Low Low Left Ventricular Ejection Fraction Research Articles

Outcomes of patients with definite and possible infective endocarditis related to a cardiac implantable electronic device.

Diagnosis of lead related infective endocarditis (LRIE) is often a real challenge. Current diagnostic criteria include LRIE definite and possible. Comparison of the outcomes of patients with definite and possible LRIE undergoing transvenous lead extraction (TLE) procedures. A retrospective analysis of data from 3782 patients undergoing TLE between 2006 and 2023 was performed. The study included 838 patients with definite and possible LRIE. The analysis of clinical data and short and long-term survival was performed. The comparison of clinical data showed more frequent occurrence of vegetations (81.58% vs 37.21%; P <0.001), positive blood cultures (66.12 % vs 51.64%; P <0.001) and septic pulmonary embolism (40.14% vs 13.78%; P <0.001) in patients with definite LRIE. Long-term mortality of patients with definite and possible LRIE (median follow up 4.61 [1.04-9.40] and 5.06 [2.07-8.75] years respectively) was 61.14% vs 49.29%; P <0.001. Predictors of mortality in patients with marked LRIE include advanced age, low left ventricular ejection fraction (LVEF), comorbidities, septic pulmonary embolism, positive blood culture, and the presence of an abandoned lead. In possible LRIE, only the influence of advanced age, low LVEF and comorbidities was demonstrated. There has been no documented direct impact of delayed diagnosis on the long-term survival of patients after TLE Conclusions: The study documented better survival in patients with possible LRIE, which confirms the need to use extended diagnostic criteria for LRIE. Implementation of appropriate treatment at an early stage of infection allows for improved prognosis.

Incidence of left ventricle thrombus formation in patients with STEMI in the current era of antithrombotic treatment

Abstract Funding Acknowledgements None. Introduction Left ventricular (LV) thrombus formation is a serious complication of acute ST-segment elevation myocardial infarction (STEMI) which may result in ischemic stroke and systemic thromboembolism. There is limited evidence on the incidence and impact of LV thrombus in STEMI patients in the current era of antithrombotic treatment. Purpose To evaluate the incidence of LV thrombus formation in STEMI patients and to assess clinical predictor factors of LV thrombus formation leading to in-hospital major cardiac events (MACCE). Methods We prospective collected data from 504 STEMI patients treated with primary percutaneous intervention (PCI) in our large volume university hospital from April 2019 to September 2019. All patients underwent echocardiography examination at presentation and at hospital discharge. Results Mean age of the patients was 66.2 years and 78.8% were male. The incidence of LV thrombus formation was 5% in overall cohort and 9.4% in anterior STEMI. Among patients with LV thrombus, the majority had anterior STEMI (96% vs 48.4%; p&amp;lt;0.001), lower LV ejection fraction (LVEF)(35% vs 43%; P&amp;lt;0.001), more increased LV dimension /volume (36%vs7.3%; p&amp;lt;0.001), more apical aneurism/dyskinesia presence (36% vs 9%; p&amp;lt;0.001), longer ischemia time (25 hours vs 14 hours; p&amp;lt;0.002), more increased TPI values (p-0.22) and underwent less coronary angiography (p&amp;lt;0.02) and primary PCI (P=0.021). Increased LV dimension/volume was associated with 3.35 times higher risk of having LV thrombus (p=0.023). Also anterior STEMI was associated with 14 times higher risk of having LV thrombus=0.012. Patients with LV thrombus had a numerically higher incidence of in-hospital MACCE events (20% vs 13.5%; p=0.36). Conclusion The incidence of LV thrombus formation in STEMI still remain high regardless of primary PCI treatment and current antithrombotic treatment, and is higher in patients with anterior STEMI, lower LVEF, adverse ventricular remodeling, apical aneurism/dyskinesia presence, late hospital presentation and longer ischemia time. The presence of LV thrombus was independently associated with in-hospital MACCE events.

Detection of left ventricular systolic dysfunction in patients with ischemic heart disease using spatial and frontal QRS-T angles of the electrocardiogram

