Severe Left Ventricular Research Articles

Subannular repair in secondary mitral regurgitation with restricted leaflet motion during systole

ObjectiveVentricular secondary mitral regurgitation (SMR) (Carpentier type IIIb) results from left ventricular (LV) remodelling, displacement of papillary muscles and tethering of mitral leaflets. The most appropriate treatment approach remains controversial....

Incidence and Risk Factors for Long-Term Persistence of Diastolic Dysfunction after Aortic Valve Replacement for Aortic Stenosis Compared with Aortic Regurgitation

(1) Background: Severe left ventricular (LV) diastolic dysfunction with a restrictive diastolic pattern (LVDFP) is generally associated with a worse prognosis. Its evolution and reversibility in the short- and medium-term after aortic valve replacement (AVR) has been little-studied. We aimed to evaluate the evolution of LV remodeling and LV systolic and diastolic function after AVR in aortic stenosis (AS) patients compared to aortic regurgitation (AR). Moreover, we tried to identify the main predictive parameters for postoperative evolution (cardiovascular hospitalization or death and quality of life) and the independent predictors for the persistence of restrictive LVDFP after AVR. (2) Methods: A five-year prospective study on 397 patients undergoing AVR for AS (226 pts) or AR (171 pts), evaluated clinically and by echocardiography preoperatively and until 5 years postoperatively. (3) Results: 1. In patients with AS, early post AVR, LV dimensions decreased and diastolic filling and LV ejection fraction (LVEF) improved more rapidly compared to patients with AR. At 1 year postoperatively, persistent restrictive LVDFP was found especially in the AR group compared to the AS group (36.84% vs. 14.16%). 2. Cardiovascular event-free survival at the 5-year follow-up was lower in the AR group (64.91% vs. 87.17% in the AS group). The main independent predictors of short- and medium-term prognosis after AVR were: restrictive LVDFP, severe LV systolic dysfunction, severe pulmonary hypertension (PHT), advanced age, severe AR, and comorbidities. 3. The persistence of restrictive LVDFP after AVR was independently predicted by: preoperative AR, the E/Ea ratio > 12, the LA dimension index > 30 mm/m2, an LV endsystolic diameter (LVESD) > 55 mm, severe PHT, and associated second-degree MR (p < 0.05). (4) Conclusions: AS patients had an immediate postoperative evolution in terms of LV remodeling, and LV systolic and diastolic function were more favorable compared to those with AR. The restrictive LVDFP was reversible, especially after the AVR for AS. The main prognostic predictors were the presence of restrictive LVDFP, advanced age, preoperative AR, severe LV systolic dysfunction, and severe PHT.

The Impact of Complete Revascularization in Symptomatic Severe Left Ventricular Dysfunction between Coronary Artery Bypass Graft and Percutaneous Coronary Intervention.

The study aimed to compare the clinical outcomes between the patients receiving coronary artery bypass surgery (CABG) or percutaneous coronary intervention (PCI) for the patients with symptomatic severe left ventricular (LV) dysfunction and coronary artery disease (CAD). Between February 2007 and February 2020, a total of 745 patients who received coronary artery angiography for reduced LV ejection fraction (LVEF) < 40% and symptomatic New York Heart Association (NYHA) functional class ≥ 3 were recruited. The patients (N = 236) who were diagnosed with dilated cardiomyopathy or valvular heart disease without coronary artery stenosis, those with prior history of CABG or valvular surgery (N = 59), those who presented ST-segment elevated myocardial infarction (STEMI), those with a CAD and SYNTAX score of ≦ 22 (N = 175), those who received emergent CABG for coronary perforation (N = 3), and those who had NYHA class ≦ 2 (N = 65) were excluded. Finally, 116 patients with reduced LVEF and those who had a SYNTAX score >22, who received CABG (N = 47) and PCI (N = 69), were recruited for this study. There was no significant difference in the incidence values of in-hospital course and those of in-hospital mortality, acute kidney injury, and postprocedural hemodialysis. There was no significant difference in the 1-yearfollow-up of recurrent MI, revascularization, or stroke between the groups. The 1-year heart failure (HF) hospitalization rate was significantly lower in the CABG group than in all patients of the PCI group (13.2% vs. 33.3%; p = 0.035); however, there was no significant difference in the same variable between the CABG group and the complete revascularization subgroup (13.2% vs. 28.2%; p = 0.160). The revascularization index (RI) was significantly higher in the CABG group than in all patients of the PCI group or complete revascularization subgroup (0.93 ± 0.12 vs. 0.71 ± 0.25; p < 0.001) and (0.93 ± 0.12 vs. 0.86 ± 0.13; p = 0.019). The 3-year HF hospitalization rate was significantly lower in the CABG group than in all patients of the PCI group (16.2% vs. 42.2%; p = 0.008); however, there was no difference in the same variable between the CABG group and the complete revascularization subgroup (16.2% vs. 35.1%; p = 0.109). In patients with symptomatic (NYHA class ≥ 3) severe LV dysfunction and CAD, CABG brought less HF admission when compared to patients in the PCI group, but this did not differ when compared to the complete revascularization subgroup. Therefore, an extensive revascularization, achieved by CABG or PCI, is associated with a lower HF hospitalization rate during the 3-yearfollow-up period in such populations.

