Left Ventricular Ejection Time Research Articles

Myocardial work in overweight and obesity: impact of sex and central haemodynamics

Abstract Background Women with increased body mass index (BMI) have better left ventricular (LV) global longitudinal strain (GLS) than men. LV global myocardial work index (GWI) is a novel measure of myocardial function that adjusts for afterload and offers the opportunity to differentiate between early systolic dysfunction and elevated myocardial workload. Purpose To investigate sex differences in myocardial work in women and men with increased BMI. Methods Clinical and echocardiographic data from 467 participants (61% women, average age 47±9 years) with a BMI above 27 kg/m2 and without cardiac disease was analysed. Central pulse wave analysis was assessed by applanation tonometry. GWI was calculated by GLS and post-echocardiography blood pressure (BP). Covariables of GWI were identified by linear regression analysis with collinearity tools. Results Women had higher BMI (31.4 vs. 31.0 kg/m2) and higher aortic augmentation pressure (12±7 vs. 8±6 mmHg), but lower clinic systolic BP (127±17 vs. 134±14 mmHg) compared to men (all P<0.05). Women also had higher LV GLS (20.0±2.8 vs. 18.8±2.8%) and GWI (2126±385 vs. 2047±389 mmHg%) (both P<0.05). In univariable regression analyses, higher GWI was significantly associated with higher age, clinic systolic BP, wall stress, ejection fraction, aortic augmentation pressure, left atrial size, and LV ejection time, and with lower waist circumference (all P<0.05), but not with BMI. In multivariable linear regression analyses, adjusting for these correlates, female sex was independently associated with higher GWI (Table 1, model 1). After additional adjustment for aortic augmentation pressure, the association between GWI and sex became non-significant (Table 1, model 2). Conclusions Women with increased BMI have higher GWI compared to men, despite lower BP. Higher GWI in women is mainly explained by elevated workload due to higher central aortic stiffness. Funding Acknowledgement Type of funding sources: Public Institution(s). Main funding source(s): Western Norwegian Regional Health Authorities

Effect of acupuncture in Pericardium 6 (Neiguan) acupoint in the acute cardiovascular response to active standing in healthy subjects

ObjectiveTo demonstrate the effect of acupuncture in Pericardium 6 (Neiguan) acupoint in the acute homeostatic response to orthostatic challenge in healthy subjects. DesignA cross-sectional experimental study was conducted at Acupuncture Facility at Universidad Autónoma Metropolitana, Ciudad de México, México. Participants: Fifteen healthy university students (seven women) aged 22.5 ± 1.36 (mean ± SD) participated in the present study to investigate the changes in cardiovascular function after standing active standing and their modification with manual acupuncture in Pericardium 6 (Neiguan) acupoint in healthy volunteers. InterventionsThe treatment consisted of one session of manual acupuncture in the Pericardium 6 (Neiguan) in the right arm. The following data for continuous beat-to-beat registration: mean arterial pressure (MAP), heart rate (HR), stroke volume (SV), total peripheral resistance (TPR), and left ventricular ejection time were computed in healthy volunteers after standing. The obtained signals were plotted and averaged, and a linear correlation of each average was calculated. Besides, the Pearson correlation coefficient was calculated for the recording periods of 1–10 after the standing position in basal and treated conditions. ResultsAcupuncture was showed to increase the speed of change in MAP, HR, and TPR and decreased the speed of changes in SV and LVET when comparing the slopes of the initial cardiovascular changes related to active standing. Besides, Pearson analysis showed that acupuncture treatment modifies to higher correlation the cardiovascular responses to orthostatic stress. ConclusionsWe found that manual acupuncture in the right PC6 boosted the initial adaptive mechanisms to orthostatic stress in healthy subjects. It is valuable to initiate clinical trials to see if this treatment improves symptoms in patients with orthostatic hypotension.