Aim. To evaluate the possibilities of the spatial QRS-T angle (sQRS-Ta) and the frontal QRS-T angle (fQRS-Ta) to detect low left ventricular ejection fraction (LVEF) in patients with chronic coronary heart disease. Materials and methods. We analyzed the data of 287 patients with chronic coronary artery disease, in 80 cases complicated by chronic heart failure with low LVEF. fQRS-Ta was calculated as absolute value of the difference between the frontal plane QRS and T axes. sQRS-Ta was calculated using the synthesized vectorcardiogram as a spatial angle between the integral QRS and T vectors. Results. The fQRS-Ta values in the group were 70 [25; 141]°. sQRS-Ta values in the group were 96 [55; 148]°. There were correlations between fQRS-Ta and LVEF (r=-0.58; p0.0001) and sQRS-Ta with LVEF (r=-0.63; p0.0001). According to the ROC analysis, fQRS-Ta with a threshold value of 90° made it possible to identify patients with LVEF≤40% with a sensitivity of 85% and a specificity of 75% (area under the ROC curve 0.85±0.03) and patients with LVEF≤35% with 87% sensitivity and 69% specificity (area under the ROC curve 0.84±0.04). sQRS-Ta with a threshold value of 125° made it possible to identify patients with LVEF≤40% with a sensitivity of 86% and a specificity of 82% (area under the ROC curve 0.89±0.03) and patients with LVEF≤35% with sensitivity 93% and specificity 76% (area under the ROC curve 0.89±0.02). Conclusion. In patients with chronic coronary artery disease, as the LVEF decreases, the frontal and spatial angles between the QRS and T vectors increase. These indicators with sufficiently high sensitivity and specificity make it possible to identify patients with reduced LVEF among patients with chronic coronary artery disease.

Recent outcomes of surgical redo aortic valve replacement in prosthetic valve failure.

As redo surgical aortic valve replacement(AVR) is relatively high risk, valve-in-valve transcatheter AVR has emerged as an alternative for failed prostheses. However, the majority of studies are outdated. This study assessed the current clinical outcomes of redo AVR. This study enrolled 324 patients who underwent redo AVR due to prosthetic valve failure from 2010 to 2021 in four tertiary centers. The primary outcome was operative mortality. The secondary outcomes were overall survival, cardiac death, and aortic valve-related events. Logistic regression analysis, clustered Cox proportional hazards models, and competing risk analysis were used to evaluate the independent risk factors. Redo AVR was performed in 242 patients without endocarditis and 82 patients with endocarditis. Overall operative mortality was 4.6% (15 deaths). Excluding patients with endocarditis, the operative mortality of redo AVR decreased to 2.5%. Multivariate analyses demonstrated that endocarditis (HR 3.990, P=0.014), longer cardiopulmonary bypass time (HR 1.006, P=0.037) and lower left ventricular ejection fraction (LVEF) (HR 0.956, P=0.034) were risk factors of operative mortality. Endocarditis and lower LVEF were independent predictors of overall survival. The relatively high risk of redo AVR was due to reoperation for prosthetic valve endocarditis. The outcomes of redo AVR for non-endocarditis are excellent. Our findings suggest that patients without endocarditis, especially with acceptable LVEF, can be treated safely with redo AVR.

Influence of COVID-19 pandemic in India on coronary artery disease clinical presentation, angiography, interventions and in-hospital outcomes: a single centre prospective registry-based observational study

ObjectiveThe study examined the influence of the COVID-19 pandemic in India on variation in clinical features, management and in-hospital outcomes in patients undergoing percutaneous coronary intervention (PCI).DesignProspective registry-based observational study.SettingA...

The relationship between heart functions and anemia in patients with end-stage renal disease receiving hemodialysis

Objective: We investigated the relationship between anemia and cardiac functions by conventional and speckle-tracking echocardiography (STE) in patients with end-stage renal disease (ESRD) receiving hemodialysis. Methods: One hundred six patients with ESRD receiving hemodialysis were included in this cross-sectional study. The conventional echocardiography and STE findings were compared between the patients with and without anemia. In addition, a comparison of the findings between the ESRD patients and healthy controls consisting of 68 participants was conducted. Results: Compared to healthy controls, ESRD patients had lower left ventricular ejection fraction (LVEF), left ventricular global longitudinal strain (LVGLS), and left atrial reservoir strain (LASr) [53% (48-57) vs. 65% (62-68), -15.2 (-16.9˗ -13.6) vs. -19.7 (-16.9˗ -13.6), and -21.9 (-29.5˗ -15.3) vs. -29.9 (-35.3˗ -22.8), respectively, P-value &amp;lt;0.001 for all]. Of the ESRD patients, 70 (66%) had anemia. ESRD patients with anemia had higher interventricular septum (IVS), posterior wall (PW), and left atrial volume index (LAVi) values than patients without anemia. In addition, ESRD patients with anemia had lower LVEF, LVGLS, and LASr than patients without anemia [median (IQR), 13 (12-15) vs. 12 (11-14), P=0.004, 13 (12-15) vs. 12 (11-13.5), P&amp;lt;0.005, 43 (35-55) vs. 34.7 (28-50), P=0.013, 52 (48-55) vs. 56 (47.5-60), P=0.016, -14.6 (-16.4˗ -13.5) vs. -16 (-18.6˗ -14.7), P=0.003, and -21.6 (-30.5˗ -16.3) vs. -30.5 (-33.6˗ -23.3), P=0.006, respectively]. In multivariable logistic regression analysis, diabetes, PW, LASr, and LVGLS were independently associated with the presence of anemia in ESRD patients. Conclusion: Our study confirmed impaired cardiac mechanics in ESRD hemodialysis patients and showed that anemia was associated with further worsening cardiac mechanics in this population.

