Echocardiographic Monitoring Research Articles

Guideline adherence to echocardiographic monitoring of aortic stenosis

Abstract Background/Introduction Close monitoring of aortic stenosis (AS) by follow-up echocardiography is recommended by all Cardiology and Imaging Societies’ guidelines. Whether these guidelines are strictly followed is unknown. Purpose We aimed to describe our institution’s practice patterns for echocardiographic monitoring in patients with aortic sclerosis (AScl) and AS of any severity. Methods Adult patients residing in our institution’s county with an echocardiographic diagnosis of AScl or AS between 01/2005-01/2022 were identified and classified into 4 groups: AScl, mild AS, moderate AS, or severe AS, at each echocardiogram during the study timeframe. Kaplan Meier analyses were used to evaluate the composite outcome, the occurrence of follow-up echocardiogram or death. Patients were censored at the time of aortic valve replacement/repair, heart transplant, or last clinical follow-up. Guideline follow-up was considered appropriate when the primary outcome occurred by 5 years (AScl/mild AS), 2 years (moderate AS), and 1 year (severe AS). Results A total of 23,726 echocardiograms from 9,578 unique patients were included. At index echocardiogram, median patient age was 74 years (IQR 65-82) and 4,806 (50.2%) were women. AScl was observed in 7,358 (76.8%) cases, mild AS in 1,442 (15.1%) cases, moderate AS in 479 (5%), and severe AS in 301 (3.1%) cases. Rates of composite outcome achievement by the end of the guideline-recommended interval were 81%, 90%, 80%, and 72% in AScl, mild, moderate, and severe AS, respectively. Rates for men were 83%, 92%, 82%, and 75% in these groups, while rates for women were 78%, 88%, 78%, and 68%, respectively (Figure 1). Follow-up rates were similar before and after 2012 (when transcatheter aortic valve replacement was approved for treatment of severe AS in high-risk surgical patients in the USA). Follow-up rates were higher in patients managed by cardiovascular providers compared to non-cardiovascular providers (Figure 2). Conclusion Depending on disease severity, between one fourth and one tenth of patients remained alive and unfollowed at the end of their guideline-recommended surveillance interval. There is significant variability in echocardiogram monitoring based on sex and referring provider specialty. Figure 1 Figure 2

Value of combined cardiopulmonary exercise testing with stress echocardiography in the management of late effects cardio-oncology patients.

Abstract Introduction Advancements in cancer treatments are resulting in improved prognosis for patients. However, these therapies may cause cardiotoxicity, including left ventricular systolic dysfunction which may manifest years later. Echocardiographic monitoring frequency for cancer survivors, timing and role of initiation of cardioprotective medication to manage asymptomatic mild systolic dysfunction in this cohort is poorly understood. Aims To assess role of combined cardiopulmonary exercise test stress echo (CPET-SE) in providing additional benefit in monitoring patients at risk of cardiotoxicity. Methods Retrospective analysis of patients in the late effects clinic who were at higher risk of cardiotoxicity due to treatment received. Patients were referred for CPET-SE due to borderline reduced LVEF (<55%) with absence of heart failure symptoms. Results A total of 57 patients (mean age 32 years, 82% male, 70% receiving anthracycline treatment) were assessed between January 2019 and September 2022. Forty-nine (86%) patients performed a maximal exercise test, with all patients reporting fatigue as the reason to stop. 86% of patients showed appropriate contractile reserve with mean increase in LVEF of 9±6%. Mean resting and peak LVEF was 50 and 59% respectively (mean difference 9±5%). Only four patients saw no improvement in peak LVEF (3 of whom experienced a decrease with mean drop of -2%). There was improvement of longitudinal function: average resting and peak GLS were -14 and -17% respectively, with mean improvement of -3±2.1%. Average lateral S’ was 7.4 cm/s at rest and 12.5cm/s at peak exercise, mean increase was 5.1± 2.5cm/s. Despite improvement in cardiac function, all patients had reduced peak VO2 on CPET: average VO2 peak 26.8 ml/kg/min (69% target or moderately reduced). Mean peak O2 pulse was 11.5 ml/beat. VE/VCO2 was 25.5 suggesting there was no respiratory limitation, supported by normal spirometry, breathing reserve and oxygen saturations in all patients. Markers of contractile reserve and peak VO2/O2 pulse were significantly correlated (Figure 1): peak O2 pulse and peak EF r = 0.4 (P=0.004); between delta S’ and VO2 peak r = 0.3 (P=0.047), albeit relatively weak, indicating likely influence of non-cardiac causes on reduced peak VO2 / O2 pulse. Limitation in most patients was thought to be secondary to deconditioning. Conclusion Our data indicate that cancer survivors may demonstrate significant exercise limitation which remains underdiagnosed, and that non-cardiac factors likely contribute. CPET-SE differentiates cardiac dysfunction from other causes of exercise limitation and guide management focusing on rehabilitation programmes or early initiation of cardioprotective medication in patients with impaired contractile reserve.

