Left Wall Research Articles

Left Atrial Structure and Function Following Ethanol Infusion into Vein of Marshall (MR‐SHALL Study)

ABSTRACTBackgroundEthanol infusion into the vein of Marshall (EI‐VOM) is an adjunctive therapy to pulmonary vein isolation (PVI), which improves the efficacy of persistent atrial fibrillation (AF) ablation procedures. It is unknown how EI‐VOM scar formation impacts left atrium (LA) structure and function.ObjectiveTo characterize scar formation after EI‐VOM, and its impact on LA function, by cardiac magnetic resonance (CMR).MethodsConsecutive patients referred for persistent AF ablation, or any repeat procedure, were included. Ablation strategy included PVI, EI‐VOM and linear lesions when deemed necessary. LA was assessed by late gadolinium enhancement (LGE) CMR at baseline and 3‐month follow‐up. CMR was post‐processed off‐line with dedicated software. The LA was regionalized into 17 segments, and global and regional scarring were calculated. Strain parameters were analyzed—including LA reservoir, conduit, and booster strain; LA ejection fraction; and LA passive and active emptying function. Follow‐up LGE‐CMR reconstruction was coregistered with the voltage map, ablation RF points, and fluoroscopy to compare the scar location with the VOM trajectory.ResultsThis study included 21 patients (65 ± 8 years; 76% men; 57% ablation of persistent AF). After EI‐VOM, 95% of patients presented new low‐voltage areas, all of whom exhibited new LGE‐CMR scarring at follow‐up. Voltage map and LGE‐CMR coregistration showed comparable scar areas (p = 0.287). LGE‐CMR scarring frequently involved the whole VOM trajectory, predominantly affecting the LA ridge, mitral isthmus, and left posterior wall. LA volume was significantly reduced after ablation, without significant changes in LA functional parameters.ConclusionEI‐VOM causes permanent scarring at 3‐month follow‐up, with no adverse impact on CMR LA functional parameters.

Multiple morcelloma of the peritoneal cavity: a case report

Introduction. Uterine fibroids are benign monoclonal hormone-sensitive tumors arising from smooth muscle cells of the cervix or body uterus. Myomectomyhas become a treatment «golden standard» upon transition to the strategy of organ-preserving surgery. The introduction of morcellation into wide clinical practice allowed to expand the indications for laparoscopic myomectomy, which is usually much better tolerated by patients due to lower invasiveness, short period of rehabilitation and low blood loss. However, the use of morcellators along with the obvious advantages has also specific complications particularly emergence of iatrogenic parasitic fibroids of the abdominal cavity upon improper surgery technique.Aim: analysis of a clinical case of multiple morcelloma.Case presentation. Female patient I., 57 years old, underwent laparoscopic myomectomy in 2003. In 2023 during a routine examination at the Central Clinical Hospital «RZD-Medicine» multiple asymptomatic iatrogenic fibroids of the abdominal cavity were revealed. The patient underwent planned surgical intervention to remove all abnormal masses.Results. During the revision upon surgical intervention, a node of 1.5×1.5 cm was found on the parietal peritoneum along the left anterior wall, as well as a node of 1.5×1.5 cm on the parietal peritoneum along the right anterior wall. There was also observed a 2×3 cm node at the edge of the omentum. In the left and right side of peritoneum of the sacro-uterine ligament, there were found nodes of up to 1 cm in size. In the area of the small intestinal mesentery, a dense node of 4.5 cm was observed 70 cm away from the ileocecal valve. Due to small size, all the fibroids were extirpated and removed from the abdominal cavity without morcellation, complete hemostasis was performed. No complications were noted during postoperative period.Conclusion. Iatrogenic fibroids are quite rare but nevertheless a potential complication of laparoscopic myomectomy. Gynecologists should pay special attention to follow proper technique upon surgical intervention. Morcellation and subsequent extraction of fibroids should be performed strictly with use of airtight container to avoid ingress of myomatous tissue into the abdominal cavity followed by emergence of iatrogenic fibroids.

Varicella zoster vasculopathy causing recurrent ischaemic strokes in an immunocompetent patient.