Left ventricular myocardial performance index in prediabetic patients without coronary artery disease

BackgroundPrediabetes is considered a major risk factor for diabetes mellitus (DM), leading to microvascular and cardiovascular disorders. Myocardial performance index (MPI) is a non-invasive Doppler method for the determination of global ventricular activity. We have not enough knowledge about the effect of prediabetes on the left ventricular (LV) function. We aimed to assess the MPI in prediabetic patients without coronary artery disease (CAD) utilizing echocardiography tissue Doppler imaging (TDI).ResultsWe conducted a randomized controlled study that included fifty prediabetic patients and fifty healthy participants as the control group. All the participants were subjected to laboratory tests and echocardiography TDI to evaluate the LV systolic and diastolic functionsWe found that the isovolumic relaxation time (IVRT) and MPI values were significantly increased in the prediabetic patients compared to the control group (P < 0.001). In contrast, left ventricular ejection time (ET) was significantly longer in the control group than in prediabetic patients.ConclusionPrediabetes may adversely affect the LV function as assessed by MPI. Screening for prediabetes and early intervention is required for the prevention of cardiovascular morbidity and mortality.

Comparison of transvalvular flow rate in aortic stenosis subtypes.

Evaluate ET and TVFR in normal patients, PLFLGAS, LGLFAS, and classic pre and post TAVR. Severe aortic stenosis (AS) is defined echocardiographically. Generating a pressure gradient to meet diagnostic criteria is dependent on left ventricular contractility, stroke volume, and ejection time. Abnormalities in these decrease the mean pressure gradient across the valve creating pathology termed low flow, low gradient AS. This occurs in two subtypes, low ejection fraction LFLGAS and paradoxical LFLGAS (PLFLGAS), in which EF is normal but stroke volume is<35ml/m2 . Paradoxical LFLGAS is difficult to diagnose and does not have a confirmatory echocardiographic parameter. Transvalvular flow rate (TVFR), which is defined as stroke volume divided by the ejection time, provides a direct measure of flow across the aortic valve. A retrospective study of patients who underwent transcatheter aortic valve replacement (TAVR) at the University of Cincinnati Medical Center between 2016 and 2019 was performed. Patients were classified by AS subtype. ET and TVFR were measured pre and post TAVR and statistically compared using SPSS statistics software and ANOVA analysis. Pre TAVR TVFR in the normal population, severe AS population, and LFLGAS were not significantly different. The pre TAVR TVFR in paradoxical LFLGAS patients was significantly lower than other groups. TVFR improved to the greatest degree post TAVR in PLFLGAS but did not meet statistical significance. The significantly lower TVFR demonstrated in PLFLGAS provides a comprehensive, direct measurement of aortic valve hemodynamics and PLFLGAS pathology and can aid in diagnosis.

The impact of total sleep deprivation upon supine and head up tilt hemodynamics using non-linear analysis in firefighters

PurposeThe impact of 31 h of total sleep deprivation (TSD) on cardiovascular autonomic modulation was evaluated in 46 volunteers all professional fire brigade units officers (all men, mean age = 32.11 ± 6.4). MethodsHemodynamic examination was obtained at baseline and after 31 h of Total Sleep Deprivation (TSD). Each measurement period included supine and head-up tilt (HUT) test response. Continuous beat-to-beat systolic blood pressure (sBP), diastolic blood pressure (dBP) and mean blood pressure (mBP), heart rate (HR), stroke volume (SV), left ventricular ejection time (LVET) and cardiac output (CO) were calculated in rest supine position and in response to HUT. Nonlinear analyses were conducted using Permutation Entropy (PE), Amplitude Aware Permutation Entropy (AAPE) and Fractal Dimension (FD). ResultsSupine increase of HR and decrease in RRI, LVET and entropy of LVET were observed after 31-h of TSD. Increase in entropy of mBP was indicated by AAPE and PE methods. Response to HUT, values of spectral analysis of blood pressure (normalized units of high frequency of sBP and dBP) was altered. Permutation entropy of mBP in response to HUT were significantly changed after 31-h of TSD. ConclusionsTSD alters autonomic nervous system modulation of cardiac and vascular functioning while supine and in response to orthostatic stress. TSD resulted in changes in cardiac and both spectral and two methods of analysis of entropy of blood pressure when supine. Values of spectral analysis of blood pressure and permutation entropy of mean blood pressure in response to HUT were significantly changed after 31 h of TSD.

Effects of adenoidectomy or adenotonsillectomy on the cardiovascular system in children: a meta-analysis.