Transesophageal echocardiography monitoring for liver transplantation: where are we now?

Intraoperative hemodynamic monitoring is crucial for managing patients with end-stage liver disease (ESLD) undergoing orthotopic liver transplantation (OLT) due to their complex cardiovascular and pulmonary abnormalities. Traditionally, pulmonary artery catheterization (PAC) has been the standard for hemodynamic monitoring during OLT. However, the use of transesophageal echocardiography (TEE) has increased due to its real-time visualization of cardiac and vascular structures, which aids in managing hemodynamic instability during the three surgical phases of OLT: pre-anhepatic, anhepatic, and neo-hepatic. TEE provides dynamic assessment of preload, afterload, and cardiac output and has been shown to detect complications such as right and left ventricular dysfunction, intracardiac thrombus, and pulmonary embolism. Although TEE in patients with ESLD poses risks, particularly in the presence of esophageal varices, studies show a low incidence of complications when performed by experienced operators. Focused TEE protocols have proven effective in detecting common causes of hemodynamic instability with fewer views. This review summarizes the applications and safety considerations of TEE during OLT.

The Therapeutic Potential of Different Surgical Approaches in the Management of Cardiac Myxoma: A Systematic Review.

Background: Cardiac myxomas are benign tumors of the heart. They occur mostly in the left atrium. The preferred treatment is surgical resection, which can be performed via conventional median sternotomy, minimally invasive, or robotic-assisted approaches. This study aimed to evaluate the outcomes, advantages, and limitations of these surgical methods, with a focus on their safety, efficacy, and impact on patient recovery. Methods: This systemic review was conducted according to PRISMA guidelines. The chosen databases were systematically searched using the keywords "cardiac myxoma", "resection", "approach", "minimally invasive", and "robotic surgery". The comparison between the surgical strategies was based on thirteen articles, which met the inclusion criteria. Results: Median sternotomy remains the standard technique, providing excellent surgical access but is associated with longer hospital stays, higher blood loss, and increased risk of complications such as stroke. Minimally invasive approaches demonstrated comparable safety with shorter ICU stays, reduced blood loss, and lower postoperative pain but presented challenges, including limited exposure and longer procedure times. Robotic-assisted surgery showed potential as a safe alternative but was limited by high costs and technical demands. However, the data on minimally invasive and robotic methods are limited due to the rarity of cardiac myxomas. Conclusions: The choice of surgical technique should be individualised by considering the tumour size, location, patient condition, and surgeon expertise. Routine postoperative echocardiographic monitoring is essential to detect residual or recurrent tumours. Further studies are needed to validate the long-term efficacy of minimally invasive and robotic approaches.

Feasibility of three dimensional and strain transthoracic echocardiography in a single-centre dedicated NHS cardio-oncology clinic

BackgroundFollowing the publication of international cardio-oncology (CO) imaging guidelines, standard echocardiographic monitoring parameters of left ventricular systolic function have been endorsed. Recommendations highlight that either two-dimensional (2D) or three-dimensional (3D) left ventricular ejection fraction (LVEF), alongside global longitudinal strain (GLS) should be routinely performed for surveillance of patients at risk of cancer therapy-related cardiac dysfunction (CTRCD). We studied the feasibility of 3D-LVEF, 2D-GLS and 2D-LVEF in a dedicated CO service.MethodsThis was a single-centre prospective analysis of consecutive all-comer patients (n = 105) referred to an NHS CO clinic. Using a dedicated Philips EPIQ CVx v7.0, with X5-1 3D-transducer and 3DQA software, we sought to acquire and analyse 2D- and 3D-LVEF and 2D-GLS, adhering to the British Society of Echocardiography (BSE) and British Cardio-Oncology Society (BCOS) transthoracic echocardiography protocol.ResultsA total of 105 patients were enrolled in the study; 5 were excluded due to carcinoid heart disease (n = 5). Calculation of 3D-LVEF was achieved in 40% (n = 40), 2D-GLS in 73% (n = 73), and 2D-LVEF in 81% (n = 81). LV quantification was not possible in 19% (n = 19) due to poor myocardial border definition. Strong correlation existed between 2D-LVEF and 3D-LVEF (r = 0.94, p < 0.0001). Bland–Altman plot demonstrated no statistical differences in that the mean deviation between 2D-LVEF and 3D-LVEF were consistent throughout a range of LVEF values. The most persistent obstacle to 3D-LVEF acquisition was insufficient myocardial border tracking (n = 30, 50%).ConclusionThis study demonstrates the high feasibility of 2D-GLS and 2D-LVEF, even in those with challenging echocardiographic windows. The lower feasibility of 3D-LVEF limits its real-world clinical application, even though only a small difference in agreement with 2D-LVEF calculation was found when successfully performed.