A 66-year-old woman reported 10 days of generalised weakness, falls and memory 'glitches'. She had developed left-sided ophthalmic herpes zoster 3 months before but was otherwise well. MR scan of brain showed acute left-sided ischaemic strokes and CT cerebral angiogram identified marked stenoses of the left anterior and middle cerebral arteries. We suspected varicella-zoster virus vasculopathy, confirmed by cerebrospinal fluid analysis. Initially she had further ischaemic strokes despite intravenous acyclovir, prednisone, aspirin and clopidogrel. However, after prolonged acyclovir and prednisone, there were no new infarcts though imaging of left anterior and middle cerebral artery vessel walls showed persistent inflammation. Varicella zoster vasculopathy can cause recurrent ischaemic strokes, even in immunocompetent people with no cardiovascular risk factors, and despite long-term antiviral therapy.

Whole-body MRI-based long-term evaluation of pediatric NF1 patients without initial tumor burden with evidence of newly developed peripheral nerve sheath tumors

BackgroundPatients with neurofibromatosis type 1 (NF1) can develop plexiform neurofibromas (PN). Large tumor burden is a predictor for the development of malignant peripheral nerve sheath tumors. Whole-body magnetic resonance imaging (WB-MRI) is the recommended imaging method for the evaluation of PN. WB-MRI is recommended for NF1 patients at transition from adolescence to adulthood. In the absence of internal PN further follow-up WB-MRI is not considered necessary. PN are often detected in early childhood, leading to the assumption that they may be congenital lesions. It remains unclear whether this invariably applies to all patients or whether patients who initially displayed no tumors can still develop PN over time. Therefore, we retrospectively reviewed WB-MRI scans of pediatric patients with NF1 without initial tumor burden and compared these with long-term follow-up scans for presence of newly developed PN.MethodsWe retrospectively reviewed WB-MRI scans of 17 NF1-children (twelve male; median age at initial scan: 9 [IQR 6.1–11.9] years) who initially displayed no PN. MRI scans with a follow-up interval of at least 6 years (median follow-up interval: 9 [IQR 5.6–12.4] years) were reviewed in consensus by two radiologists regarding the development of new PN over time.ResultsNew PN were identified in two out of 17 children without initial tumor burden in follow-up examinations. One of these two patients developed two larger distinct PN of 4.5 cm on the right upper arm and of 2.5 cm on the left thoracic wall between the age of ten and twelve. The second child developed multiple smaller PN along the major peripheral nerves between the age of eleven and 16. In addition, 15 of the children without initial tumor burden did not develop any distinct tumors for a period of at least 6 years.ConclusionOur results indicate that PN can be newly detected in pediatric patients over time, even if no PN were detected on initial MRI scans. Therefore, it seems reasonable to perform at least a second MRI in pediatric NF1 patients at transition to adulthood, even if they did not display any tumor burden on initial MRI, and when the MRI was performed significantly under the age of 18. With this approach, tumors that may have developed between scans can be detected and patients at risk for complications can be identified.

Thermal analysis of nonlinear mixed convection effects within wavy enclosure

The analysis in this study focusses on the transfer of heat within a wavy cavity in the presence of nonlinear mixed convection and MHD. We conduct the investigation under conditions where the upper wall of the cavity remains cold, the lower wall receives heat, and the left and right wavy walls remain adiabatic. Using the PDE solver in COMSOL, the non-dimensional system is simplified, employing the finite element method. The study aims to explore the impact of parameters such as nanoparticle concentration, Hartmann number, Reynolds number, Richardson number, and nonlinear mixed convection parameters on fluid flow and heat transfer. An artificial neural network has been employed to examine the behaviour of the Nusselt number within a cavity. The isotherms reveal that the temperature is higher near the lower wall for all parameters due to the heated source. Analysis of the streamline plots indicates that heat increases as it moves towards the upper wall, influenced by the Hartman number and volume fraction parameter. The use of ANN in the study forecasts the accuracy, smoothness, and convergence of the data through plots of mean squared error (MSE), error histogram, regression analysis, and transition state plot. The authors believe that using artificial neural networks to explore the heat transfer rate under the assumptions of MHD and nonlinear mixed convection is a novel approach that has not been previously investigated. Additionally, researchers can utilise ANN concepts to predict intricate cavity formations through multiphysics. This approach will require less human effort and computing time to analyse the heat response of any dataset.

Catheter ablation in a monochorionic diamniotic twin pregnancy: A case report and literature review.