Severe Left Ventricular Dysfunction Earlier after Acute Myocardial Infarction Treated with Primary Percutaneous Coronary Intervention: Predictors and In-Hospital Outcome- A Middle Eastern Tertiary Center Experience.

A single-center retrospective study included 2863 myocardial infarction patients who were admitted to our center and treated with successful PPCI. Out of 2863 consecutive patients who underwent PPCI from May 2018 to August 2021, 1021 (36%) developed server LV dysfunction. They showed a higher history rate of ischemic heart disease and previous revascularization before AMI (P = 0.05 and 0.001 respectively). Also, they presented more with anterior myocardial infarction (P < 0.001) and heavy thrombus burden (P = 0.002 and 0.004 for indication of peri-procedural glycoprotein IIb/IIIa inhibitors use and thrombus aspiration) compared to the other group of patients. Moreover, they also had a more critical anatomy of coronary artery disease (P < 0.001 for both left main and multi-vessel coronary artery disease). The independently associated predictors for early severe LV dysfunction post-AMI treated with PPCI were anterior localization of AMI, the greater value of troponin, renal impairment, and severe coronary artery disease (P= <0.001, 0.036, 0.002, and <0.07 respectively). Despite optimal treatment for those patients, they showed poor outcomes including in-hospital morbidity and mortality (P < 0.001). Sizable proportion of patients following successful PPCI develop severe LV systolic dysfunction and associated with poor clinical outcomes. Larger myocardial infarction, renal impairment, and severe coronary artery disease are independent predictors of severe LV systolic dysfunction post-PPCI.

Effect of scar and His-Purkinje and myocardium conduction on response to conduction system pacing.

Conduction system pacing (CSP), in the form of His bundle pacing (HBP) or left bundle branch pacing (LBBP), is emerging as a valuable cardiac resynchronization therapy (CRT) delivery method. However, patient selection and therapy personalization for CSP delivery remain poorly characterized. We aim to compare pacing-induced electrical synchrony during CRT, HBP, LBBP, HBP with left ventricular (LV) epicardial lead (His-optimizedCRT [HOT-CRT]), and LBBP with LV epicardial lead (LBBP-optimized CRT [LOT-CRT]) in patients with different conduction disease presentations using computational modeling. We simulated ventricular activation on 24four-chamber heart geometries, including His-Purkinje systems with proximal left bundle branch block (LBBB). We simulated septal scar, LV lateral wall scar, and mild and severe myocardium and LV His-Purkinje system conduction disease by decreasing the conduction velocity (CV) down to 70% and 35% of the healthy CV. Electrical synchrony was measured by the shortest interval to activate 90% of the ventricles (90% of biventricular activation time [BIVAT-90]). Severe LV His-Purkinje conduction disease favored CRT (BIVAT-90: HBP 101.5 ± 7.8 ms vs.CRT 93.0 ± 8.9 ms, p < .05), with additional electrical synchrony induced by HOT-CRT (87.6 ± 6.7 ms, p < .05) and LOT-CRT (73.9 ± 7.6 ms, p < .05). Patients with slow myocardium CV benefit more from CSP compared to CRT (BIVAT-90: CRT 134.5 ± 24.1 ms; HBP 97.1 ± 9.9 ms, p < .01; LBBP: 101.5 ± 10.7 ms, p < .01). Septal but not lateral wall scar made CSP ineffective, while CRT was able to resynchronize the ventricles in the presence of septal scar (BIVAT-90: baseline 119.1 ± 10.8 ms vs.CRT 85.1 ± 14.9 ms, p < .01). Severe LV His-Purkinje conduction disease attenuates the benefits of CSP, with additional improvements achieved with HOT-CRT and LOT-CRT. Septal but not lateral wall scars make CSP ineffective.

Relevance of subclinical right ventricular dysfunction measured by feature-tracking cardiac magnetic resonance in non-ischemic dilated cardiomyopathy

BackgroundRight ventricular (RV) dysfunction in patients with non-ischemic dilated cardiomyopathy (NICM) is associated with cardiovascular events. To analyze the feasibility of assessing RV myocardial deformation by feature tracking (FT)-cardiac magnetic resonance (CMR), and its usefulness as a prognostic marker.MethodsRetrospective study of NICM patients undergoing CMR. Longitudinal FT-RV free wall (LFT-RVFW) and fractional area change (FAC) were obtained. Correlation with standard RV parameters was studied. An association with combined event (heart failure (HF), ICD implantation or cardiovascular death) was assessed using a logistic regression model.Results98 patients (64 ± 13 years) were included. Left ventricular (LV) systolic function (LVEF 29.5 ± 9.6%, 47% with LVEF ≥ 30%) and RV (RVEF 52.2 ± 14.6%, 72% with RVEF ≥ 45%). Follow-up of 38 ± 17 months, 26.5% presented at least one admission for HF. An excellent correlation of LFT-RVFW (r = 0.82) and FAC (r = 0.83) with RVEF was evident. No association of RV-FT parameters with prognosis entire study population was found. However, in patients with LVEF ≥ 30%, admissions for HF were associated with lower LFT-RVFW (−21.6 ± 6.6% vs −31.3 ± 10%; p = 0.006) and FAC (36.6 ± 9.6% vs 50.5 ± 13.4%; p < 0.001) values. Similar differences were observed when only patients with RVEF ≥ 45% were considered. An LFT-RVFW cut-off point of -19.5% and FAC of 36.5% showed good prognostic performance. Decreased LFT-RVFW or FAC represented an independent predictor of combined event in patients with LVEF ≥ 30%.ConclusionsIn NICM patients without severe LV dysfunction, decreased values of LFT-RVFW and/or FAC were associated with HF admissions, independently of RVEF.