Left Ventricular Reverse Remodeling After Successful Living Donor Kidney Transplantation: The VINTAGE Study.

The impact of kidney transplantation (KT) on left ventricular (LV) remodeling remains poorly understood. This study aimed to evaluate the effect of KT on LV reverse remodeling, utilizing echocardiographic LV geometric patterns as a key assessment tool. In 100 recipients who underwent living KT between 2012 and 2022, we evaluated changes in the distribution of LV geometric patterns (normal geometry, concentric remodeling, eccentric hypertrophy, and concentric hypertrophy) between baseline and 1 year post-transplantation. These patterns were categorized based on LV mass index (LVMI) and relative wall thickness (RWT) assessed via echocardiography. Overall, LV geometric patterns improved or remained stable in 81% of recipients, with worsening in 19%. The proportion of normal geometry increased from 15% to 19%, and concentric remodeling from 30% to 45%, while eccentric hypertrophy decreased markedly from 20% to 3%. Concentric hypertrophy remained relatively stable at 33% (p=0.036). Subgroup analysis revealed that 47% of those with pre-KT normal geometry progressed to LV remodeling, while 77% with concentric remodeling remained stable. In contrast, 55% with eccentric hypertrophy experienced reverse remodeling, and 49% with concentric hypertrophy also showed reverse remodeling. These subgroup results suggest an interaction between the effect of KT on LV reverse remodeling and the pre-KT LV geometric patterns. Multivariable analysis identified E/e' > 9.5 (OR 2.01, 95% CI 1.10-3.67, p=0.024) and acute antibody-mediated rejection (OR 2.44, 95% CI 1.01-5.87, p=0.047) as independent predictors of LV remodeling progression. KT can lead to improvements in even advanced LV geometric patterns, although this effect may be diminished in the presence of pre-KT diastolic dysfunction or the occurrence of acute rejection. Since recipients rarely achieve complete renal recovery, echocardiographic monitoring remains crucial post-KT. Future studies are needed to establish whether these observed improvements in LV reverse remodeling directly translate into long-term reductions in cardiovascular events.

Artificial intelligence-assisted echocardiographic monitoring in pediatric patients on extracorporeal membrane oxygenation.

Percutaneous extracorporeal membrane oxygenation (ECMO) is administered to pediatric patients with cardiogenic shock or cardiac arrest. The traditional method uses focal echocardiography to complete the left ventricular measurement. However, echocardiographic determination of the ejection fraction (EF) by manual tracing of the endocardial borders is time consuming and operator dependent. The standard visual assessment is also an inherently subjective procedure. Artificial intelligence (AI) based machine learning-enabled image analysis might provide rapid, reproducible measurements of left ventricular volumes and EF for ECMO patients. This study aims to evaluate the applicability of AI for monitoring cardiac function based on Echocardiography in patients with ECMO. We conducted a retrospective study involving 29 hospitalized patients who received ECMO support between January 2017 and December 2021. Echocardiogram was performed for patients with ECMO, including at pre-ECMO, during cannulation, during ECMO support, during the ECMO wean, and a follow up within 3 months after weaning. EF assessment of all patients was independently evaluated by junior physicians (junior-EF) and experts (expert-EF) using Simpson's biplane method of manual tracing. Additionally, raw data images of apical 2-chamber and 4-chamber views were utilized for EF assessment via a Pediatric ECMO Quantification machine learning-enabled AI (automated-EF). There was no statistically significant difference between the automated-EF and expert-EF for all groups (P > 0.05). However, the differences between junior-EF and automated-EF and expert-EF were statistically significant (P < 0.05). Inter-group correlation coefficients (ICC) indicated higher agreement between automated-EF and expert manual tracking (ICC: 0.983, 95% CI: 0.977∼0.987) compared to junior assessments (ICC: 0.932, 95% CI: 0.913∼0.946). Bland-Altman analysis showed good agreements among the automated-EF and the expert-EF and junior-EF assessments. There was no significant intra-observer variability for experts' manual tracking or automated measurements. Automated EF measurements are feasible for pediatric ECMO echocardiography. AI-automated analysis of echocardiography for quantifying left ventricular function in critically ill children has good consistency and reproducibility with that of clinical experts. The automated echocardiographic EF method is reliable for the quantitative evaluation of different heart rates. It can fully support the course of ECMO treatment, and it can help improve the accuracy of quantitative evaluation.