Preexcitation syndrome is an uncommon congenital cardiac disorder that impairs the normal cardiac conduction system. Radiofrequency ablation is one of the most effective treatments for this condition. Nevertheless, radiofrequency ablation is rare in women with preexcitation syndrome during pregnancy. A 33-year-old woman with monochorionic diamniotic twin pregnancy complicated by sinus arrhythmia with ventricular preexcitation at 14 weeks and 5 days of gestation, with paroxysmal palpitations and shortness of breath at 16 weeks with paroxysmal supraventricular tachycardia with preexcitation syndrome and a heart rate ranging from 180 to 225 beats per minute. The pregnant occurred sudden palpitations and shortness of breath in the shower. Electrocardiography revealed paroxysmal supraventricular tachycardia, and electrophysiological study revealed preexcitation syndrome (dominant accessory route of the left free wall) with atrioventricular reentrant tachycardia. Radiofrequency catheter ablation was performed at 20 weeks. Symptoms of preexcitation syndrome resolved after the radiofrequency catheter ablation, and 2 healthy infants were delivered at 36 weeks and 2 days of gestation by cesarean section. Preexcitation syndrome may result in life-threatening arrhythmias such as supraventricular tachycardia during pregnancy and delivery. It might be efficiently controlled through optimal treatment by a multidisciplinary team, which would effectively minimize arrhythmia risk events during pregnancy and improve maternal-fetal outcomes. Based on the patient's individual situation, radiofrequency ablation may be a procedure in pregnant women with preexcitation syndrome.

Total resection via right mini-thoracotomy for left atrial myxoma in juvenile Carney complex: a case report

BackgroundCarney complex is a rare syndrome characterized by skin pigmentation, endocrine disorders, and myxomas. It is particularly notorious for its tendency to exhibit aggressive cardiac myxomas. Herein, we present a case of a juvenile female patient diagnosed with Carney complex who underwent a right lateral mini-thoracotomy.Case presentationA 13-year-old girl presented with sudden-onset left hemiplegia and dysarthria. Magnetic resonance imaging revealed multiple areas of restricted diffusion. Echocardiography identified a tumor in the left atrium, suspected to be related to Carney complex based on her medical history and physical examination findings. Surgery was performed via right lateral mini-thoracotomy, which minimized the risk of embolism and ensured a cosmetically favorable outcome. The left atrial wall defect was repaired with autologous pericardium. At 3 years postoperatively, follow-up echocardiography indicated no tumor recurrence and normal cardiac function.ConclusionsOngoing follow-ups are essential due to the aggressive nature of the Carney complex and its high recurrence rates. Right lateral mini-thoracotomy offers the advantage of avoiding re-sternotomy and minimizing adhesion dissection, making it the optimal choice for this case.

True-MAD and pseudo-MAD in consecutive patients undergoing cardiovascular magnetic resonance

Abstract Background Mitral annulus disjunction (MAD) is a controversial imaging entity with uncertain clinical significance, which has been either considered a pathological entity potentially related to mitral valve prolapse (MVP) and sudden cardiac death or, on the contrary, a benign finding in normal hearts. Cardiovascular magnetic resonance (CMR) is poised to be the ideal imaging modality to assess MAD. Recently, a distinction between pseudo-MAD, present only in systole and secondary to juxtaposition of the billowing posterior leaflet on the adjacent left atrial wall, and true-MAD, where the insertion of the posterior leaflet is clearly displaced on the atrial wall either in diastole or in systole, has been suggested. Purpose We aimed to investigate the prevalence of pseudo-MAD and true-MAD in consecutive patients undergoing clinically-referred CMR. Methods This was a single-center retrospective study including consecutive patients referred to CMR from September 2023 to November 2023. Patients with feasible MAD assessment were included. MAD was defined as a ≥1 mm displacement between the left atrial wall-mitral valve leaflet junction hinge and the top of the left ventricular wall, measured from cine-CMR images in the three long-axis views. Pseudo-MAD and true-MAD were defined according to the presence of MAD only in systole or both in systole and diastole, respectively. MVP was defined as a systolic displacement ≥2 mm of one or both mitral valve leaflets above the annulus in 3-chamber view. Results Two-hundred-ninety patients (mean age 57±18 years; 181 men, 62%) were included. MVP and MAD were respectively found in 24 (8%) and 145 (50%) patients, of which 98 (34%) with true-MAD and 47 (16%) with pseudo-MAD. In all measurements, systolic MAD (2.6±1.3 mm) resulted equal to or greater than diastolic MAD (2.2±1.1 mm). The most frequent MAD location was the inferior wall in the two-chamber view (42%), whereas the rarest one was the inferolateral wall in the three-chamber view (17%). In patients with MVP, the prevalence of MAD was higher when considering all long-axis views (22 patients, 92%), of which 50% presented with true-MAD and 50% with pseudo-MAD. The extent of pseudo-MAD and true-MAD were both greater in patients with MVP (4.2±1.5 mm and 3.0±1.6 mm, respectively) than in those without MVP (2.3±1.0 and 2.1±0.9 mm; p<0.001 and p=0.007, respectively) in all locations. At the level of the inferolateral wall, the prevalence of MAD was 71% vs. 12% (p<0.001) in patients with vs. without MVP. Conclusions The presence of true-MAD was a common imaging finding in consecutive patients undergoing CMR, thus not resulting in a distinctive abnormal feature related to MVP or sudden cardiac death. Patients with MVP showed higher prevalence and extent of true-MAD and pseudo-MAD in all locations, in line with greater degeneration of the mitral annulus. Larger studies are needed to identify potential malignant characteristics of MAD.True-MAD (A,B) and pseudo-MAD (C,D).