S-29-5: EARLY CHANGES IN LEFT ATRIAL STRAIN AND GLOBAL VENTRICULAR FUNCTION IN HYPERTENSIVE PATIENTS WITH HEART FAILURE WITH PRESERVED EF

Background: Hypertension is one of leading causes in heart failure with preserved ejection fraction (HFpEF).Left atrial (LA) maximal volume and index (LAVI) had a prognostic value in patients with heart failure and incidence of atrial fibrilation (AF). Recently, LA mechanical function and LA strain have been introduced as alternative methods to assess LA performance more accuratly. Aim: To evaluate the relation between early changes in LA function and strain (PALS) and correlate the association with global left ventricular (LV) function and longitudinal strain (GLS) in patients with HFpEF.and arterial hypertension. Methods: We evaluated 152 subjects in sinus rhythm: 22 normals (31y ± 5), and 70 pts with HFpEF (65y ± 12), 60 pts HFrEF (64 y ± 10). Echocardiography was performed in all patients and follow up after 12 monts and analyzed offline in order to extract the global and segmental strain values of the LV and LA and LA volume and LAVI. Results: The two groups of patients were comparable for most of clinical variables. LV volumes, ejection fraction, stroke volume, and mitral valve effective regurgitant orifice were similar between the two groups. The LA diameter and maximal volume were higher in HFrEF group. The GLS is significantly reduced in HFrEF group. LV GLS is the main parameter for myocardial dysfunction, which changed significantly in the HFrEF (p &lt; 0,001) at 12mFU. Reduced PALS in HFrEF was associated with impairment of all measures of LV systolic and diastolic function and events of atrial fibrilation / 33 % in HFrEF and 12 % in HFpEF/ and the correlation between global longitudinal strain and PALS was highly significant (p &lt; 0.001; r = 0.71). At 12mFU, PALS was significantly associated with lower global longitudinal strain in group with HFrEF (p &lt; 0.001, r = 0.61), LAVI &gt; 28 ml/m2 (p &lt; 0.01,r = 0.57) and slightly decreased in HFpEF /p &lt; 0.5, r = 0.34/. ROC analysis shows the cut of value of 29 % for PALS which correlated with AF events. Conclusions: PALS and GLS are significantly reduced in HFpEF patients and decreased in HFpEF. PALS provides additional,prognostic value beyond LA volume and LAVI. Severe LV myocardial dysfunction and reduced GLS and decreased PALS, even still normal LAVI is a prognostic index for AF.

1151 MYOCARDIAL VIABILITY IN PATIENTS WITH ISCHEMIC LEFT VENTRICULAR DYSFUNCTION: A CARDIAC MAGNETIC RESONANCE SINGLE-CENTRE EXPERIENCE

Abstract Background Whether assessment of myocardial viability (MV) by delayed enhancement cardiac magnetic resonance (DE-CMR) can help identify patient with severe ischemic left ventricular (LV) disfunction who might benefit from coronary revascularization has not been yet clearly established. Moreover, although improvement in LV function is one of the heart failure treatment goal, its prognostic implication remains controversial. Methods We retrospectively evaluated all consecutive patients with a LV ejection fraction (EF) of 35% or less and extensive coronary artery disease undergoing DE-CMR for assessment of MV in our Department from November 2013 to December 2020. DE-CMR was routinely prescribed before any heart team indication, either coronary intervention (surgical or percutaneous) plus optimal medical therapy (OMT) or OMT only. Quantification of DE was determined visually by comparing the ratio of the thickness of infarcted myocardium to that of total wall thickness within a given segment. A dysfunctional segment (hypokinetic/akinetic) was considered viable when DE transmurality was ≤50%. Accordingly, a patient was considered to have MV when ≥4 dysfunctional but viable segments were present. The primary end point was death from any cause. Secondary end point was improvement in LVEF during follow-up, defined as an increase in LVEF class compared to baseline. Results Of the 70 patients (64 males, median age 67 years [62-75], median LVEF 27% [21-30]) enrolled, 46 (66%) underwent coronary revascularization, of which 16 with surgery and 30 with percutaneous intervention. Only 16 procedures were considered complete, fully revascularizing all diseased vessels and dysfunctional segments. The baseline clinical characteristics (including age, diabetes, eGFR, peripheral vascular disease, LVEF, LV end diastolic volume, and Syntax score) of revascularized patients did not differ significantly to those receiving OMT only, except for number of viable segments, which were significantly higher in patients undergoing revascularization (p=0.017). Over a median follow-up of 31 months (18-45), 15 patients (21%) died. Revascularization plus OMT was associated with a lower incidence of death from any cause than OMT only group (hazard ratio, 0.26; 95% CI 0.09-0.74; p=0.01). However, no significant interaction was observed between the presence/absence of MV and the beneficial effect of revascularization (p=0.39). Improvement in LVEF was observed only among patients with MV, irrespective of treatment assignment (p=0.02). However, survival did not differ significantly between patients who had improvement in LVEF from those who did not have such improvement (logRank p=0.81) Conclusion Among patients with severe ischemic LV systolic dysfunction, coronary revascularization plus OMT was beneficial in prolonging survival, compared to OMT only. However, this beneficial effect was not driven by MV. Furthermore, although increase in LVEF was more likely to occur among patients with MV, such improvement was not related to long-term survival.