Digitalization of ECG in optimization of diagnostics of acute and chronic coronary syndromes

The aim is to study the additional diagnostic possibilities of indicators obtained by digitalization of ECG in patients with ST-elevation myocardial infarction (STEMI) and stable angina (SA).Material and methods. 135 patients were examined, who were divided into groups depending on the diagnosis: 45 people with STEMI and 90 patients with SA. According to the value of the first derivative of the T wave - the maximum speed ratio (MSR) indicator, patients with STEMI were divided into two groups: group I included 25 people with MSR &lt;0.66, group II - 20 patients with MSR ≥0.66. Patients with SA were also distinguished depending on MSR: group A included 41 patients with MSR &lt;0.87 and group B - 49 patients with MSR ≥0.87. The results of echocardiography, Holter ECG monitoring, coronary ventriculography and digitalization of ECG based on the «Smart-ECG» medical software were evaluated.Results. In the STEMI group, significantly lower MSR values of ischemic zone were noted, compared to the group of patients with SA (0.65±0.02, Δ –25.29%, p&lt;0.001), higher STH values in ischemic zone (0.76±0.04 mm, Δ +58.33%, p&lt;0.001), lower left ventricular ejection fraction (LVEF) (51.96±1.21 %, Δ -9.82%, p&lt;0.001), longer ischemia (919.00 (133, 00; 1310.00) min, Δ +3729.17%, p&lt;0.001), lower standart deviation values of N-N intervals (SDNN) (88.11±6.65 ms, Δ -20.88%, p=0.094). Individuals with SA and MSR &lt;0.87 showed slightly higher values of MSR in lead V2, compared to the group of SA and MSR ≥0.87 (2.51±0.08, Δ +8.19%, p=0.058). In patients with STEMI and MSR &lt;0.66 and with SA and MSR &lt;0.87, compared to the group with STEMI and MSR ≥0.66 and with SA and MSR ≥0.87, lower LVEF were detected (respectively (52.00 (47.75; 55.00) %, Δ -10.34%, p=0.071) and (56.73±0.83%, Δ -3.14%, p=0.088).Conclusions. Primary changes in the repolarization phase, which are inherent for patients with STEMI and SA, cause a change in the speed parameters of the differentiated ECG – reducing of MSR (more intense for patients with STEMI), which indicates a pronounced electrical disbalance of the ischemic myocardium. Lower values of MSR result in worse clinical and functional characteristics of the myocardium for STEMI and SA and are associated with negative prognostic markers of ischemia.

Detection of left ventricular contractile dysfunction in patients with premature ventricular contractions using electrocardiogram trained using a deep learning model

Abstract Background Premature ventricular contractions (PVCs) are the most common arrhythmia affecting the ventricle. Frequent PVCs are associated with the development of PVC-cardiomyopathy (CM). It is known that the PVC burden has a direct correlation to the severity of left ventricular (LV) dysfunction. However, only 5% of patients with frequent PVCs (&amp;gt;10,000 per day) have associated PVC-CM. Thus, selecting patients for therapy options with drugs or catheter ablation is challenging, especially, when patients are asymptomatic with the PVCs. Purpose To train a deep learning model to predict the probability of low LV ejection fraction (LVEF) in patients with PVCs on a 12-lead electrocardiogram (ECG). Methods Using 69,440 paired 12-lead ECGs (containing at least one PVC), and echocardiogram data, including the left ventricular ejection fraction at Mayo Clinic, we trained a convolutional neural network to identify patients with ventricular dysfunction, defined as ejection fraction ≤35%, using the ECG data alone. ECGs were acquired at a sampling rate of 500 Hz using a Marquette ECG machine (GE Healthcare) and stored using the MUSE data management system for later retrieval. Comprehensive 2-D or 3-D and Doppler echocardiography were available for all patients. We trained a convolutional neural network using the Keras framework with TensorFlow (Google). The ECG-echocardiogram pairs were divided into a 60:20:20 training:validation:test split. Results The mean age of the patients used to train the model was 69.9 ± 13.0 years, and 65.2 percent of patients were male. The mean LVEF for this population was 52 ± 14.9 %, and the proportion of patients with low LVEF was 16.8 percent. The model yielded values for area under the curve, sensitivity, specificity, and accuracy of 0.897, 0.830, 0.813, and 0.816, respectively (Figure 1). A representative example of model prediction of normal LVEF and low LVEF is shown in Figure 2. Conclusion Using large-scale data, we have trained a highly accurate convolutional neural network with excellent predictive accuracy for LV systolic dysfunction using the surface ECG. Such a tool would be invaluable for cardiologists when risk-stratifying patients with frequent PVCs, especially those that are asymptomatic. Patients at risk will benefit from early referral to electrophysiologists for drug therapy and catheter ablation to mitigate the risk of PVC-CM.Figure 1Figure 2