Systemic-to-Pulmonary Collateral Artery in a Preterm Infant.

This case involved the detection of a systemic-to-pulmonary collateral artery (SPCA) in a preterm infant at 18 days using echocardiography, with SPCA closure identified at 11 months. Regular echocardiographic monitoring is essential to prompt therapeutic intervention in cases of elevated pulmonary flow, emphasizing the importance of timely management.

Abstract 4137145: Aortic Stenosis in Pregnancy: A Multidisciplinary Team Approach

Introduction: The hemodynamic adaptations that occur during pregnancy can have significant effects on patients with aortic stenosis (AS). These changes can lead to structural changes identified on echocardiogram even during uncomplicated pregnancies. While some cases can be managed with medical therapy and activity modification, others may require valve intervention in the gestational period. Case: A 29-year-old female with history of congenital bicuspid aortic valve, G1P0 presented at 42+2 weeks of pregnancy and was admitted to cardiac intensive care unit for continuous hemodynamic monitoring via use of arterial line. Her prior aortic valve disease was treated by valve repair with valvotomy, removal of tissue from pseudo raphe, removal of calcified scar tissue from both commissures, and a mitral valve repair for closure of an iatrogenic tear in her anterior leaflet. She followed closely with maternal fetal medicine and cardiology but became symptomatic at week 28 with lightheadedness, shortness of breath and decreased exercise tolerance (NYHA Class II). By week 33 she noticed lower extremity edema. Despite recommendations for planned delivery, she opted to wait until full term for delivery. Surveillance echoes revealed rising velocities yet stable valve area by planimetry. She ultimately underwent an uncomplicated Cesarean delivery of baby boy in week 42. At 6 months post partum she had successful transcatheter aortic valve replacement. Discussion: As the severity of valvular disease worsens there is a higher risk of complications during pregnancy. In our case, aortic valve velocities were elevated due to the expected hemodynamic changes of pregnancy. Thus, echocardiography monitoring should be used to assess the left ventricle’s ability to tolerate and compensate for these changes, while intervening based on symptoms and NYHA classification. We highlight the importance of multidisciplinary collaboration for safe and successful delivery in patients with AS.

An infant case of coronary artery aneurysms with no systemic symptoms after treatment for Kawasaki disease.

This case is a 4-month-old patient with Kawasaki disease who showed coronary artery lesions after a disease relapse. Following the guidelines from the Randomised Controlled Trial to Assess Immunoglobulin plus Steroid Efficacy, the patient initially saw an improvement in symptoms. However, a relapse occurred despite low levels of C-reactive protein, leading to significant coronary artery growth. Treatment with a third dose of intravenous immunoglobulin and cyclosporine led to a slow reduction in the size of the coronary artery abnormalities. This case highlights the difficulty in monitoring Kawasaki disease progression through clinical symptoms and C-reactive protein levels alone. We also emphasise the necessity of echocardiographic monitoring in patients receiving anti-inflammatory treatments, including steroids, because coronary artery problems can arise or continue without the usual signs of Kawasaki disease or increased C-reactive protein levels.

Anesthetic and Perioperative Considerations for Convergent Procedure for Atrial Fibrillation, A Retrospective Observational Cohort Study

ObjectivesTo summarize anesthetic and perioperative considerations in patients undergoing the convergent procedure for atrial fibrillation (AF). DesignRetrospective observational study. SettingSingle center quaternary teaching hospital. ParticipantsAdult patients with atrial fibrillation undergoing the convergent procedure before January, 2024. InterventionsRetrospective chart review. Measurements/main resultsA total of 40 patients were included; of them 35 patients had persistent longstanding AF. The mean age (SD) was 64 (6) years and 33 patients (83%) were male. Common comorbidities included obesity 27 (68%), obstructive sleep apnea 29 (73%), history of tachycardia-mediated cardiomyopathy 10 (25%), and significant alcohol use 10 (25%). Sixteen of 40 patients (40%) had a history of prior endocardial ablation, and 37 patients (93%) required a cardioversion in the past. In all, 39 patients (98%) were anticoagulated and 38 (95%) were on at least 1 anti-arrhythmic medication prior to the procedure. All patients received general anesthesia; 39 patients (98%) inhalational and 1 patient (3%) total intravenous, with regional analgesia adjuncts in 36 patients (88%). All patients required lung isolation, arterial line, central venous access, and transesophageal echocardiographic monitoring. While cardiopulmonary bypass (CPB) was on standby and ready to be initiated for every patient, only 3 patients (8%) required CPB (1 planned, 2 emergent). Thirty seven of 40 patients (93%) were extubated in the operating room, and 11 (28%) of patients required intensive care unit (ICU) admission (planned or unplanned). The median ICU and hospital length of stay were 1 and 4 days, respectively. ConclusionsThis retrospective analysis of medical records showed that many patients with recurrent atrial fibrillation presenting for convergent procedure carry a burden of multiple comorbidities (obesity, obstructive sleep apnea), and history of unsuccessful ablations. Multistage multidisciplinary convergent procedure might be lengthy, potentially complicated and requires meticulous preparation (endotracheal intubation, lung isolation, advanced cardiac monitoring, central venous access) to ensure optimal outcomes. Anesthesiologists and perioperative physicians should tailor their approach to this multimorbid population, while anticipating perioperative respiratory events, rapid hemodynamic shifts, blood loss, and a possibility of cardiopulmonary bypass.