470 MYOCARDIAL FIBROSIS IN ASYMPTOMATIC PATIENTS UNDERGOING SURGERY FOR MITRAL AND AORTIC VALVE REGURGITATION

Abstract Background Chronic heart valve regurgitation induces left ventricular (LV) volume overload, leading to the development of hypertrophy and progressive dilatation of the ventricle to maintain physiological cardiac output. In order to prevent potential irreversible LV structural changes, the identification of the best timing for treatment is pivotal. Objective To assess the presence and extent of fibrosis in myocardial tissue in asymptomatic patients with valvular heart disease (VHD) and preserved LV dimensions and function undergoing cardiac surgery. Methods Thirty-nine patients were enrolled. Sixteen patients were affected by aortic or mitral regurgitation: they were all asymptomatic, undergoing valve surgery according to VHD European Society of Cardiology guidelines. Twentythree patients with end-stage nonischemic dilated cardiomyopathy (DCM) and severe LV dysfunction undergoing cardiac surgery for implantation of a durable left ventricular assist device (LVAD) served as controls. During surgery, VHD patients underwent three myocardial biopsies at the level of the septum, the lateral wall and LV apex, while in LVAD patients the coring of the apex of the LV was used. For both groups, the tissue samples were analyzed on one section corresponding to the apical area. All slides were stained with hematoxylin and eosin and Masson's trichrome staining and further digitalized. The degree of fibrosis was then calculated as a percentage of the total area. Results Of 39 patients, 23 met the inclusion criteria: 12 had mitral or aortic insufficiency with a preserved ejection fraction and 11 had idiopathic dilated cardiomyopathy. Quantitative analysis of apical sections revealed a myocardial fibrosis amount of 10±6% in VHD patients, while in LVAD patients the mean apical myocardial fibrosis rate was 38±9%. In VHD patients, fibrosis was also present in the lateral wall (9±4%) and in the septum (9±6%). Conclusion Our case series study highlights the presence of tissue remodeling with fibrosis in asymptomatic patients with VHD and preserved LV function. According to our results, myocardial fibrosis is present at an early stage of the disease, well before developing detectable LV dysfunction and symptoms. Since the relationship between the progressive magnitude of myocardial fibrosis and potential prognostic implications are not yet defined, further studies on this topic are warranted.

Myopericarditis After COVID-19 mRNA Vaccination Among Adolescents and Young Adults

Published data on COVID-19 mRNA vaccine-associated myopericarditis in adolescents and young adults have been derived from small case series, national population-based studies, or passive reporting systems. Pooled evidence from a larger, international cohort is scarce. To investigate the clinical features and early outcomes associated with myopericarditis after COVID-19 mRNA vaccination in a heterogeneous population of adolescents and young adults. PubMed and EMBASE were searched through August 2022. Language restrictions were not applied. Observational studies and case series describing COVID-19 vaccine-associated myopericarditis in adolescents and young adults aged 12 to 20 years and reporting clinical characteristics and early outcomes were included. Two independent investigators extracted relevant data from each study. One-group meta-analysis in a random effects model was performed. The Preferred Reporting Items for Systematic Reviews and Meta-analysis and Meta-analysis of Observational Studies in Epidemiology reporting guidelines were followed. The primary outcomes were clinical features and early outcomes for COVID-19 mRNA vaccine-associated myopericarditis, including incident rate, cardiac findings, hospitalization, intensive care unit (ICU) admission, and in-hospital mortality. A total of 23 observational studies were identified, including 854 individuals (mean age, 15.9 [95% CI, 15.5-16.2] years) with COVID-19 vaccine-associated myopericarditis. Male sex was predominant, at 90.3% (95% CI, 87.3%-93.2%) of individuals. The incident rate was higher after the second dose than the first dose, with 74.4% (95% CI, 58.2%-90.5%) of events occurring after the second dose. Most patients (84.4% [95% CI, 80.5%-88.3%] of patients) had preserved left ventricular (LV) function. Of the 15.6% (95% CI, 11.7%-19.5%) of patients with LV systolic dysfunction (LV ejection fraction [LVEF] <55%), most (14.1% [95% CI, 10.2%-18.1%]) were mild (ie, LVEF 45%-54%), and only 1.3% (95% CI, 0%-2.6%) of patients had severe LV systolic dysfunction (ie, LVEF<35%). Interestingly, cardiac magnetic resonance imaging revealed late gadolinium enhancement in 87.2% (95% CI, 79.8%-94.7%) of patients. Although 92.6% (95% CI, 87.8%-97.3%) of patients were hospitalized and 23.2% (95% CI, 11.7%-34.7%) of patients required ICU admission, inotropes were used in only 1.3% (95% CI, 0%-2.7%) of patients, no patients died or required mechanical support, and the hospital length of stay was 2.8 (95% CI, 2.1-3.5) days. This systematic review and meta-analysis found low incidence rate and largely favorable early outcomes of COVID-19 mRNA vaccine-associated myopericarditis in adolescents and young adults from a wide range of populations. These findings are reassuring but continued follow-up is warranted.