Ablation outcome in elderly women with atrial fibrillation undergoing pulsed-field ablation for electrical isolation of pulmonary veins and left atrial posterior wall

Abstract Background Documented evidences indicate higher prevalence of non-paroxysmal atrial fibrillation (AF) as well as in elderly women but also demonstrate the need to go beyond the pulmonary veins (PV) when treating these patients. Objective We compared the ablation outcome in elderly women (>70 years) with that in men in the same age group as well as in younger women (≤70 years) undergoing pulsed-field ablation (PFA) for persistent AF (PerAF). Methods This multicenter study included consecutive PerAF patients undergoing PFA as their first procedure. Patients were divided into 3 groups: Group 1: women >70 years, Group 2: men ≥70 years and Group 3: women ≤70 years. All received PV isolation (PVI) and isolation of left atrial posterior wall (LAPWI). Concentric overlapping lesions were placed in the LAPW. Number of applications were determined on a case-by-case basis. Isolation was confirmed by electrograms recorded on the multispline catheter. In all patients, ICE and fluoroscopy were used to optimize contact between the PFA catheter and the targeted tissue. Arrhythmia-monitoring was performed for 1-year with periodic clinic visits, event recorders and 7-day Holter monitoring. Results A total of 229 patients (group 1: 73; group 2: 47 and group 3: 109) were included in this analysis. Baseline characteristics of the study population is presented in table 1. At 1-year follow-up, 15 (20.5%), 3 (6.38%) and 10 (9.17%) from group 1, 2 and 3 respectively, experienced arrhythmia recurrence off-antiarrhythmic drugs. Recurrence rate in group 1 was significantly higher than that in group 2 (p=0.034) and group 3 (p=0.029). Conclusion In women aged ≤70 years and in elderly men (>70 years), PVI plus isolation of LAPW using ICE-guided PFA was associated with significantly lower recurrence rate compared to that in the elderly women. Given the higher recurrence rate following PVI+LAPWI in the elderly females, the operators should consider addressing all other AF-initiating extra-PV triggers for better ablation-outcome in this subset of the AF population.

AI-enabled automated cardiac chambers volumetry in non-contrast ECG-gated cardiac scans vs. non-contrast non-gated lung scans

Abstract Introduction We have developed an AI-enabled automated volume measurement of cardiac chambers (AutoChamber) that works on ECG-gated coronary artery calcium scans and correlates well with contrast enhanced coronary CT angiography scans. We have recently reported that increased left atrial volume measured by AutoChamber is a strong predictor of new onset atrial fibrillation (AF) in asymptomatic individuals of Multi-Ethnic Study of Atherosclerosis (MESA). In this study, we compare the volumetry results in ECG- gated CAC scans with those of non-gated full-chest lung cancer screening scans in the same individuals. Methods We have studied 169 cases of paired ECG-gated cardiac CT scans and non-gated lung scans obtained from Harbor UCLA. Mean±SD for age was 62.1±10.0 years with 52% female participants. All cases were asymptomatic and were scanned for preventive health assessment. AutoChamber was run on all cases by an independent operator who was not involved in data analysis. P value was calculated using a two-tailed test of significance with α=0.05. Results AutoChamber in cardiac scans vs lung scans reported volume (Mean±SD) for left atrium (LA) was 63.8 ± 18.5 vs. 65.5 ± 19.4, left ventricle (LV) 102.8 ± 25.3 vs. 105.5 ± 25.2, right atrium (RA) 81.9 ± 20.5 vs. 85.7 ± 21.9 right ventricle (RV), 140.7 ± 34.2 vs. 134.2 ± 33.7, left ventricle wall (LVW) 113.0 ± 26.6 vs. 109.7 ± 27.0 respectively (P < 0.0001). Strong correlation was shown between cardiac and lung scans for each cardiac chamber: LA (R = 0.92), LV (R = 0.93), RA (R = 0.91), RV (R = 0.92), and left ventricular wall (LVW) R = 0.95. Conclusions AutoChamber volumetry results are similar in ECG-gated cardiac scans vs non-gated full-chest lung scans. This AI-enabled automated tool is promising as it can provide added value to patients undergoing coronary calcium and lung cancer screening scans flagging enlarged cardiac chambers at risk of AF and heart failure.