Predictors of long-term outcomes of patients with concomitant moderate aortic and mitral valves diseases: a single tertiary care center experience 2010-2018

Abstract Background To date, moderate concomitant valvular heart diseases have been scarcely studied. This study aimed to further define predictors of long-term outcomes in patients diagnosed with concomitant moderate aortic and mitral valve disease at a tertiary center. Methods In this cohort we included 3257 patients (aged 71.7 ± 12.9 years; 55.2% male; 83.1% white) diagnosed with concomitant moderate aortic and mitral valves diseases who presented to the Cleveland Clinic between 2010 and 2018. The patients’ demographic, clinical and echocardiographic variables were collected. The primary endpoint of the study was the long-term composite outcome defined as heart failure hospitalization or all-cause mortality. We then conducted a univariate and multivariate cox proportional hazard survival analysis for the primary endpoint. Results The patients were followed up for 21.8 months. Baseline demographic characteristics are presented in table 1. Multiple demographic, clinical, and echo variables were evaluated. Using a univariate Cox proportional hazard survival analysis, older Age, history of smoking, Diabetes, Hypertension, Chronic Kidney Disease (CKD), Coronary Artery Disease (CAD), Atrial Fibrillation (Afib), Dyslipidemia, higher Right Ventricular Systolic Pressure (RVSP), higher New York Heart Association (NYHA) class, and lower Left Ventricular Ejection Fraction (LVEF) were associated with worse long-term outcomes. Additionally, patients who underwent an aortic (39.1%) or a mitral valve intervention (29.4%) were associated with better long-term outcomes (HR, 0.710, 0.708; respectively). In comparison, on Multivariable Cox analysis, female sex was significantly associated with worse survival (HR of 1.151, p-value=0.019). However, older Age, history of smoking, Diabetes, CKD, higher RVSP, NYHA class 2, 3, and 4, and lower LVEF remained significantly associated with worse long-term (table 2). Aortic valve intervention remained significantly associated with better survival (HR, 0.861, P-value=0.021). Compared to the Aortic Stenosis/ Mitral Stenosis (AS/MS) group, univariate analysis showed that patients in the Aortic Regurgitation/Mitral Regurgitation (AR/MR), and the AR/MS groups were significantly associated with better long term outcomes (HR, 0.738, HR, 0.575; respectively). Conversely, on Multivariate Cox analysis, AR/MR and AS/MR groups were significantly associated with better survival compared to AS/MS group (HR, 0.580, HR, 0.716; respectively). Conclusion In patients diagnosed with concomitant moderate aortic and mitral valve diseases, female sex, older age, history of smoking, diabetes, CKD, RVSP, NYHA class, LVEF and aortic valve intervention are independent predictors of the composite endpoint of heart failure hospitalization or all-cause mortality.Table 1Table 2

Prevalence and Risk Factors of Mitral, Tricuspid, and Aortic Regurgitation: A Population-Based Study from Rural Northeast China

The population-based studies on the epidemiologic features of valvular regurgitation in Northeast China are scarce. We aim to estimate the prevalence and risk factors of mitral regurgitation (MR), tricuspid regurgitation (TR), and aortic regurgitation (AR) in a general population from rural Northeast China. Valvular regurgitation was assessed by color flow Doppler echocardiography in a population-based survey of 11,278 participants aged ≥35years in rural areas of Liaoning Province during 2012 to 2013. The prevalence of mild or greater MR and TR were 1.6% and 1.5%, respectively. Trace or greater AR was present in 4.1% of the participants. In the multivariable regression model, older age, left atrial dimension, low left ventricular (LV) ejection fraction, and fasting plasma glucose were associated with higher risk of MR in men, whereas only older age and left atrial dimension increased the risk in women. Body mass index was found to be a protective factor for MR in women (odds ratio 0.847, 95% confidence interval 0.741 to 0.969). TR was independently associated with age, heart rate, low LV ejection fraction, current drinking status, and high-density lipoprotein cholesterol. The risk for AR significantly increased with age in both genders. LV mass index and aortic dimension increased the risk of AR in males, and females with higher LV mass index and high-density lipoprotein cholesterol had an increased risk for AR. In both genders, systolic blood pressure presented as a risk factor for AR, while diastolic blood pressure as a protective factor. In this large Chinese population-based study, we found remarkably low prevalence of valvular regurgitation, adding evidence for estimating disease burden and making policy strategies in Northeast China.

Assessing the association between genetic and phenotypic features of dilated cardiomyopathy and outcome in patients with coronary artery disease.