Clinical Features of Heart Failure in Patients With Hypertrophic Cardiomyopathy in a Regional Japanese Cohort - Results From the Kochi RYOMA Study.

The clinical features of heart failure (HF) in patients with hypertrophic cardiomyopathy (HCM) in Japan have not been fully elucidated.Methods and Results: In 293 patients with HCM (median age at registration, 65 (57-72) years) in a prospective cardiomyopathy registration network in Kochi Prefecture (Kochi RYOMA study), HF events (HF death or hospitalization for HF) occurred in 35 patients (11.9%) (median age, 76 (69-80) years), including 11 HF deaths during a median follow-up of 6.1 years. The 5-year HF events rate was 9.6%. Atrial fibrillation, low percentage of fractional shortening, and high B-type natriuretic peptide level at registration were predictors of HF events. The combination of these 3 factors had a relatively high positive predictive value (55%) for HF events and none of them had a high negative predictive value (99%). There were 4 types of HF profile: left ventricular (LV) systolic dysfunction (40%), severe LV diastolic dysfunction (34%), LV outflow tract obstruction (LVOTO) (20%), and primary mitral regurgitation (MR) (6%). HF deaths occurred in patients with LV systolic dysfunction or LV diastolic dysfunction, but none of patients with LVOTO or primary MR due to additional invasive therapies. In a Japanese HCM cohort, HF was an important complication, requiring careful follow-up and appropriate treatment.

Abstract 15269: Late Recovery of Left Ventricular Function After Surgical Aortic Valve Replacement for Severe Aortic Regurgitation

Introduction: Surgical aortic valve replacement (SAVR) is recommended in symptomatic severe aortic regurgitation (AR) or asymptomatic severe AR with reduced left ventricular (LV) ejection fraction (LVEF). Although most patients have improvement in LV dimensions and LVEF early (&lt; 6 months) after SAVR, severe baseline LV enlargement and reduced LVEF, along with persistent LV dilation after SAVR, carries a worse prognosis. We present a case in which a patient with these features had complete recovery of LVEF late (&gt; 9 months) after SAVR for severe AR. Case Description: A healthy 62-year-old male presented with dyspnea and chest pain. Cardiac workup was significant for ECG showing left bundle branch block; both transthoracic and trans-esophageal echocardiograms showed bicuspid aortic valve with severe AR (Eccentric jet, pressure half time (PHT): 221 msec, jet width &gt; 60% of LV outflow tract diameter), severely reduced LVEF 20-25%, and severe LV dilation (LVESD of 75 mm), and cardiac catheterization showed mild coronary disease. SAVR was performed without complications and heart failure therapy initiated. Patient declined cardiac resynchronization therapy. The LVEF and LVESD were persistently abnormal in TTE at 5 and 9 months. The TTE at 21 months showed normalization, with LVEF of 55% and LVESD of 46 mm, despite no prior improvement (Figure). Discussion: In severe AR following SAVR, volume overload reduction results in LV size reduction and improved LVEF, usually within a few months and in those with smaller baseline LV dimensions. Some studies suggest a specific LV dimension to perform SAVR. This report indicates that SAVR should not be excluded based on severe LV dilation alone. Conclusion: The incidence and mechanisms of delayed reverse cardiac remodeling in severe AR after SAVR and optimal timing of decision about device placement needs further investigation.

Abstract 11302: Natural Heart Regeneration After Myocardial Infarction in Newborn Rats Provides Ultra-Long-Term Protection From Cardiac Dysfunction and Mortality