Ultrasound findings of ovarian intravenous leiomyomatosis: a case report

Intravenous leiomyomatosis (IVL), an abnormal growth pattern of uterine leiomyomas, is a rare tumor characterized by masses of smooth muscle cells appearing histologically benign and proliferating within the blood vessels but not invading the tissue. Currently, there have been limited reports of early cases of IVL, and the imaging characteristics of IVL remain uncertain, resulting in frequent misdiagnosis prior to surgery. The present study utilized a case of early IVL detected through conventional ultrasound and subsequently confirmed via contrast-enhanced ultrasound (CEUS) to further investigate ultrasound’s diagnostic efficacy for early IVL detection. Here, a case of a 49-year-old woman was reported who presented with uterine leiomyoma and an echogenic mass in the left adnexal region on physical examination. Subsequent transvaginal CEUS examination revealed a left ovarian venous leiomyoma. The patient underwent resection of tumors in the uterus, bilateral ovaries, and left ovarian vein under general anesthesia. A venous plexus was identified above the left broad ligament close to the left ovary, and a myoma-like growth was detected in the posterior uterine wall during the operational procedure. Reports on pathology and immunohistochemistry verified leiomyomatosis with fatty metaplasia in the left broad ligament and uterine wall vein. The prognosis of patients with IVL is determined based on the appropriate surgical methods and the timely diagnosis of the condition. In this case, conventional ultrasound aided in the early identification of IVL, which was later verified by a CEUS examination, resulting in a successful surgical treatment. This example highlights the importance of ultrasound technology in diagnosing this uncommon condition and presents a new method for preoperative detection of IVL.

Early result of minimally invasive cardiac myxoma resection at University Medical Center, Ho Chi Minh City

Objective: The study aimed to evaluate various clinical and paraclinical characteristics, as well as early surgical outcomes of minimally invasive cardiac myxoma resection at University Medical Center HCMC. Subjects and methods: This is a retrospective descriptive case series study involving all patients diagnosed with cardiac myxomas who underwent minimally invasive surgery at University Medical Center HCMC from January 2020 to June 2024. Results: There were 31 patients, consisting of 22 females and 9 males. The mean age was 56,2 ± 10,7 years old (from 37 to 77 years old). The clinical manifestations were diverse: asymptomatic (45,2%), cerebral embolism (6,4%), fatigue (29,0%), dyspnea (35,5%), palpitations (12,9%), and dizziness (12,9%). Echocardiographic results: 90,3% left atrial myxoma, 9,7% right atrial myxoma. The tumor attachment sites: interatrial septum (93,6%), left atrial wall (6,4%). The average tumor size was 36,3 ± 15,1 mm. All tumors were completely resected (100%). Additional surgical procedures: mitral valve repair (3,2%), interatrial septum repair (6,4%). Cardiopulmonary bypass time was 82,4 ± 31,1 minutes (from 49 to 199 minutes), cross - clamp time was 39,2 ± 17,6 minutes (from 18 to 85 minutes), with 3 cases not requiring cardiac arrest. Ventilation time was 13,2 ± 6,3 hours (from 6,7 to 32,4 hours), intensive care unit stay was 52,6 ± 28,1 hours (from 13 to 113,7 hours), postoperative recovery time was 6,9 ± 2,3 days (from 4 to 16 days). Early outcomes: 3 cases of atrial fibrillation with rapid ventricular response, treated medically (9,7%), 1 case of acute kidney injury (3,2%), 4 cases of pleural effusion (12,9%), 3 cases of pneumothorax (9,7%), 1 case of right external iliac artery thrombosis requiring surgical thrombectomy (3,2%), and 2 cases of deep vein thrombosis (6,4%). No surgical site infections, cerebrovascular accidents, or mortality within 30 days post-surgery were reported. Conclusion: Minimally invasive cardiac myxoma resection demonstrates a low complication rate, with no reported tumor recurrence or early postoperative mortality. This technique offers a safe and effective alternative to traditional median sternotomy and may be gradually adopted and implemented in lower - level healthcare facilities.