Cardiological monitoring during BTK inhibitor, ICI, and RAF/MEK inhibitor therapy: the single-center prospective registry for cardiovascular events under new cancer therapies (RECENT)

Abstract Background The advent of novel targeted cancer therapies have revolutionized cancer treatment. However, concerns about their impact on cardiovascular health persist and current guidelines recommend cardiac monitoring. Yet, prospective data on incidence rates of cardiovascular events are lacking. The Registry for Cardiovascular Events under new cancer Therapies (RECENT) aims to systematically assess clinical as well as subclinical cardiovascular incidents in patients undergoing these novel therapies to identify baseline risk factors and derive individualized monitoring strategies. Methods This ongoing single-center prospective registry enrolls cancer patients receiving BTK inhibitors, ICI, or RAF/MEK inhibitors. Baseline cardiovascular assessment, risk stratification according to HFA-ICOS risk score, and follow up visits for 12 months at three-monthly intervals (including ECG, biomarkers and echocardiography) during treatment are conducted. Treatment-related events, in particular hypertension, arrhythmias, cancer therapy-related cardiac dysfunction (CTRCD), and (peri-) myocarditis, as defined according to current guideline recommendations, are recorded. Results We report data of the first 85 patients (60.9 ± 14.7 years, 52.9% male) included in this ongoing registry. Of those, 17/85 patients received treatment with BTK inhibitors (20%), 45/85 with ICI (53%) and 23/85 with RAF/MEK inhibitors (27%). Most common treatment indication were dermatological (39/85, 45.9%), hematologic (17/85, 20%), urological (13/85, 15.3%) and head and neck (11/85, 12.9%) cancers. Before treatment, the majority of patients were stratified as low-risk (31/85) or moderate-risk (32/85), and 22/85 (25.9%) as high-risk. 7/85 (8.2%) patients were newly diagnosed with cardiovascular disease at baseline visit, resulting in a change in risk category and subsequent initiation of cardiovascular treatment. This includes 3 patients who had been initially categorized as low-risk and would not have been referred for further cardiac workup due to current guideline recommendations. The six months follow up visit has been completed in 44/85 patients. Among these, 1/20 patients (5%) with ICI developed a perimyocarditis and 2/11 patients (18.2%) with BTK inhibitors developed atrial fibrillation. 1/13 patients (7.7%) with RAF/MEK inhibitor therapy, classified as low-risk at baseline, developed asymptomatic CTRCD, which resolved after initiation of cardioprotective drug therapy. Conclusion This interim analysis of the RECENT registry indicates benefit of a structured baseline cardiac assessment prior to cancer treatment in all patients, irrespective of the initial risk stratification. Contrary to current guidelines, which recommend routine echocardiographic monitoring in patients receiving RAF/MEK inhibitors only in high-risk patients, the current data advocate for extending this also to low-risk patients to detect subclinical deterioration of the cardiovascular status.

Low clinical utility of global longitudinal strain in a real-world breast cancer population