Introduction: Newborn rats exhibit natural heart regeneration after myocardial infarction (MI), yielding no evidence of cardiac dysfunction or scar at 3 weeks post-MI. This phenotype is absent when MI occurs after 1 week of age. The long-term function of the regenerated heart and its impact on survival post-MI have not been studied. We hypothesized that natural heart regeneration preserves cardiac function and normalizes survival through adulthood. Methods: Wistar rat neonates (n=51) underwent left anterior descending coronary artery ligation on postnatal day 1 (P1, n=17) or postnatal day 9 (P9, n=12). Sham surgery was performed in littermates (P1 n=12, P9 n=10). The rats were observed for the entirety of their lifespan, reaching 18 months post-MI (equivalent to 45 human years) at the time of this analysis. Echocardiography was obtained at 15 months post-MI. After each mortality event, hearts were sectioned and stained with Masson’s trichome. Results: Echocardiography at 15 months after P1 MI vs P1 sham surgery revealed no differences in left ventricular (LV) wall thickness (p=0.881, Fig 1A) or end-diastolic diameter (p=0.118, Fig 1B), and LV ejection fraction (EF) was sustained within normal limits (63.2% vs 68.5%, p=0.003, Fig 1C). In contrast, after P9 MI, severe LV wall thinning (p&lt;0.001), massive LV dilation (p&lt;0.001), and profoundly depressed EF were observed (41.8% vs 69.1%, p&lt;0.001). Concordant results were observed for both sexes. Trace scar was detected after P1 MI, while large infarcts and LV aneurysms were observed after P9 MI (Fig 1D). At 18 months post-MI, overall survival was 13/17 (76.5%) in the P1 MI group compared to 9/12 (75.0%) in the P1 sham group (p&gt;0.999) and 3/12 (25.0%) in the P9 MI group (p=0.009). Conclusions: Natural heart regeneration mechanisms may offer long-term protection from LV dysfunction and mortality after cardiac injury, suggesting potential applications in congenital heart surgery and as a durable treatment for ischemic cardiomyopathy.

Characterization of myocardial mechanics and its prognostic significance in patients with severe aortic stenosis undergoing aortic valve replacement.

Aortic stenosis (AS) induces characteristic changes in left ventricular (LV) mechanics that can be reversed after aortic valve replacement (AVR). We aimed to comprehensively characterize LV mechanics before and after AVR in patients with severe AS and identify predictors of short-term functional recovery and long-term survival. We prospectively performed comprehensive strain analysis by 2D speckle-tracking echocardiography in 88 patients with severe AS and LV ejection fraction ≥50% (mean age 71 ± 12 years, 42% female) prior to and within 7 days after AVR. Patients were followed for up to 5.2 years until death from any cause or last encounter. Within days after AVR, we observed an absolute increase in global longitudinal strain (GLS) (-16.0 ± 2.0% vs. -18.5 ± 2.1%, P<0.0001) and a decrease in apical rotation (10.5 ± 4.0° vs. 8.3 ± 2.8°, P = 0.0002) and peak systolic twist (18.2 ± 5.0° vs. 15.5 ± 3.8°, P = 0.0008). A baseline GLS is less negative than -16.2% was 90% sensitive and 67% specific in predicting a ≥ 20% relative increase in GLS. During a median follow-up of 3.8 years, a global circumferential systolic strain rate (GCSRs) less negative than -1.9% independently predicted lower survival. In patients with severe AS, a reversal in GLS, apical rotation, and peak systolic twist abnormalities towards normal occurs within days of AVR. Baseline GLS is the strongest predictor of GLS recovery but neither was associated with long-term survival. In contrast, abnormal baseline GCSRs are associated with worse outcomes.

SEVERITY OF LEFT VENTRICULAR DYSFUNCTION IN PATIENTS WITH TACHYCARDIA-INDUCED CARDIOMYOPATHY: IMPACTS ON REMODELING AFTER ATRIAL FLUTTER ABLATION

Tachycardia-induced cardiomyopathy (TIC) is defined as a reversible systolic left ventricular (LV) dysfunction resulting from an elevated heart rate. It has been reported in patients with incessant or very frequent tachyarrhythmias, including atrial flutter. However, little is known about the evolution of LV remodeling in these patients, especially when severe LV dysfunction is present at diagnosis. Hence, the objectives of this study were to evaluate the proportion of severe LV dysfunction, and to describe the timing of LV recovery after atrial flutter ablation in patients with a presumed TIC.

Cardiovascular adaptations and inflammation in marathon runners.

Long-distance running has become increasingly popular. Cardiovascular adaptations to exercise are relevant to the specific sports and this is also the case in long-distance running. Significant changes regarding inflammatory and endothelial markers along with indices of oxidative stress are observed in marathon and ultra-marathon runners. However, data linking inflammatory marker levels with cardiovascular adaptations to marathon running are limited. The aim of the present study was to describe the cardiovascular adaptations observed in a group of ultra-marathon runners and the association with a series of inflammatory and endothelial markers measured in their plasma. A total of 43 ultra-marathon runners were assessed by echocardiography and a treadmill exercise test. Blood samples were used for tumor necrosis factor-α (TNF-α), asymmetric dimethylarginine (ADMA), interleukin (IL)-6, IL-10, C-reactive protein, creatine phosphokinase (CPK) and oxidative stress indice measurements. Ultra-marathon runners who presented augmented left ventricular (LV) end diastolic diameters >55 mm had higher ADMA values (1.07±0.07 vs. 0.99±0.08 µmol/ml, P<0.01) and lower CPK values (192.5±21.3 vs. 219.1±37.3 mg/dl, P<0.05) compared with those with normal LV diameters. Runners with a moderate and severe abnormal indexed LV mass >131 g/m2 had statistically significant higher TNF-α values compared with runners, with mildly elevated and a normal LV mass indexed (16.2±1.42 vs. 14.0+1.16 pg/ml, P<0.05). Runners with an abnormal left atrial volume index (LAVI; >29 ml/m2) had higher IL-6 values compared with runners with a normal LAVI (1.09+0.19 vs. 0.99±0.08 pg/ml, P<0.05). ROC curves analysis revealed that ADMA values were able to predict an abnormal LV diameter detected by echocardiography [P<0.05; area under the curve (AUC), 0.763], while TNF-α values could predict an abnormal LV mass in marathon runners (P<0.05; AUC, 0.78). On the whole, the present study demonstrates that, in ultra-marathon runners, cardiovascular adaptations to running are characterized by a specific pattern of changes in inflammatory and endothelial markers, which in turn can be used to predict the occurrence of the observed adaptations.