Adenoid or adenotonsillar hypertrophy (AATH) causes upper airway obstruction, leading to cardiovascular complications. This meta-analysis was conducted to evaluate the efficacy of adenoidectomy or adenotonsillectomy (AATE) on the cardiovascular system. Using the Cochrane Central Register of Controlled Trials, PubMed, and EMBASE databases, we identified studies involving a comparison of preoperative and postoperative cardiovascular function in children with AATH. The Cochrane Collaboration's Review Manager 5.3 software was used for meta-analysis. A total of 13 studies with 706 participants were included. The meta-analysis demonstrated a significant reduction in mean pulmonary artery pressure (mPAP) of patients after AATE compared with preoperative values. The left ventricular myocardial function index (LVMPI) and the right ventricular myocardial function index (RVMPI) showed a significant decrease after the operation. Moreover, AATE prominently increased left ventricular ejection time (LVET) and right ventricular ejection time (RVET) and reduced the left ventricular interventricular septumdiameter (LVIVSD) and the right ventricular end-diastolic diameter (RVedD). There was no significant difference in mPAP, LVMPI, RVMPI, LVET, RVET, LVIVSD, and RVedD between postoperative patients and healthy children (P > 0.05). AATE can improve cardiovascular function in pediatric patients with AATH. Specifically, it reduces mPAP and LVMPI/RVMPI in pediatric patients. Furthermore, AATE increases LVET and RVET and reduces LVIVSD and RVedD.

Sensitivity Analysis of Single Beat Left Ventricular Elastance Estimation by Chen Method.

Left ventricular (LV) end-systolic elastance (Ees) can be estimated using single-beat (Ees(sb)) Chen method, employing systolic and diastolic arm-cuff pressures, stroke volume (SV), ejection fraction and estimated normalized ventricular elastance at arterial end-diastole. This work aims to conduct a sensitivity analysis of Chen formula to verify its reliability and applicability in clinical scenario. Starting from a baseline condition, we evaluated the sensitivity of Ees(sb) to the parameters contained in the formula. Moreover, a mathematical model of the cardiovascular system was used to evaluate the sensitivity of Ees(sb) to end-diastolic LV elastance (Eed), Ees, arterial systemic resistance (Ras) and heart rate (HR). In accordance with Ees definition, Ees(sb) increases by increasing aortic pressure and pre-ejection time, reaching the highest value for a pre-ejection time = 40 ms, and then decreases. In contrast with Ees definition, Ees(sb) increases (from 3.21 mmHg/mL to 12.15 mmHg/mL) by increasing the LV end-systolic volume and decreases by increasing the SV. In the majority of the analysis with the mathematical model, Ees was underestimated using the Chen method: by increasing Ees (from 0.5 to 2.5 mmHg/mL), Ees(sb) passes only from 0.56 to 1.54 mmHg/mL. Ees(sb) increases for higher Eed (from 1.03 to 2.33 mmHg/mL). Finally, Ees(sb) decreases (increases) for HR < 50 bpm (< 50 bpm), and for Ras < 1100 mmHg/gcm4 (> 1100 mmHg/gcm4). Unexpectedly Ees(sb) increases for higher LV end-systolic volume and decreases for higher SV. These results contrast with Ees definition, which is the ratio between the LV end-systolic pressure and the LV end-systolic volume. Moreover, Ees(sb) is influenced by cardiocirculatory parameters such as LV Eed, HR, Ras, ejection time, and pre-ejection time. Finally, Ees(sb) computed with the model output often underestimates model Ees.

SARS-CoV-2 vaccination of people living with human T leukaemia virus type 1

<b>Hardarson, T., Ziady, G. M., and Khattri, H. N. (1974).</b><i>Thorax</i>, <b>29</b>, 359-365. <b>Assessment of left ventricular function following coronary bypass surgery: a non-invasive study.</b> In a series of 15 patients...

The underlying mechanism of intersite discrepancies in ejection time measurements from arterial waveforms and its validation in the Framingham Heart Study.