Abstract Background The 2022 European Society of Cardiology (ESC) Cardio-Oncology guidelines recommend the use of global longitudinal strain (GLS) to detect mild asymptomatic cancer therapy related cardiac dysfunction (ma-CTRCD). However, it remains unknown how to best manage these patients in order to prevent clinically significant CTRCD. Purpose To assess the course and outcomes of breast cancer patients meeting criteria for ma-CTRCD. Methods Echocardiograms and medical records were assessed for breast cancer patients receiving trastuzumab or an anthracycline, who underwent serial echocardiographic monitoring, including routine GLS. CTRCD was defined as an absolute decline in LVEF of &amp;gt;10% to &amp;lt;50%. ma-CTRCD was defined as a relative decline in average GLS of &amp;gt;15%, in the absence of significant LVEF decline. Normal was defined as no significant change in LVEF or GLS during cancer therapy. Clinical and echocardiographic course post ma-CTRCD detection was assessed. Baseline risk factors were compared between the three groups. Results 878 echocardiograms from 258 patients were analysed. GLS analysis was available in 76% of echocardiograms. CTRCD occurred in 23 (9%) and ma-CTRCD in 63 (24%). Only eight ma-CTRCD patients had management altered (cancer therapy withheld/ceased in three and heart failure medication commenced in six). Only two ma-CTRCD patients subsequently developed CTRCD, and GLS improved in 74%. Compared to the normal group (172, 67%), at baseline the ma-CTRCD group had higher average GLS (-21.8 vs -19.4, p&amp;lt;0.0001) and less borderline/abnormal average GLS (4% vs 36%, p&amp;lt;0.004). Conclusion Isolated declines in GLS are common and may have low clinical utility in preventing CTRCD. The findings support ESC guideline recommendations that cancer therapy should not be withheld in these patients. Those with higher baseline GLS may be more prone to clinically insignificant declines in GLS during cancer therapy.

Echocardiographic variables may improve baseline risk prediction of cancer therapy related cardiac dysfunction

Abstract Background Baseline prediction of cancer therapy related cardiac dysfunction (CTRCD) in clinical practice is difficult, despite many known cancer and cardiovascular risk factors. Risk scores exist, including the HFA-ICOS score which is recommended by the 2022 European Society of Cardiology (ESC) Cardio-Oncology guidelines. Validation of such risk scores is required though, and identification of alternative risk factors that may improve risk prediction is needed. Purpose To assess the accuracy of the HFA-ICOS score for predicting CTRCD, and identify new risk factors with a focus on baseline echocardiography. Methods Echocardiograms and medical records were assessed for a cohort of breast cancer patients receiving trastuzumab or an anthracycline, who underwent serial echocardiographic monitoring. CTRCD was defined according to the 2022 ESC Cardio-Oncology guidelines. Baseline risk factors and echocardiography were compared between CTRCD and non-CTRCD groups, and the accuracy of the HFA-ICOS score in predicting CTRCD assessed. Results Data from 258 patients were analysed with CTRCD occurring in 23 (9%). 135 were low risk, 85 moderate-risk, 31 high-risk and 8 very high-risk according to the HFA-ICOS score with a trend of increasing rates of CTRCD with each risk category: 5%, 12%, 10%, 25%, respectively. The sensitivity and specificity of a combined moderate/high/very high-risk group was 70% and 54% (AUC 0.618, 95% CI 0.5-0.73). Only three individual baseline variables were associated with CTRCD in this cohort; ejection fraction 50-54%, (18% vs 2%, p=0.0027), borderline/abnormal average global longitudinal strain &amp;lt;-18, (43% vs 19%, p=0.04) and combination anthracycline plus trastuzumab, (45% vs 22%, p=0.0392). Left atrial volume index &amp;gt;34mL/m² was also higher in the CTRCD group (38% vs 23%) although not statistically significant. A simplified risk score using only these variables yielded a sensitivity and specificity of 74% and 53%, respectively (AUC 0.633, 95% CI 0.52-0.75). Conclusion Baseline prediction of CTRCD remains difficult in clinical practice. Although HFA-ICOS risk categories correlate with CTRCD diagnosis, the overall sensitivity is only moderate. Echocardiographic variables may further enhance risk prediction to enable development of targeted monitoring strategies.HFA-ICOS risk score categoriesROC curves

His bundle pacing is continually relevant for patients with atrial fibrillation and bradycardia without prior atrioventricular nodal ablation, data from mid-term follow-up.

In patients with atrial fibrillation (AF) and symptomatic bradycardia, His Bundle pacing (HBP) is used to achieve an appropriate heart rate and physiological depolarization of the left ventricle (LV). We aimed to evaluate the impact of HBP on LV function in two different populations: normal LV ejection fraction (LVEF) and low LVEF (<50%). Patients who received HBP as de novo therapy or as an upgrade were divided into two groups based on initial LVEF, followed by echocardiographic and device monitoring. One hundred and twenty three patients (aged 76.0 [69.2-79.8] years, 74.0% men) with AF and bradycardia received HBP and completed follow-up with a median of 6.2 months (6.0-8.0). LV function remained unchanged in initially normal LV function patients (65 participants, LVEF 59.0% [55.0 - 62.0] vs. 58.0% [55.0-63.0]). In patients with low LVEF (58 participants), there was an increase in LVEF (37.5% [30.0-43.0] vs. 44.0% [35.0-50.0]; p < 0.0001), reduction of indexed LV end-systolic volume (62.4 [20.7] ml vs. 51.5 [21.5] ml; p = 0.001) and indexed LV end-diastolic volume (97.5 [26.2] ml vs. 88.1 [25.1] ml; p = 0.009), and improvement in the New York Heart Association class (2.3 [0.71] to 1.6 [0.9]; p < 0.0001). With permanent HBP, patients with AF and bradycardia and without prior atrioventricular nodal ablation did not experience LV systolic function deterioration. Those with reduced baseline LVEF experienced improvements in LV function and its reverse remodeling at the mid-term follow-up.