To examine the relevance of genetic and cardiovascular magnetic resonance (CMR) features of dilated cardiomyopathy (DCM) in individuals with coronary artery disease (CAD). This study includes two cohorts. First, individuals with CAD recruited into the UK Biobank (UKB) were evaluated. Second, patients with CAD referred to a tertiary centre for evaluation with late gadolinium enhancement (LGE)-CMR were recruited (London cohort); patients underwent genetic sequencing as part of the research protocol and long-term follow-up. From 31 154 individuals with CAD recruited to UKB, rare pathogenic variants in DCM genes were associated with increased risk of death or major adverse cardiac events (hazard ratio 1.57, 95% confidence interval [CI] 1.22-2.01, p < 0.001). Of 1619 individuals with CAD included from the UKB CMR substudy, participants with a rare variant in a DCM-associated gene had lower left ventricular ejection fraction (LVEF) compared to genotype negative individuals (mean 47 ± 10% vs. 57 ± 8%, p < 0.001). Of 453 patients in the London cohort, 63 (14%) had non-infarct pattern LGE (NI-LGE) on CMR. Patients with NI-LGE had lower LVEF (mean 38 ± 18% vs. 48 ± 16%, p < 0.001) compared to patients without NI-LGE, with no significant difference in the burden of rare protein altering variants in DCM-associated genes between groups (9.5% vs. 6.7%, odds ratio 1.5, 95% CI 0.4-4.3, p = 0.4). NI-LGE was not independently associated with adverse clinical outcomes. Rare pathogenic variants in DCM-associated genes impact left ventricular remodelling and outcomes in stable CAD. NI-LGE is associated with adverse remodelling but is not an independent predictor of outcome and had no rare genetic basis in our study.

Evaluation of left atrial and ventricular remodeling in atrial fibrillation subtype by using speckle tracking echocardiography.

Atrial fibrillation (AF) is associated with cardiac structural and functional remodeling. We investigated the left atrial (LA) and left ventricular (LV) changes in AF subtypes by using two-dimensional echocardiography strain techniques. The study population consisted of 102 subjects with sinus rhythm (control group) and 463 patients with AF, among which 284 patients had paroxysmal AF (PAF) and 179 patients had persistent AF (PerAF). A speckle tracking automatic functional imaging software was used to perform the strain analysis. Patients with AF had dilated LA maximum and minimum volume, decreased LA reservoir strain, lower LV ejection fraction (LVEF), and impaired global longitudinal strain (GLS) compared to those of the sinus rhythm control group. In patients with PerAF, the LA maximum and minimum volumes were larger, and the LA reservoir strain [PAF vs. PerAF, 28% (21,33) vs. 19% (14, 28), P < 0.05], LVEF, and absolute GLS value (PAF vs. PerAF, -16.9 ± 3.3 vs. -14.1 ± 3.5%) were lower than those in patients with PAF. Patients with AF regardless of LA enlargement had decreased LA reservoir strain and lower LVEF and absolute GLS value than those in the sinus rhythm control group. Compared with those with normal sinus rhythm, patients with AF had dilated LA volume and impaired LA function, which were further worsened in patients with PerAF than those in patients with PAF. LA functional impairment occurred before LA enlargement. Left atrioventricular remodeling happened across different stages of AF development.

Clinical Outcomes and Predictors of All-Cause Mortality After Complex High-Risk and Indicated Revascularization Using Percutaneous Coronary Intervention.

The concept of complex and high-risk indicated procedures using percutaneous coronary intervention (CHIP-PCI) has recently been defined. However, few studies have investigated the prognosis of patients after CHIP-PCI. We enrolled 322 consecutive patients who underwent CHIP-PCI. CHIP-PCI was defined as a procedure satisfying at least one criterion each for both patient and procedure characteristics, as follows: patient characteristics [age ≥ 75 years old, low left ventricular ejection fraction (LVEF), diabetes mellitus, acute coronary syndrome, previous coronary artery bypass surgery, peripheral arterial disease, severe chronic kidney disease (CKD), chronic obstructive pulmonary disease (COPD), and severe valvular disease] and procedure characteristics [unprotected left main disease, degenerated saphenous or radial artery grafts, severely calcified lesions, last patent conduit, chronic total occlusions, multivessel disease, and use of mechanical circulatory support]. On Kaplan-Meier analysis, 1-, 2-, and 3-year survival rates following CHIP-PCI was 93.8%, 89.2%, and 85.4%, respectively. Moreover, on Cox multivariate hazard analysis, age (≥ 75 years old) (hazard ratio: 4.01, 95% confidence interval: 1.92-8.38, P < 0.01), COPD (hazard ratio: 2.95, 95% confidence interval: 1.38-6.32, P < 0.01), low LVEF (hazard ratio: 3.35, 95% confidence interval: 1.55-7.22, P < 0.01), severe CKD (hazard ratio: 3.02, 95% confidence interval: 1.44-6.36, P < 0.01), and use of mechanical circulatory support (hazard ratio: 5.97, 95% confidence interval: 2.72-13.10, P < 0.01) remained significant predictors of mortality. In conclusion, we revealed the clinical outcomes after CHIP-PCI. The presence of advanced age, COPD, low LVEF, severe CKD, and mechanical circulatory support use might lead to worse clinical outcomes.