Ablation outcome in patients with atrial fibrillation undergoing ICE-guided pulsed-field ablation

Abstract Background Prior experiences from preclinical studies indicate the critical need of catheter-tissue- contact for creation of consistent transmural lesions in pulsed-field ablation (PFA). Intracardiac echocardiography (ICE) not only provide real-time visualization of cardiac structures, but also ensure adequate contact with the tissue. Objective We evaluated ablation outcome and reconnection rate following ICE-guided PFA procedure in patients with atrial fibrillation (AF). Methods Consecutive patients receiving ICE-guided PFA procedure were included in this multi-center analysis. All patients received isolation of PVs (PVI). Additional ablation of left atrial posterior wall (LAPW) was decided based on operator’s discretion. Concentric overlapping lesions were placed in the LAPW. Number of applications were determined on a case-by-case basis. ICE and fluoroscopy were used to optimize contact between the PFA catheter and the targeted tissue. All procedures were performed under uninterrupted anticoagulation. Mapping was done before and after ablation to confirm electrical isolation. Arrhythmia-monitoring was done for 1-year with periodic clinic visits, event recorders and 7-day Holter monitoring. Results A total of 372 patients [age: 62.69 ± 10.41 years, male: 201 (71.3%), paroxysmal AF: 67 (18%)] were included in this analysis of which 48 (12.9%) underwent PVI-only and the remaining subjects received additional ablation of LAPW. Mean number of applications were 34.67 ± 8.88 and 73.65 ± 37.21 for PVI-only and PVI+LAPWI cohorts respectively (p<0.001). No major procedural complications such as esophageal injury, atrio-esophageal fistula, pericardial effusion requiring drainage or cerebrovascular accidents were reported. During 1-year follow-up, 38 (10.2%) patients underwent repeat procedure for recurrence. Reconnection of PV and LAPW were found in only 2 (5.2%) patients. In all 38 patients, new triggers initiating AF were detected to be originating from interatrial septum: 25 (65.8%), superior vena cava: 9 (23.7%), coronary sinus: 7 (18.4%) and left atrial appendage: 6 (15.8%). Conclusion ICE-guided PFA procedures are safe and produce durable lesions leading to very low reconnection rate. The recurrence was mostly due to new triggers initiating AF.

Cardiac morphology and function in patients with primary biliary cholangitis (PBC) without cirrhosis

Abstract Background Primary biliary cholangitis (PBC) is a chronic, autoimmune liver disease causing destruction of the small intralobular bile ducts in the liver. PBC patients can also develop extrahepatic manifestations. Though patients with PBC have often elevated levels of serum lipids, data concerning cardiac involvement is inconsistent and cardiovascular changes may be underdiagnosed. Purpose The purpose of the study was to assess cardiac morphology and function in patients with PBC without cirrhosis and comparison with control subjects. Methods We studied 52 females with PBC, and included in the analysis 22 females without cirrhosis, who were compared to 44 healthy female controls matched for age (53.4 ± 9.2 and 51 ± 8.3 yrs., respectively, p =0.312). Transthoracic echocardiography (TTE) was performed with the analysis of the left ventricular (LV) global longitudinal strain (GLS) and myocardial work. Additionally, impedance cardiography was conducted, with the analysis of the autonomic function using BRS (baroreceptor sensitivity), HRV (heart rate variability) and BPV (blood pressure variability). Results Systolic blood pressure (SBP), diastolic blood pressure (DBP) and heart rate (HR) differed between PBC and control group (128 ± 17 mmHg vs. 116 ± 11 mmHg, p=0.007 and 78± 12 mmHg vs. 75 ± 8 mmHg, p=0.024, and 73.5 ± 12 bpm vs. 71 ± 8 bpm , p=0.024, respectively). PBC group had larger diameter of the cardiac chambers when adjusted for body surface area (BSA), including left atrium (LA/BSA) and right ventricle (RV/BSA), as well as left ventricular mass (LWMI) and relative wall thickness (RWT), with no difference in the left ventricular end diastolic diameter (LVEDD/BSA). LV ejection fraction (EF) measured by bi-plane Simpson method was higher in PBC group. LV diastolic function parameters (E/A, E/e’) differed in patients with PBC when compared with controls, however, without signs of diastolic dysfunction. LV GLS indices (GLSAVG, GLSLAX, GLS4C, GLS2C) were significantly higher in PBC group, as well as global myocardial work indexes: global myocardial work (GWI) and global constructive work (GCW). Non-invasive autonomic assessment showed lower BPV in patients with PBC without cirrhosis, but no differences in baroreceptor sensitivity and HRV. Impedance cardiography did not show differences between both groups. Conclusion Our study shows that PBC patients without cirrhosis are characterized by remodeling and functional changes of the heart, when compared to age-matched controls. These changes could imply hyperkinetic circulation even before the development of cirrhosis in PBC patients.