Role of MMP-2, MMP-9, TIMP-1, and TIMP-2 in children with ventricular septal defect.

Ventricular septal defect (VSD) is the second most common congenital heart anomaly. In most cases, it closes spontaneously in the first year of life, but it sometimes requires surgical closure due to the risk of serious complications. This is why it is important to identify markers that could help predict its course. Findings that matrix metalloproteinases (MMPs) and tissue inhibitors of metalloproteinases (TIMPs) play an important role in the cleavage of the extracellular matrix were the reasons to investigate their role in cardiogenesis. In prior studies on this topic, their concentrations were studied in the blood. The aim of this prospective study was to investigate the role of MMP-2, MMP-9, TIMP-1, and TIMP-2 in the etiology and pathophysiology of VSD using urine samples, as an innovative non-invasive approach, and the enzyme-linked immunosorbent assay (ELISA) method. It involved 52 children with isolated VSD and 20 healthy children up to one year of age. We found that these MMPs and TIMPs are significantly (P = 0.000) higher in children with VSD, and the correlations between their concentrations and the size of the defect are positive, especially for MMP-9 and TIMP-1. MMP-9 was significantly (P = 0.044) higher in cases in which VSD did not close in the first year of life compared to cases in which it closed. Our results suggest the role of MMP-2, MMP-9, TIMP-1, and TIMP-2 in the aetiopathogenesis of VSD and that their urinary concentrations, especially of MMP-9, in combination with echocardiographic and clinical monitoring, could be useful in predicting its natural course.

Post-Operative Haemodynamic Monitoring of Patients Undergoing Corrective Open Heart Surgery for Structural Heart Defects

Abstract Background Accurate hemodynamic monitoring is vital in the diagnosis and management of critically ill patients. The best method for monitoring remains controversial, Adequate perioperative management guided by effective monitoring can help reduce the risk of complications and thus potentially improve outcomes. Aim of Work To compare monitoring methods of cardiac output and systemic haemodynamics post cardiac surgery and its correlation to the clinical status of patients (reflected by clinical signs and laboratory assessment) and outcome, focusing on noninvasive cardiometry and echocardiography. Methodology This is a cross sectional study that was conducted on 40 pediatric patients under 5 years old who were admitted to Post Cardiac Surgery Intensive Care Unit –Academic Institute of Heart Surgery undergoing corrective cardiac surgeries for congenital cardiac lesions. Assessment of hemodynamic changes during immediate post operative period was done by tracing and comparing vital data, echocardiography, non- invasive cardiometry parameters and levels of serum BNP and lactate in all patients at 6 hours and 24 hours post operatively. Results There was statistically significant change in heart rate, urine output, lactate and BNP being high in 1st 6 hours then decreased in 24 hours assessment, versus the observed increase in temperature and SVO2 between the 2-time intervals in immediate post operative period. This was significantly correlated with the decrease in (TAPSE, thoracic fluid content, Cardiac index) and the increase in (LVOT, IVC collapsibility index, fluid total content) parameters by echocardiography and non-invasive cardiometry. Significant correlation was found between clinical evaluation of low cardiac output patients and TAPSE in the 1st 6 hours being decreased in low COP group, while with EF in the 1st 24 hours assessment being decreased in the low COP group. Thoracic fluid content measured by non-invasive cardiometry was significantly related to time on the bypass machine which may affect outcome of patients post operatively. Icon and echocardiography were significantly related on fluid assessment paraments between IVC collapsibility by echo and FTC, TFC by icon, this was also observed in contractility parameters between TAPSE by echo and cardiac index by icon. There was no significant correlation between the end outcome of the studied groups and the 1st 24 hours assessment. Conclusion Clinical evaluation by the attended Physician observing low cardiac output signs and symptoms remains a corner stone in the assessment of haemodynamics in critically ill patients, however fluid assessment tools by both echocardiography and non-invasive cardiometry along with contractility assessment by echocardiography for both right and left ventricle potentially assists physician in his task. There is no upper role for non-invasive cardiometry over echocardiography in monitoring of haemodynamics postoperatively except for assessment of thoracic fluid content which may aid in ventilation and early extubation of patients.

Can central venous pressure help identify acute right ventricular dysfunction in mechanically ventilated critically ill patients?