NOCTURNAL HYPOXIA INDEXES ARE ASSOCIATED WITH LEFT VENTRICULAR REMODELING AND DIASTOLIC DYSFUNCTION IN OBSTRUCTIVE SLEEP APNEA PATIENTS

Objective: Echocardiography features of obstructive sleep apnea (OSA) are heart derangements as higher left ventricular mass index (LVMI) and left ventricular end-diastolic diameter, lower left ventricular ejection fraction (LVEF), and impaired diastolic function. The apnea/hypopnea index (AHI), the parameter currently used to define diagnosis and severity of OSA, poorly predicts cardiovascular damage, cardiovascular events, and mortality. Thus, we aimed to assess, if, in addition to AHI, other polygraphic indices of OSA presence and severity might serve as better predictors of echocardiographic cardiac remodeling. Design and method: We enrolled two cohorts of subjects referred for suspected OSA to the outpatient facilities of the IRCCS Istituto Auxologico Italiano, Milano, and of the Clinica Medica 3, Padova. All patients underwent home sleep apnea testing and echocardiography. Based on the AHI the cohort was divided into no-OSA (AHI&lt;15 events/hour) and moderate-severe OSA (AHI&gt; = 15 events/hour). A stepwise multiple regression analysis was used to identify the covariates among age, gender, body mass index, past medical history, and polygrapic variables, independently associated to four echocardiographic variables, e.g., LVMI, LVEF, left ventricular end-diastolic volume (LVEDV), early and late ventricular filling velocity ratio (E/A). Results: We recruited 162 patients and found that compared to patients with no-OSA, those with moderate-severe OSA showed higher LV remodeling [LVEDV 48.4±11.5 ml/m2 vs. 54.1±14.0 ml/m2, respectively, p = 0.005] and lower LVEF (65.3±5.8 % vs. 61.6±7.8%, respectively, p = 0.002), whereas we could not find any difference in LVMI and E/A. At multivariate linear regression analysis, the only polygraphic independent predictor of LVEDV was the percentage of time with SatO2 &lt; 90% (↓ = 0.262), whereas, the independent predictors of E/A were AHI (↓ = -0.379) and oxygen desaturation index (↓ = -0.422). None of the polygraphic variables was associated to LVMI and LVEF at multivariate linear regression analysis. Conclusions: Our study shows that nocturnal hypoxia-related indexes were associated with left ventricular remodeling and diastolic dysfunction in OSA patients. If confirmed in future studies with a wider sample of patients included, these results support the adoption of hypoxia indexes in the evaluation of OSA patients, particularly those at a greater cardiovascular risk.

Importance of concomitant functional mitral regurgitation on survival in severe aortic stenosis patients undergoing aortic valve replacement

Mitral regurgitation (MR) is commonly seen in patients with severe aortic stenosis (AS) undergoing aortic valve replacement (AVR). But the long-term implications of MR in AS are unknown. To investigate MR's impact on survival of patients undergoing surgical AVR for severe AS. Of the 740 consecutive patients with severe AS evaluated between 1993 and 2003, 287 underwent AVR forming the study cohort. They were followed up to death or till the end of 2019. Chart reviews were performed for clinical, echocardiographic, and therapeutic data. MR was graded on a 1-4 scale. Mortality data was obtained from chart review and the Social Security Death Index. Survival was analyzed as a function of degree of MR. The mean age of the severe AS patients who had AVR (n = 287) was 72 ± 13 years, 46% women. Over up to 26 years of follow up, there were 201 (70%) deaths, giving deep insights into the determinants of survival of severe AS who had AVR. The 5, 10 and 20 years survival rates were 75%, 45% and 25% respectively. Presence of MR was associated with higher mortality in a graded fashion (P = 0.0003). MR was significantly associated with lower left ventricular (LV) ejection fraction and larger LV size. Impact of MR on mortality was partially mediated through lower LV ejection fraction and larger LV size. By Cox regression, MR, lower ejection fraction (EF) and larger LV end-systolic dimension were independent predictors of higher mortality (χ2 = 33.2). Presence of greater than 2+ MR in patients with severe AS is independently associated with reduced survival in surgically managed patients, an effect incremental to reduced EF and larger LV size. We suggest that aortic valve intervention should be considered in severe AS patients when > 2+ MR occurs irrespective of EF or symptoms.

Bundle branch block in cardiac arrest survivors without ischemic heart disease.