Prevalence of Hyperuricemia in Thrice Weekly Hemodialysis Patients

Background: Hyperuricemia is a well-established prognostic marker for chronic kidney disease (CKD) patients. Therefore, in this study, our aim was to determine the prevalence of hyperuricemia in thrice-weekly hemodialysis patients at a tertiary care hospital in Karachi, Pakistan.&#x0D; Methods: This was a descriptive cross-sectional study that included consecutive patients diagnosed with end-stage renal disease (ESRD) on maintenance thrice-weekly hemodialysis (HD). Based on serum urate concentrations, hyperuricemia was labeled in male patients with &gt; 7 mg/dL, and in female patients, the threshold value was &gt;6 mg/dL.&#x0D; Results: The study included a total of 73 thrice-weekly hemodialysis patients out of which 64.4% (47) were male and mean age of the study sample was 50.3 ± 12.1 years. Hyperuricemia was observed in 76.7% (56) of the patients. Females (41.1% vs. 17.6%), diabetes (46.4% vs. 23.5%), and glomerulonephritis (5.4% vs. 0%) were relatively more common among patients with hyperuricemia than non- hyperuricemia patients, respectively. Similarly, severe left ventricular (LV) dysfunction (75% vs. 35.3%), severe mitral regurgitation (14.3% vs. 5.9%), and severe tricuspid regurgitation (12.5% vs. 5.9%) were relatively more common among patients with hyperuricemia than non- hyperuricemia patients, respectively.&#x0D; Conclusion: Hyperuricemia was prevalent in more than 3/4th of the thrice-weekly hemodialysis patients. Females, diabetics, glomerulonephritis, severe LV dysfunction with mitral regurgitation (severe) and tricuspid regurgitation (severe) were relatively more common among hyperuricemic patients.

Emergency decompressive craniotomy with scalp block and closed-loop TCI sedation for acute ischemic stroke in a patient with incidental diagnosed large left ventricular mass, presenting with severe LV dysfunction.

Dear Editor, An average built 35-year-old male presented to the emergency-department with a history of a sudden onset of left-sided weakness and bi-frontal headache, with a chronic history of ischemic cardiomyopathy, and acute myocardial infarction one year back, with current functional status New York Heart Association classification (NYHA) class III. Patient underwent thrombolytic therapy with 0.9 mg/kg alteplase (r-TPA) over 60 minutes after evaluating risk factors during the precious golden hour period. Over the next 12 hours, the GCS deteriorated. There was cerebral swelling with a midline shift of 8 to 12 mm, although the patient was not intubated or ventilated. In a repeat scan and the neurosurgeon planned to proceed with emergency decompressive craniotomy. Complete hemogram was normal, electrocardiogram revealed sinus tachycardia with left anterior hemiblock. Routine trans-thoracic echocardiogram suggested global left ventricular (LV) dysfunction with an ejection fraction of 20%, large left ventricular mass (query myxoma or thrombus attached to LV apex measuring 44 mm × 36 mm), and grade III mitral regurgitation with eccentric jet. [Figure 1] Computerized tomography showed Acute Ischemic Stroke (AIS) in the right middle cerebral artery territory. After explaining due appropriate risks and benefits of surgery to the patient relatives and interdisciplinary consensus, the team decided to proceed with craniotomy under Monitored Anesthesia Care using scalp block and manual closed-loop TCI Propofol sedation under spectral entropy monitoring.Figure 1: Echocardiography (ECHO) Revealing Large Left Ventricular Mass Attached LV Apex Measuring 44 Mm × 36 Mm (A) Parasternal Long Axis View, (B) Apical Four Chamber ViewBilateral scalp anesthesia was given using 24-gauge short bevel needle with 40 ml 0.2% Ropivacaine. After assessing for adequate block by pin prick method, entropy leads were attached and secured with 1-inch plaster tape. TCI sedation with Propofol was started with the initial effect site concentration of 1 microgram/ml, later escalated to 3 microgram/ml to maintain spectral entropy between 60-80 and hemodynamic parameters. Decompressive craniotomy was completed in 2 hours 10 minutes, with no complications; patient recovery was rapid and was obeying verbal comments when effect-site concentration reached 0.5 microgram/ml. After this emergency surgery, the patient was operated for his cardiac mass after 9 months and it was found to be thrombus on histopathological diagnosis. Thrombus, tumor, and vegetation are the most common causes of intracardiac mass and must be distinguished from normal variants such as papillary muscles, false tendons, sigmoid septum, and apical trabeculation.[1] Our patient was at high risk with associated large left ventricular mass, severe left ventricular dysfunction, and ischemic cardiomyopathy and grade III mitral regurgitation for emergency craniotomy. Anesthetic management in this clinical scenario could be associated with risk of complications ranging from peri-operative myocardial infarction, pulmonary edema, LV outlet obstruction and sudden cardiac arrest, new thrombo-embolic episodes, and hemorrhagic changes in infraction.[2] Scalp block with TCI Propofol sedation prevents hemodynamic perturbances associated with general anesthesia with intubation and cardio depressant effects of anesthetic agents. Manual closed loop TCI Propofol sedation with deep anesthesia control offers optimal titration with stable hemodynamic sedation and eliminates the need for unintended protection of the airway.[3] Considering the risk and benefit ratio, craniotomy with closed loop TCI Propofol sedation outweighed the risks of general anesthesia in our patient. Though awake craniotomy with TCI sedation is safe but has a few limitations like difficulty to alter ventilation in case of intraoperative cerebral edema and airway securement may be difficult in case requirement occur intraoperatively due to positioning of patient. In spite of appropriate anticoagulation, a thrombus traveling across the cardiac cycle has a high potential to embolize. It is imperative LV masses should be surgically removed as early as possible, owing to risk of recurrent thrombo-embolic phenomenon. We conclude that craniotomy under scalp block may be performed even in an emergency craniotomy in patients with high peri-operative risk. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Aortic Valve Repair in Neonates With Aortic Stenosis and Reduced Left Ventricular Function