Radial applanation tonometry is a well-established method for clinical hemodynamic assessment and is also becoming popular in wrist-worn fitness trackers. The time difference between the foot and the dicrotic notch of the arterial pressure waveform is a well-accepted approximation for the left ventricular ejection time (ET). However, several clinical studies have shown that ET measured from the radial pressure waveform deviates from that measured centrally. In this work, we consider the systolic wave and the dicrotic wave as two independent traveling waves and hypothesize that their wave speed difference leads to the intersite differences of measured ET (ΔET). Accordingly, we derived a mathematical dicrotic wave decomposition model and identified the most influential factors on ΔET via global sensitivity analysis. In our clinical validation on a heterogeneous cohort (N = 5,742) from the Framingham Heart Study (FHS), the local sensitivity analysis results resembled the sensitivity variation patterns of ΔET from model simulations. A regression analysis on FHS data, using morphological features of radial pressure waveforms to estimate the carotid ET, produced a root mean square error of 3.76 ms and R2 of 0.91. The proposed dicrotic wave decomposition model can explain the intersite ET measurement discrepancies observed in the clinical data of FHS and can facilitate the precise identification of ET with radial pressure waveforms. Therefore, the proposed model will improve various physics-based pulse wave analysis methods as well as prospective artificial intelligence methods for tackling the subsequent big data produced from widespread wearable radial pressure monitoring.NEW & NOTEWORTHY Based on a new understanding of pressure wave propagation, we propose a novel dicrotic wave decomposition model considering the dicrotic wave as an independent traveling component. The proposed model can explain the mechanism underlying the intersite discrepancies in ejection time measurement from arterial waveforms and then, in principle, enhance the accuracy of both classical physics-based as well as more contemporary artificial intelligence-based pulse wave analysis methods in clinical and wearable radial blood pressure monitoring applications.

A Close Examination of the Use of Systolic Time Intervals in the Calculation of Impedance Derived Cardiac Autonomic Balance and Regulation

Traditionally, impedance derived measures of cardiac autonomic balance (CAB) and regulation (CAR) are calculated using indices of heart rate variability (HRV) that primarily reflect parasympathetic nervous system activity (e.g., high-frequency HRV | HF-HRV) and pre-ejection period (PEP; a systolic time interval and measure of sympathetic activity). However, HF-HRV and PEP are considered measures of chronotropic and inotropic cardiac influence, respectively. Left ventricular ejection time (LVET) is a systolic time interval that reflects sympathetic chronotropic influence, and therefore may be a more appropriate measure for calculating CAB and CAR compared to PEP. Thus, the current study evaluates both PEP and LVET in the calculation of CAB and CAR. Data from 158 healthy participants (mean age = 19.09 years old, SD = 1.84 years) were available for analyses. CAB and CAR values were calculated using both HF-HRV and the root mean square of successive differences, in addition to both PEP and LVET, in accordance with previously established guidelines. Analyses showed that correlations were significantly weaker between CAB and CAR calculated using LVET for both HF (z = 5.12, p < 0.001) and RMSSD (z = 5.26, p < 0.001) than with PEP. These data suggest that LVET, compared to PEP, provides better “autonomic space” as evidenced by a lack of correlation between CAB and CAR computed using LVET. We stress that future research consider calculating CAB and CAR using chronotropic measures for both parasympathetic and sympathetic activity, as doing so may yield more accurate and independent measures of cardiac autonomic activity compared to a mixture of inotropic (i.e., PEP) and chronotropic (i.e., HF-HRV) measures.

April 2021 at a glance: focus on systolic function, quality of life and treatment in heart failure.