Preoperative echocardiography and anesthetic drugs as predictors of post-induction hypotension during general anesthesia: a prospective observational study

Post-induction hypotension (PIH) during general anesthesia is a serious concern due to its high incidence and association with adverse postoperative outcomes and prognosis. We prospectively enrolled consecutive 1,603 patients scheduled for non-cardiac and cardiac surgery under general anesthesia. The primary outcome was defined as the lowest mean blood pressure from induction of general anesthesia to the start of surgery: post-induction blood pressure (PIB). Multivariable regression analysis was used to investigate the relationships between PIB and preoperative echocardiographic measurements, types and doses of anesthetic agents, and preoperative comorbidities and oral medication. Left ventricle regional wall motion abnormality (RWMA) and lower estimated glomerular filtration rate significantly associated lower PIB. Factors significantly associated with higher PIB were high BMI, beta blockers, high pre-induction mean blood pressure, and starting induction in the afternoon. Sevoflurane and prophylactic norepinephrine use were associated with higher PIB as anesthetic interventions. Significant interactions were found between sevoflurane and RWMA (P for interaction: 0.01). This is the first study to demonstrate the feasibility of intervening in the selection of anesthetic agents based on echocardiographic findings and to recommend the use of sevoflurane and prophylactic norepinephrine for the prevention of PIH, especially in patients with RWMA.

Interleukin-6 levels in atrium and onset of spontaneous atrial fibrillation: is there a causal relationship

Abstract Background Cumulative evidence suggests that atrial interleukin-6 (IL-6) may play a significant role in the development of spontaneous postoperative atrial fibrillation (sPOAF) in coronary artery bypass grafting (CABG) patients. Our previous studies found that the IL-6 produced by the atrium is positively related to the development of sPOAF. However, the causal relationship between IL-6 and sPOAF is not established. Purpose This study aims to explore the potential causality between atrial IL-6 and spontaneous AF(sAF), alongside assessing the impact of IL-6 on the electrophysiological properties of atrial myocytes (AM). Methods To determine the causal link between IL-6 and sAF, mice were randomly divided into eight groups: seven receiving injections of varying doses of recombinant IL-6 protein groups (15ng/kg to180ng/kg) into the left atrial wall, and one control group (vehicle). Mice were monitored for sAF for 7 days using implanted telemetry device. At 48 hrs post-injection, the left atrial appendages of another set of mice were collected for analyzing levels of IL-6, Myeloperoxidase (MPO), Transforming Growth Factor-β1 (TGF-β1), and Tumor Necrosis Factor-α (TNF-α). To assess the effect of IL-6 on the electrophysiological characteristics of AM, AMs were isolated from the hearts of 12-week-old mice and divided into experimental and control groups for electrophysiological testing. The experimental group was perfused with extracellular solutions containing 100 ng/mL of IL-6 while the control group was perfused with standard extracellular solutions. The measurements focused on action potential (AP), transient outward potassium current (Ito), and inward rectifier potassium current (Ik1) after a 30-minute perfusion. Results As depicted in Fig. 1A, a dose-response relationship between IL-6 levels and sAF occurrence was observed, with incidence increasing from 0% at 15 ng/kg to 75% at 180 ng/kg (χ²= 16.691, P = 0.005). The injection of IL-6 also induced the production of MPO, TGF-β1, and TNF-α with a dose-dependent effects (Fig. 2). In comparison to control, the AP duration at 90% (APD90) and APD50 of repolarization of atrial myocytes were significantly shortened in IL-6 group (Fig. 1B). For voltages from -10mV to +70mV, atrial myocytes in the IL-6 group showed significantly lower Ito current density than those in the control (Fig. 1C). No significant alterations were observed in the impact of IL-6 on Ik1 current density in atrial myocytes (Fig.1D). Conclusion To the best of our knowledge, this is the first study that experimentally tested the causal relation between IL-6 and sAF. The injection of IL-6 could cause the onset of sAF and produce MPO, TGF-β1, and TNF-α with a significant dose-dependent effect. The effect of IL-6 on inducing sAF might be through its effect on reducing APD and Ito current density in mouse atrial myocytes. This suggests that inhibition of atrial IL-6 might be a potential novel sPOAF prevention strategy.