This study assessed outcomes of neonatal aortic valve (AoV) repair in presumed high-risk patients with depressed left ventricular (LV) function. A retrospective analysis of all neonates who underwent isolated AoV repair for severe aortic stenosis (AS) was performed. Patients with moderate or severe LV dysfunction were compared to those with normal or mild LV dysfunction. From 1980-2021, 43 neonates underwent isolated AoV repair for AS. Of these, 16 patients (37.2%) had ≥moderate LV dysfunction. Mean LV ejection fraction (EF) was 32.8 ± 9.1%. Valve morphology was mostly unicuspid (68.75%, 11/16). Median age at surgery was 6.5 days (IQR 1-17.5). An optimal repair result with ≤mild AS or aortic regurgitation was achieved in 75% (12/16). There was no early death. One patient (6.25%) required postoperative extracorporeal membrane oxygenation (ECMO) support for 3 days. LVEF improved after surgery to 56.4 ± 12.6% before discharge (P < 0.0001) and normalized in 87.5% (14/16) with a median time of 6.4 days (IQR 3.4-39). Freedom from AoV reoperation was 45.1% (95%CI 17.9-69.3%) and 27.1% (95%CI 6.8-53%) at 5 and 10 years, respectively. Freedom from AoV replacement was 59% (95%CI 27-80.8%) and 31.4% (95%CI 6-62.2%) at 5 and 10 years, respectively. While survival was similar, freedom from AoV reoperation and replacement tended to be lower compared to neonates with preserved LVEF. AoV repair was associated with a low incidence of postoperative ECMO and mortality. LV function normalized after relief of obstruction in most patients before discharge. Late reoperation remained common for those with severely dysplastic valves.

Myocardial fibrosis in asymptomatic patients undergoing surgery for mitral and aortic valve regurgitation.

Chronic heart valve regurgitation induces left ventricular (LV) volume overload, leading to the development of hypertrophy and progressive dilatation of the ventricle to maintain physiological cardiac output. In order to prevent potential irreversible LV structural changes, the identification of the best timing for treatment is pivotal. To assess the presence and extent of fibrosis in myocardial tissue in asymptomatic patients with valvular heart disease (VHD) and preserved LV dimensions and function undergoing cardiac surgery. Thirty-nine patients were enrolled. Sixteen patients were affected by aortic or mitral regurgitation: they were all asymptomatic, undergoing valve surgery according to VHD European Society of Cardiology guidelines. Twenty-three patients with end-stage nonischemic dilated cardiomyopathy (DCM) and severe LV dysfunction undergoing cardiac surgery for implantation of a durable left ventricular assist device (LVAD) served as controls. During surgery, VHD patients underwent three myocardial biopsies at the level of the septum, the lateral wall and LV apex, while in LVAD patients the coring of the apex of the LV was used. For both groups, the tissue samples were analyzed on one section corresponding to the apical area. All slides were stained with hematoxylin and eosin and Masson's trichrome staining and further digitalized. The degree of fibrosis was then calculated as a percentage of the total area. Of 39 patients, 23 met the inclusion criteria: 12 had mitral or aortic insufficiency with a preserved ejection fraction and 11 had idiopathic dilated cardiomyopathy. Quantitative analysis of apical sections revealed a myocardial fibrosis amount of 10 ± 6% in VHD patients, while in LVAD patients the mean apical myocardial fibrosis rate was 38 ± 9%. In VHD patients, fibrosis was also present in the lateral wall (9 ± 4%) and in the septum (9 ± 6%). Our case series study highlights the presence of tissue remodeling with fibrosis in asymptomatic patients with VHD and preserved LV function. According to our results, myocardial fibrosis is present at an early stage of the disease, well before developing detectable LV dysfunction and symptoms. Since the relationship between the progressive magnitude of myocardial fibrosis and potential prognostic implications are not yet defined, further studies on this topic are warranted.