Left ventricular (LV) systolic ejection time is a prognostic marker in patients with heart failure (HF) and reduced ejection fraction (HFrEF).1, 2 Alhakak et al.3 reviewed the definition and methods of measurement of LV ejection time, the mechanisms behind its shortening in HFrEF, its role as a prognostic marker and in the assessment of the response to medical treatment. Left ventricular ejection fraction (LVEF) remains the landmark parameter of LV systolic function. It is a major prognostic marker both in acute and chronic HF.4, 5 Strange et al.5, 6 furthered their previous findings showing in a large cohort of 117 275 subjects followed up by echocardiography that even modest LVEF changes over time, i.e. at least 6 months, have a significant prognostic impact. Five-year all-cause mortality increased from 12% to 29% among subjects with the smallest to the largest decrease in LVEF (from <5 units to >30 units). Health-related quality of life (QoL) scores are clinically relevant in patients with HF.7-9 In a recent analysis of BIOSTAT-CHF, Ravera et al.10 reported worse QoL scores in women with HFrEF as compared with men, both when assessed with the Kansas City Cardiomyopathy Questionnaire (KCCQ) overall score (median 44 vs. 53; P < 0.001) and the EuroQol 5 dimensions utility score (median 0.62 vs. 0.73; P < 0.001). Of note, QoL was independently associated with subsequent outcome both in women and men. Turgeon et al.11 synthetized evidence regarding the impact of HFrEF pharmacotherapy on QoL in a comprehensive systematic review and meta-analysis. QoL was improved by angiotensin receptor blockers, angiotensin receptor–neprilysin inhibitor, sodium–glucose co-transporter 2 inhibitors, ivabradine, hydralazine–nitrate, and intravenous iron whereas findings were inconclusive for angiotensin-converting enzyme inhibitors, beta-blockers, digoxin, and oral iron. Sodium–glucose co-transporter 2 inhibitors have a pivotal role in the treatment of patients with HFrEF.12-14 Their cost-effectiveness has also been shown.15 Despite differences in the pathophysiology of ischaemic and non-ischaemic HF,16 dapagliflozin had similar effects on the risk of worsening HF or cardiovascular death as well as on symptoms and QoL in patients with HFrEF of ischaemic and non-ischaemic aetiology in DAPA-HF.17 Comorbidities have a major role in patients with HF, including those enrolled in clinical trials.18 Two analyses from DAPA-HF reported that patients with concomitant anaemia or chronic obstructive pulmonary disease had poorer outcomes. However, the benefit of dapagliflozin on cardiovascular events was independent of their presence.19, 20 Rivaroxaban 2.5 mg twice daily may be considered among treatment options for patients with HF, coronary artery disease and LVEF >30%.14 An analysis of COMMANDER-HF demonstrated that high plasma D-dimer levels (>515 ng/mL) identify patients at high risk of stroke who can benefit from rivaroxaban administration.21 Iron deficiency is a major therapeutic target in HF.9, 14, 22 In a non-randomized, open-label, prospective pilot study, oral sucrosomial iron improved exercise capacity and QoL in patients with HFrEF and Iron deficiency, with significant improvement in 6-min walk distance and KCCQ at 3 and 6 months (all adjusted P-values <0.01).23 The MSC-HF trial reported a positive effect of intramyocardial injection of autologous bone marrow-derived mesenchymal stromal cells (MSCs) in patients with ischaemic HF.24 The Phase II CONCERT-HF trial demonstrated that the combination of MSCs and c-kit positive cardiac cells was associated with further improvement in clinical outcome and QoL.25

The significance of left ventricular ejection time in heart failure with reduced ejection fraction.

Left ventricular ejection time (LVET) is defined as the time interval from aortic valve opening to aortic valve closure, and is the phase of systole during which the left ventricle ejects blood into the aorta. LVET has been used for several decades to assess left ventricular function and contractility. However, there is a recent interest in LVET as a measure of therapeutic action for novel drugs in patients with heart failure with reduced ejection fraction (HFrEF), since LVET is shortened in these patients. This review provides an overview of the available information on LVET including methods of measuring LVET, mechanistic understanding of LVET, association of LVET with outcomes, mechanisms behind shortened LVET in HFrEF and the potential implications of drugs that affect and normalize LVET.

A pilot study of short-term hemodynamic effects of negative pressure ventilation in chronic obstructive pulmonary disease assessed using electrical cardiometry.

BackgroundPulmonary rehabilitation combined with negative pressure ventilation (NPV) demonstrated benefits in patients with chronic obstructive pulmonary disease (COPD). The effect of NPV remains unknown. This study aims to clarify the short‐term response of the hemodynamic outcome of NPV in patients with COPD undergoing pulmonary rehabilitation program by electrical cardiometry.MethodsThis is an observational retrospective study of COPD patients who had been treated in a pulmonary rehabilitation unit with NPV between January 2018 and December 2019 that were enrolled to analyze the hemodynamic outcomes.ResultsThirty patients with COPD that were undergoing a pulmonary rehabilitation program and were regularly receiving NPV were enrolled. Cardiac output (p < .001) and heart rate (p < .001) showed a significant decrease after NPV. Stroke volume did not demonstrate significant change (p = .15). There was a significant decrease in thoracic fluid content (p = .016) and a significant increase in stroke volume variation (p = .038) systemic vascular resistance (p < .001) and left ventricular ejection time (p < .001). Other hemodynamic parameters were all comparable before and after NPV.ConclusionsNegative pressure ventilation demonstrated an impact on hemodynamics in patients with chronic obstructive pulmonary disease undergoing pulmonary rehabilitation. Electrical cardiometry is a feasible method of determining the hemodynamic effects of negative pressure ventilation. Thoracic fluid content significantly decreased immediately after the NPV.