ObjectiveTo investigate the relationship between central venous pressure (CVP) and acute right ventricular (RV) dysfunction in critically ill patients on mechanical ventilation.MethodsThis retrospective study enrolled mechanically ventilated critically ill who underwent transthoracic echocardiographic examination and CVP monitoring. Echocardiographic indices including tricuspid annular plane systolic excursion (TAPSE), fractional area change (FAC), and tricuspid lateral annular systolic velocity wave (S’) were collected to assess RV function. Patients were then classified into three groups based on their RV function and presence of systemic venous congestion as assessed by inferior vena cava diameter (IVCD) and hepatic vein (HV) Doppler: normal RV function (TAPSE ≥ 17 mm, FAC ≥ 35% and S’ ≥9.5 cm/sec), isolated RV dysfunction (TAPSE < 17 mm or FAC < 35% or S’ <9.5 cm/sec with IVCD ≤ 20 mm or HV S ≥ D), and RV dysfunction with congestion (TAPSE < 17 mm or FAC < 35% or S’ <9.5 cm/sec with IVCD > 20 mm and HV S < D).ResultsA total of 518 patients were enrolled in the study, of whom 301 were categorized in normal RV function group, 164 in isolated RV dysfunction group and 53 in RV dysfunction with congestion group. Receiver operating characteristic analysis revealed a good discriminative ability of CVP for identifying patients with RV dysfunction and congestion(AUC 0.839; 95% CI: 0.795–0.883; p < 0.001). The optimal CVP cutoff was 10 mm Hg, with sensitivity of 79.2%, specificity of 69.4%, negative predictive value of 96.7%, and positive predictive value of 22.8%. A large gray zone existed between 9 mm Hg and 12 mm Hg, encompassing 95 patients (18.3%). For identifying all patients with RV dysfunction, CVP demonstrated a lower discriminative ability (AUC 0.616; 95% CI: 0.567–0.665; p < 0.001). Additionally, the gray zone was even larger, ranging from 5 mm Hg to 12 mm Hg, and included 349 patients (67.4%).ConclusionsCVP may be a helpful indicator of acute RV dysfunction patients with systemic venous congestion in mechanically ventilated critically ill, but its accuracy is limited. A CVP less than10 mm Hg can almost rule out RV dysfunction with congestion. In contrast, CVP should not be used to identify general RV dysfunction.

Modern Management of Pregnancy in Systemic Lupus Erythematosus: From Prenatal Counseling to Postpartum Support.

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease that predominantly affects women of childbearing age. Pregnancy in SLE patients poses unique challenges due to the potential impact on maternal and fetal outcomes. We provide an overview of the management of SLE during pregnancy, including preconception risk stratification and counseling, treatment, and disease activity monitoring. These assessments are critical to minimize maternal and fetal adverse events in pregnant patients with SLE. Disease flares, preeclampsia, antiphospholipid syndrome complications, and maternal mortality are the major risks for a woman with SLE during gestation. Timely treatment of SLE relapse, differentiation of preeclampsia from lupus nephritis, and tailored management for antiphospholipid syndrome are essential for a successful pregnancy. Fetal outcomes include neonatal lupus (NL), preterm birth, cesarean delivery, fetal growth restriction (FGR), and small-for-gestational-age (SGA) infants. We focused on NL, linked to maternal anti-Ro/SS-A and anti-La/SS-B antibodies, which can lead to various manifestations, particularly cardiac abnormalities, in newborns. While there is a common consensus regarding the preventive effect of hydroxychloroquine, the role of echocardiographic monitoring and fluorinated steroid treatment is still debated. Finally, close postpartum monitoring and counseling for subsequent pregnancies are crucial aspects of care.

Rare Case of Right Ventricular Perforation during Pericardiocentesis: A Case Report

Iatrogenic cardiac injuries are potential complications arising from diagnostic and therapeutic procedures in cardiology, including interventions like cardiac catheterization, coronary angioplasty, and pacemaker implantation ­­[1,2]. Pericardial tamponade can occur, with a prevalence of 0.12%, often requiring urgent intervention such as pericardiocentesis. Patients with chronic pericardial effusion and signs of tamponade may adapt to gradual fluid accumulation, but vigilance for iatrogenic injuries remains crucial. Transthoracic echocardiography aids in rapid diagnosis and guides timely interventions [3]. Therefore, the right ventricular perforation seems to be one of these complications, and it may occur during pericardiocentesis. Surgical approaches for acute tamponades vary, with median sternotomy enabling comprehensive exploration [4]. Echocardiographic monitoring can signal clinical deterioration, necessitating prompt fluid management and early intervention to optimize outcomes. Although, the therapies in right ventricular perforation are variable. In our case, we emphasize about the conservative approach.