration rate. At inclusion, the kidney cortical flow velocity indicated a decrease in perfusion (lower systolic and diastolic flow velocity) in all patients. Kidney cortical flow velocity increased significantly with the supplement (P<0.05) in comparison with controls with improvement in systolic velocity and in diastolic component. High sensitivity CRP (hs-CRP) and Il-6 plasma levels decreased progressively over 3 months with a significant more pronounced decrease in the supplement group (P<0.05). The number of patients with normal plasma IL-6 levels at the end of the study was higher (P<0.05) with the supplement. ESR followed the same pattern with a progressive and a more significant decrease in the supplemented subjects (P<0.02). Oxidative stress decreased significantly in the supplemented group (P<0.05) compared with the control group. Systolic blood pressure was significantly lower in the supplemented group (P<0.05) at the end of the study. Finally, the scores of Quality-of-life, mood and fatigue questionnaire and the Karnofsky Scale Performance Index significantly improved in the supplement group (P<0.05) compared to controls after 1 and 3 months. All other blood parameters (including platelets and clotting factors) were within normal values at the end of the study. In conclusion, Pycnogenol® may offer a significant option for managing some of the signs and symptoms associated with post-COVID-19 syndrome. This pilot evaluation offers some potential rationale for the use of Pycnogenol® in this condition that will have significant importance in the coming years.