Comparison of maternal third trimester hemodynamics between singleton pregnancy and twin pregnancy.

The impedance cardiography (ICG) technique measures the variation of impedance in the thorax due to the physical contractile activity of the heart. Twin pregnancy is characterized by greater maternal hemodynamic changes than a singleton pregnancy. In a study on 121 pregnant women in the last trimester we performed ICG, evaluating the following hemodynamic parameters: stroke volume, heart rate, cardiac output, ventricular ejection time, left ventricular ejection time, thoracic impedance, and systemic vascular resistance. The study included singleton and twin pregnancies. Heart rate values in women with single fetus was lower than in those carrying twins (85 vs. 100 beats/min, p=0.021) as were the stroke volume values (64 vs. 83mL, p=0.010) and the cardiac output (p<0.0001). Systemic vascular resistance decreased in twin pregnancies compared to singleton pregnancy (p=0.023). ICG studies are rare, and the validation of their results is an ongoing process. However, the ICG technique is applicable in the third trimester of pregnancy and can yield important information regarding the hemodynamic profile of singleton and twin pregnancies, revealing maternal heart changes specific to twin pregnancies.

Timing the opening and closure of the aortic valve using a phonocardiogram envelope: a performance test for systolic time intervals measurement

Objective. This work explored the reliability of using points on the heart sounds envelope as indicators of the opening and closure of the aortic valve (AVO, AVC) to measure the pre-ejection period (PEP) and the left ventricular ejection time (LVET). Approach. 36 phonocardiograms (PCGs) from healthy subjects and cardiovascular disease subjects were denoised using single-channel independent component analysis (SCICA) and, from the Hilbert envelopes, the positions of the S1 and S2 peaks were detected (pS1, pS2). Complementarily, the positions of the local maxima of S1 and S2 (mS1, mS2) and the points surrounding pS1 and pS2 (tS1, tS2) were obtained. Finally, the reliability of these points (and the corresponding PEP and LVET intervals) was evaluated by the calculation of three error indexes (ePEP, eLVET, and score) and by comparison to reference annotations provided by echocardiography using the Bland–Altman analysis and the paired T-test. Main results. The results indicated that, from a total of 920 and 341 heartbeats in the healthy and diseased groups, respectively, the timing points given by pS1 and pS2 (or mS1 and mS2) were unlikely to substitute for the reference annotations and, thus, are unreliable for measuring the PEP and LVET intervals in the PCG. The t-points evaluation, on the other hand, indicated that tS1 was likely to substitute for AVO and was thus reliable for measuring the PEP using the PCG, with median and interquartile ranges of 0.3(8.3) ms and −0.2(7.5) ms for each group. Future work will generate an envelope with higher temporal resolution, from where tS1 and tS2 can be more accurately detected to improve the PEP and LVET measurements on a larger dataset. Significance. The statistical tests revealed that the envelope of S1 is suitable for extracting a timing point from which the pre-ejection interval can be reliably quantified, and discarded the local maximum used in other studies.