Cardiac arrest (CA) survivors with left/right bundle branch block (LBBB/RBBB) and no ischemic heart disease (IHD) have not been previously characterized. The aim of this study was to describe heart failure, implantable cardioverter defibrillator (ICD) therapy and mortality in this population. Between 2009 and 2019 we consecutively identified all CA survivors with a consistent bundle branch block (BBB) defined as a QRS≥120ms, who had a secondary prophylactic ICD implanted. Patients with congenital and ischemic heart disease (IHD) were excluded. Among 701 CA-survivors who survived to discharge and received an ICD, a total of 58 (8%) were free from IHD and had BBB; 46 (79%) had LBBB, 10 (17%) had RBBB and 2 (3%) had non-specific BBB (NSBBB). The prevalence of LBBB was 7%. Pre-arrest ECG were available in 34 (59%) patients; 20 patients (59%) had LBBB, 6 (18%) had RBBB, 2 (6%) had NSBBB, 1 had (3%) incomplete LBBB, and 4 (12%) without BBB. At discharge, patients with LBBB had a significantly lower left ventricular ejection fraction (LVEF) than patients with other types of BBB, p<0.001. During follow-up, 7 (12%) died after a median of 3.6years (IQR: 2.6-5.1) with no difference between BBB subtypes. We identified 58 CA-survivors with BBB and no IHD. The prevalence of LBBB among all CA-survivors was high, 7%. During CA hospitalization LBBB patients presented with a significantly lower LVEF than patients with other types of BBB (P<0.001). ICD treatment and mortality did not differ between BBB subtypes during follow-up.

Prognostic Value of Right Ventricular Dysfunction in Patients With Decompensated Chronic Heart Failure

Aim To determine the incidence rate and the practical significance of right ventricular dysfunction (RVD) in the development of cardiovascular complications in patients with decompensated chronic heart failure (DCHF).Material and methods This prospective, single-site observational study included 171 patients older than 18 years with NYHA functional class (FC) II-IV chronic heart failure (CHF) who were hospitalized for DCHF. Standard and extended 2D and 3D echocardiography (EchoCG) was performed for all patients on admission. Additionally, functional characteristics of the right ventricle (RV) were evaluated in the 3D mode followed by autonomic 3D processing with a EchoPac station (USA). RVD was taken as a disorder of two or more RV functional parameters according to results of 2D EchoCG, or a reduced RV free wall strain according to results of 2D speckle-tracking EchoCG, or a reduced RV ejection fraction (EF) according to results of 3D EchoCG. Statistical analysis was performed with a SPSS Statistics v. 26.0 software.Results The incidence rate of RVD in general population of patients with DCHF was 75.4 % (n=129). A higher prevalence of RVD was observed in patients with CHF with a low left ventricular (LV) EF (90.1 %). Patients with RVD had a more severe clinical status (significantly higher FC and higher Clinical Condition Scale (CCS) scores), more frequent atrial fibrillation (AF), and higher concentrations of uric acid and total bilirubin. RVD significantly correlated with male sex (odds ratio (OR), 2.05; 95 % confidence interval (CI), 1.01–4.19; р=0.046) and AF (OR, 3.52; 95 % CI, 1.71–7.26; р&lt;0.001). Patients with RVD had lower values of both LV and RV function. Lower LV EF and AF increased the probability of RVD by 1.06 times (95 % CI, 0.90–0.98; р=0.001) and by 2.63 times (95 % CI, 1.08–6.40; р=0.001), respectively. Evaluation of the predictive significance of RV parameters measured by 2D and 3D EchoCG showed only effects of RV EF (2D) and RV global longitudinal strain (GLS) (3D) on all-cause hospitalization. RVD as evaluated by accepted criteria did not influence adverse outcomes.Conclusion The determined incidence, correlations, and the predictive value of RVD in patients with DCHF indicated the appropriateness of assessing the RV function to optimize the management of patients regardless of the CHF phenotype.

Outcome of surgical repair of anomalous left coronary artery from the pulmonary artery in a single-center experience

BackgroundThis study aims to review the midterm results of surgical repair of anomalous left coronary artery from the pulmonary artery (ALCAPA) in our center and assess the postoperative cardiac function recovery and misdiagnosis. MethodPatients who underwent repair of ALCAPA between January 2005 and January 2022 at our hospital were retrospectively reviewed. ResultsA total of 136 patients underwent repair of ALCAPA, among which 49.3% were misdiagnosed before referral to our hospital. On multivariable logistic regression analysis, patients with low left ventricular ejection fraction (LVEF) (odds ratio = 0.975, p = 0.018) were at increased risk for misdiagnosis. The median age at surgery was 0.83 years (range, 0.08 to 56 years), and the median LVEF was 52% (range, 5% to 86%). The mortality rate was 6.6% (n = 9), and four patients underwent reintervention. The median postoperative recovery time of left ventricular function (LVF) was 10 days (1 to 692 days). Competing risk analysis revealed that a low preoperative LVEF (hazard ratio = 1.067, p < 0.001) and age younger than 1 year (hazard ratio = 0.522, p = 0.007) were risk factors for a longer postoperative recovery time of LVF. During the follow-up period, 91.9% (113/123) of the patients had no aggravation of mitral regurgitation. ConclusionThe perioperative and intermediate outcomes after ALCAPA repair were favorable, but preoperative misdiagnosis deserved attention, especially in patients with low LVEF. LVF normalized in most patients, but patients younger than 1 year and with low LVEF required longer recovery times.