Organization of atrial flutter during pulse field ablation for atrial fibrillation

Abstract Background Pulse Field Ablation (PFA) has been acknowledged as an effective and safe tool for ablation of Atrial Fibrillation (AF). It is known that during AF ablation, the arrhythmia may organize into atrial flutter. The left atrial posterior wall is identified as a critical source of non-Pulmonary Vein (PV) triggers that facilitate maintenance of atrial fibrillation. Objective The purpose of this study is to investigate the phenomenon of atrial flutter organization from AF during the application of PFA. Methods This prospective multicentric study encompasses 117 consecutive patients with persistent AF across American and European institutions, undergoing first time catheter ablation. All receive isolation of the Pulmonary Veins (PV) plus Posterior Wall (PW) isolation. The PW isolation procedure targeted the standard area between the PVs and extended to the area demarcated by the line connecting the inferior borders of the inferior PV-encircling lesions to the coronary sinus defined lower part of PW (Fig. 1). The study documented the specific locations where AF organized into atrial flutter with a stable cycle length during PFA. Results Organization of AF to atrial flutter during PFA was observed in 72 (61.5%) patients. Analysis of the organization of flutter revealed that in 41 (56.9%) of these cases, flutter began while ablating the lower part of the PW. Moreover, 9 (12.5%) initiated at one of the PVs, and 22 (30.5%) during the ablation of the posterior wall. Notably, the flutter was described as perimitral flutter in 33 (45.8%), as typical flutter in 24 (33.3%), and as roof-dependent flutter in 15 (20.8%) of cases. Conclusion The findings underscore that during PFA for AF, there is a pronounced tendency for the arrhythmia to organize into atrial flutter, particularly during the ablation of the lower posterior wall. Notably ablation in the left atrium organized AF in typical atrial flutter at a considerable rate.Ablation on lower part of PW

Efficacy of the peak frequency map for left atrial posterior wall isolation.

Complete isolation of the left atrial posterior wall (LAPW) is challenging owing to overlapping epicardial conduction. Peak frequency (PF) is a novel parameter that focuses on near- and far-field electrogram components. In this study, we aimed to determine whether transmural block completion is related to the ablation site PF. We analyzed 44 consecutive patients undergoing initial LAPW isolation (LAPWI) between June 2023 and February 2024. Pre-LAPWI and PF maps were obtained using an HD-Grid catheter. In 17 of the 44 patients (Group-1), LAPWI was performed conventionally. In the remaining 27 patients (Group-2), PF-guided LAPWI was applied based on Group-1 results. In Group-1, the left atrial (LA) roof and floor line success rates were 58.8% and 76.5%, respectively. The average PF value in the roof lines of patients with a completed block line was significantly higher than that of the remaining patients (286.6 ± 29.3 Hz vs. 236.1 ± 40.9 Hz, p = .012), but the floor lines were similar. In Group-2, relatively high PF values were targeted to achieve complete block of the LA roof and floor lines, following the results obtained in Group-1. The LA roof line success rates (92.6% vs. 58.8%, p = .007), total number of radiofrequency (RF) applications (22.7 ± 5.6 vs. 27.6 ± 8.5, p = .03), and procedural time (32.6 ± 18.3 vs. 47.9 ± 25.6 min, p = .03) differed between Group-1 and Group-2. Using a PF map for determining the optimal ablation line for LAPWI by RF catheter ablation is feasible.

See-saw-like movement of right heart

Abstract Right atrial appendage aneurysm is a rare disease, which is usually diagnosed initially by transthoracic echocardiography and differentiated from pericardial effusion and other diseases. We described the motion pattern of the right heart wall in the case of a giant right atrial appendage aneurysm, which is different from the “pendulum-like” motion in the case of massive pericardial effusion. It merely affects the right heart wall, presenting a see-saw-like movement, while the left heart wall remains unaffected.

Comparative effects of different power settings for achieving transmural isolation of the left atrial posterior wall with radiofrequency energy.

Abstract