February 2021 at a glance: focus on amyloidosis, myocarditis and cardiomyopathy

Cardiac amyloidosis (CA) is emerging as a major cause of heart failure (HF).1-3 Castiglione et al.4 reviewed the role of circulating biomarkers as tools to guide diagnosis, prognostic stratification, and therapy in CA. The independent prognostic role of cardiopulmonary exercise testing in patients with light chain or transthyretin CA (TTR-CA) was shown by Nicol et al.5 in a multicentre study. Both peak oxygen consumption (VO2) ≤13 mL/kg/min and N-terminal pro B-type natriuretic peptide (NT-proBNP) ≥1800 ng/L had independent prognostic value with a hazard ratio (HR) of 2.7 [95% confidence interval (CI) 1.6–4.8] and 2.2 (95% CI 1.1–4.3), respectively. No events occurred in patients with peak VO2 >13 mL/kg/min and NT-proBNP <1800 ng/L during a median follow-up of 20 months, despite overall 25% mortality and 29% hospitalization rates. Amyloidosis may be present in patients with severe aortic stenosis.2, 6 TTR-CA was detected in 13% of patients with severe aortic stenosis undergoing transcatheter aortic valve replacement. It had no impact on mortality but was associated with a higher HF hospitalization rate during a 3-year follow-up.3 Tafamidis has emerged as an effective treatment option to improve prognosis in patients with TTR-CA.7, 8 A single-centre study in 648 real-world patients with TTR-CA matching the inclusion criteria of the Tafamidis in Transthyretin Cardiomyopathy Clinical Trial (ATTR-ACT) showed a significant benefit of tafamidis on major cardiovascular outcomes (HR after propensity score matching 0.546, P = 0.0132).9 In an analysis of the long-term extension of ATTR-ACT, both tafamidis 80 mg and 20 mg reduced all-cause mortality and cardiovascular hospitalizations at 30 months compared with placebo, with the higher dose associated with better outcomes without safety issues in the long-term extension.10 Sinagra et al.11 reviewed data about the role of viral detection for immunomodulation in acute lymphocytic myocarditis, highlighting current limitations of this approach and providing a framework for future dedicated studies. The Authors pointed out that the value of viral presence to guide immunosuppressive treatment in lymphocytic myocarditis requires more evidence and remains a subject of debate. As a further support, intravenous immunoglobulin did not improve cardiac systolic function or functional status in patients with chronic inflammatory cardiomyopathy, namely idiopathic dilated cardiomyopathy with parvovirus B19 persistence, in a randomized controlled trial.12 Over the last years, improvement in survival was observed in patients with dilated cardiomyopathy, with many patients with new-onset cardiomyopathy who may show reverse remodelling.13, 14 In TRED-HF, withdrawal of pharmacological treatment for HF in patients with recovered dilated cardiomyopathy was associated with relapses in 44% of patients.15 In a further analysis by cardiac magnetic resonance, treatment withdrawal resulted in early ventricular remodelling with an increase in myocardial mass and a reduction in global longitudinal strain. Interestingly, these changes may also occur in patients who do not show clinical deterioration.16 Shorter left ventricular systolic ejection time has been identified as a marker of worse prognosis among patients with HF with reduced ejection fraction (HFrEF).17 Alhakak et al.18 confirmed the prognostic impact of left ventricular systolic ejection time on mortality in a large HFrEF population (per 10 ms decrease: adjusted HR 1.06, 95% CI 1.01–1.11, P = 0.030), hence supporting its use to stratify patients' risk and to guide therapeutic response. Heightened chemosensitivity has a major role in the excessive ventilatory response to exercise and sleep breathing abnormalities in patients with HF. Buspirone, a 5HT1A receptor agonist that inhibits serotonergic chemoreceptor neuron firing, reduced carbon dioxide chemosensitivity and improved central apnoeas in patients with HF.19 A relatively large number of patients with advanced HF may benefit from long-term mechanical circulatory support.20 This indication might be further expanded if this device therapy may cause regression of myocardial fibrosis. Unfortunately, such hypothesis was not proven in a recent study in 125 patients.21

Systolic time intervals and its relation to intraventricular dyssynchrony of the left ventricle in patients with dilated cardiomyopathy

Aim To assess the value of systolic time intervals [as simple echocardiographic parameters of left ventricle (LV) systolic performance] and its relation to intraventricular dyssynchrony (by speckle tracking) of the LV in patients with dilated cardiomyopathy. Patients and methods All the studied individuals were subjected to ECG and transthoracic echocardiography to measure LV dimensions and systolic function by conventional and speckle-tracking echo. Left ventricular pre-ejection time (LVPET), left ventricular ejection time (LVET), and the ratio of LVPET to LVET were also measured (LVPET/LVET). Two-dimensional strain to measure time to peak negative strain value of the LV segments was averaged to calculate TPS-SD. Results The enrolled population were 153 cases, divided into 123 patients and 30 normal individuals. There was a significant lower LV global longitudinal strain % in the patient group. Moreover, insignificant shorter LVET was seen in the patients. LVET had an inversely significant correlation with QRS duration and dyssynchrony index. The LVPET and PET/LVET ratio had a significant linear correlation with QRS duration and dyssynchrony index measured by two-dimensional strain (r=0.4, P&lt;0.01). Conclusion Systolic time interval can be easily and accurately measured in patients with DCM and may be considered as an indicator for presence of LV intraventricular dyssynchrony.