Nocturnal hypoxia indexes are associated with left ventricular remodeling and diastolic dysfunction in obstructive sleep apnea patients

Background and objectiveObstructive sleep apnea (OSA) is associated with heart derangements detected at echocardiography as higher left ventricular mass index (LVMI), higher left ventricular end-diastolic diameter, lower left ventricular ejection fraction (LVEF), and impaired diastolic function. However, the currently used parameter to define OSA diagnosis and severity, the apnea/hypopnea index (AHI), poorly predicts cardiovascular damage, cardiovascular events, and mortality. Our study aimed to assess if other polygraphic indices of OSA presence and severity, in addition to AHI, might better predict echocardiographic cardiac remodeling. Methods and resultsWe enrolled two cohorts of individuals referred for suspected OSA to the outpatient facilities of the IRCCS Istituto Auxologico Italiano, Milano, and of the Clinica Medica 3, Padova. All patients underwent home sleep apnea testing and echocardiography. Based on the AHI the cohort was divided into no-OSA (AHI<15 events/hour) and moderate-severe OSA (AHI≥15 events/hour). We recruited 162 patients and found that compared to patients with no-OSA, those with moderate-severe OSA showed higher LV remodeling [left ventricular end-diastolic volume (LVEDV) 48.4 ± 11.5 ml/m2 vs. 54.1 ± 14.0 ml/m2, respectively, p = 0.005] and lower LVEF (65.3 ± 5.8% vs. 61.6 ± 7.8%, respectively, p = 0.002), whereas we could not find any difference in LVMI and early and late ventricular filling velocity ratio (E/A). At multivariate linear regression analysis two polygraphic hypoxic burden-related markers were independent predictors of LVEDV and E/A, i.e., the percentage of time with O2 saturation below 90% (β = 0.222) and ODI (β = −0.422), respectively. ConclusionsOur study shows that nocturnal hypoxia-related indexes were associated with left ventricular remodeling and diastolic dysfunction in OSA patients.

Predictors of thrombosis of left atrium and its appendage before catheter ablation or cardioversion in patients with non-valvular atrial fibrillation or atrial flutter

Aim. To determine the incidence of left atrial (LA) and/or LA appendage (LAA) thrombosis in patients with non-valvular atrial fibrillation (AF) (NAF) or atrial flutter (AFL) on transesophageal echocardiography (TEE) before elective catheter ablation (CA) or cardioversion (CV) and characterize the predictors of LA/LAA thrombosis among the indicators available in the routine practice of cardiologists and general practitioners.Material and methods. In this retrospective, single-center, casecontrol study, the medical records of 1994 patients with NAF or AFL for the period 2014-2019, who underwent TEE before CA or elective CV, were analyzed. A thrombus in the LA/LAA was detected in 33 (1,6%) of them. For the comparison group, 167 patients were randomly selected without LA/LAA thrombosis. Demographic, anamnestic and clinical parameters, transthoracic echocardiography data, and laboratory results were analyzed as potential predictors of LA/LAA thrombosis.Results. Patients with LA/LAA thrombosis were older (mean age, 64,8±1,6 vs 59,4±10,8 (p=0,01), more often had persistent or longstanding persistent AF, hypertension, heart failure, enlarged LA, lower left ventricular ejection fraction (LVEF) and estimated glomerular filtration rate, as well as more severe symptoms according to the modified European Heart Rhythm Association (EHRA) score and a higher CHA2DS2-VASc score (median, 4,0 vs 2,0; p=0,0001). Oral anticoagulants were taken by 88% of patients; there were no significant differences in the presence and composition of anticoagulant therapy between the groups. Functional class (FC) according to the modified EHRA score (odds ratio (OR), 5,4; 95% confidence interval (CI): 1,9814,96; p=0,001) and LVEF were independent predictors of LA/LAA thrombosis (OR, 0,87; 95% CI: 0,80-0,95; p=0,002). For EHRA class 3-4, the OR was 5,1; 95% CI: 2,3-11,4 (p&lt;0,0001), for LVEF &lt;48% — 7,4; 95% CI: 1,2-46,7 (p=0,03). For EHRA class 3-4, the sensitivity for LA/LAA thrombosis was 93,7%, specificity — 71,9%, positive predictive value — 50,0%, negative predictive value — 87,6%; for LVEF &lt;48% — 66,7, 32,3, 31,9 and 91,6%, respectively.Conclusion. In the studied group of patients with NAF or AFL, without severe structural heart disease and severe concomitant diseases, most of whom received oral anticoagulants, LA/LAA thrombosis at TEE before elective CA or CV was detected in 1,6% of cases. Among the indicators available in routine medical practice, the severity of arrhythmia symptoms, assessed by the modified EHRA score, and lower LVEF were independent predictors of LA/LAA thrombosis.