Noninvasive Accelerometric Approach for Cuffless Continuous Blood Pressure Measurement

Pulse transit time (PTT) has been widely used for cuffless blood pressure (BP) measurement. However, it requires more than one cardiovascular signal involving more than one sensing device. In this article, we propose a method for cuffless continuous blood pressure measurement with the help of left ventricular ejection time (LVET). A microelectromechanical system (MEMS)-based accelerometric sensor acquires a seismocardiogram (SCG) signal at the chest surface, and then, the LVET information is extracted. Both systolic and diastolic BPs are estimated by calibrating the system with the original arterial BPs of the subjects. The performance evaluation is done using different statistical quantitative measures for the proposed method. The performance is also compared with two earlier approaches, where PTT intervals are measured from electrocardiogram (ECG)–photoplethysmogram (PPG) and SCG–PPG pairs. The performance results clearly show that the proposed method is comparable with the state-of-the-art methods. Also, the estimated BP is compared with the original one, measured through a reference system. It gives the mean errors of the systolic and diastolic BPs within the range of −0.197 ± 3.332 and −1.299 ± 2.578 mmHg, respectively. The BPs estimation errors satisfy the requirements of the IEEE standard 5 ± 8 mmHg deviation, and thus, our method may be used for ubiquitous continuous BP monitoring.

Cardiac Myosin Activation for the Treatment of Systolic Heart Failure.

Left ventricular systolic dysfunction is the hallmark pathology in heart failure with reduced ejection fraction. Increasing left ventricular contractility with beta-adrenergic receptor agonists, phosphodiesterase-3 inhibitors, or levosimendan has failed to improve clinical outcomes and, in some situations, increased the risk of sudden cardiac death. Beta-adrenergic receptor agonists and phosphodiesterase-3 inhibitors retain an important role in advanced heart failure. Thus, there remains an unmet need for safe and effective therapies to improve left ventricular systolic function. Two novel cardiac myotropes, omecamtiv mecarbil and danicamtiv, target cardiac myosin to increase left ventricular systolic performance. Neither omecamtiv mecarbil nor danicamtiv affects cardiomyocyte calcium handling, the proposed mechanism underlying the life-threatening arrhythmias associated with cardiac calcitropes and calcium sensitizers. Phase 2 clinical trials have demonstrated that these cardiac myosin activators prolong left ventricular systolic ejection time and promote left ventricular and atrial reverse remodeling. At higher plasma concentrations, these agents may be associated with myocardial ischemia and impaired diastolic function. An ongoing phase 3 clinical trial will estimate the clinical efficacy and safety of omecamtiv mecarbil. An additional study of these agents, which have minimal hemodynamic and renal effects, is warranted in patients with advanced heart failure refractory to guideline-directed neurohormonal blockers.

Acute hemodynamic effects of non-invasive ventilation in patients with obesity hypoventilation syndrome.

To evaluate the acute effects of volume-targeted non-invasive ventilation (NIV) on hemodynamic parameters assessed by impedance cardiography in patients with obesity hypoventilation syndrome (OHS). Despite the well-described beneficial effects of NIV using volume-targeted pressure support ventilation modes on respiration in OHS patients, questions were raised about the impact of this treatment on the cardiovascular system. In 15 patients (10 men; mean age, 55.8±9.3 years) impedance cardiography recordings were taken at baseline, after 120 minutes while on NIV and 20 minutes after NIV termination. A repeated-measures analysis of variance was used for comparisons. Compared to baseline, a reduction in heart rate (from 80±11 to 73±10 beats per min, p<0.05) was observed on NIV whereas the stroke volume and cardiac index remained stable throughout all three assessed intervals (p=0.347, p=0.344; respectively). The pre-ejection period increased on NIV (from 113±16 to 127±20 ms, p<0.05), and the left ventricular ejection time increased after NIV termination compared to baseline (from 259±25 to 269±25 ms, p<0.05). Volume-targeted NIV may acutely improve systolic time intervals without any negative impact on the left ventricular function in OHS patients (Tab. 2, Ref. 17).