Ischemic and non-ischemic patterns of late gadolinium enhancement in heart failure with reduced ejection fraction

Background: Late gadolinium enhancement (LGE) by cardiac magnetic resonance (CMR) may revealmyocardial fibrosis which is associated with adverse clinical outcomes in patients undergoing implantablecardioverter-defibrillator (ICD) placement. At the same time, transmural LGE in the posterolateral wall isrelated to nonresponse to conventional cardiac resynchronization therapy (CRT). Herein, the aim was toassess the presence and determinants of LGE in CMR in heart failure (HF) with reduced ejection fraction.Methods: Sixty-seven patients were included (17.9% female, aged 45 [29–60] years), who underwentLGE-CMR and had left ventricular ejection fraction (LVEF) as determined by echocardiography.Results: In HF patients with LVEF ≤ 35% (n = 29), ischemic and non-ischemic patterns of LGE wereobserved in 51.7% and 34.5% of patients, respectively. In controls (n = 38), these patterns were noted in23.7% and 42.1% of patients, respectively. HF patients with LVEF ≤ 35% and transmural LGE in theposterolateral wall (31.0%) were characterized by older age, coronary artery disease (CAD) and previousmyocardial infarction (MI) (61 ± 6 vs. 49 ± 16 years, p = 0.008, 100% vs. 40%, p = 0.003 and 78%vs. 25%, p = 0.014, respectively). In patients with LVEF ≤ 35%, LGE of any type, diagnosed in 86.2%of patients, was associated with CAD (68% vs. 0%, p = 0.02), while only trends were observed for itsassociation with older age and previous MI (p = 0.08 and p = 0.12, respectively).Conclusions: Among HF patients with LVEF ≤ 35%, clinical factors including older age, CAD, andprevious MI are associated with transmural LGE in the posterolateral wall, while CAD is associated with LGE. This data may have potential implications for planning ICD and CRT placement procedures

Contact force-sensing versus standard catheters in non-fluoroscopic radiofrequency catheter ablation of idiopathic outflow tract ventricular arrhythmias

Background: Adequate contact between the catheter tip and tissue is important for optimal lesion formation and, in some procedures, it has been associated with improved effectiveness and safety. We evaluated the potential benefits of contact force-sensing (CFS) catheters during non-fluoroscopic radiofrequency catheter ablation (NF-RFCA) of idiopathic ventricular arrhythmias (VAs) originating from outflow tracts (OTs). Methods: A group of 102 patients who underwent NF-RFCA (CARTO, Biosense Webster Inc., Irvine, CA, USA) of VAs from OTs between 2014 to 2018 was retrospectively analyzed. Results: We included 52 (50.9%) patients in whom NF-RFCA was performed using CFS catheters and 50 (49.1%) who were ablated using standard catheters. Arrhythmias were localized in the right and left OT in 70 (68.6%) and 32 (31.4%) patients, respectively. The RFCA acute success rate was 96.1% (n = 98) and long-term success during a minimum 12-month follow-up (mean 51.3 ± 21.6 months) was 85.3% (n = 87), with no difference between CFS and standard catheters. There was no difference in complications rate between CFS (n = 1) and standard catheter (n = 2) ablations. Conclusions: There is no additional advantage of CFS catheters use over standard catheters during NF-RFCA of OT-VAs in terms of procedural effectiveness and safety

Pathogenesis and Management of Brugada Syndrome: Recent Advances and Protocol for Umbrella Reviews of Meta-Analyses in Major Arrhythmic Events Risk Stratification

Brugada syndrome (BrS) is a primary electrical disease associated with life-threatening arrhythmias. It is estimated to cause at least 20% of sudden cardiac deaths (SCDs) in patients with normal cardiac anatomy. In this review paper, we discuss recent advances in complex BrS pathogenesis, diagnostics, and current standard approaches to major arrhythmic events (MAEs) risk stratification. Additionally, we describe a protocol for umbrella reviews to systematically investigate clinical, electrocardiographic, electrophysiological study, programmed ventricular stimulation, and genetic factors associated with BrS, and the risk of MAEs. Our evaluation will include MAEs such as sustained ventricular tachycardia, ventricular fibrillation, appropriate implantable cardioverter−defibrillator therapy, sudden cardiac arrest, and SCDs from previous meta-analytical studies. The protocol was written following the Preferred Reporting Items for Systematic review and Meta-Analysis Protocols (PRISMA-P) guidelines. We plan to extensively search PubMed, Embase, and Scopus databases for meta-analyses concerning risk-stratification in BrS. Data will be synthesized integratively with transparency and accuracy. Heterogeneity patterns across studies will be reported. The Joanna Briggs Institute (JBI) methodology, A MeaSurement Tool to Assess systematic Reviews 2 (AMSTAR 2), and the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) are planned to be applied for design and execution of our evidence-based research. To the best of our knowledge, these will be the first umbrella reviews to critically evaluate the current state of knowledge in BrS risk stratification for life-threatening ventricular arrhythmias, and will potentially contribute towards evidence-based guidance to enhance clinical decisions

Chronic Kidney Disease and Its Impact on a Prothrombotic State in Patients with Atrial Fibrillation

It is unclear whether chronic kidney disease (CKD) increases thromboembolism in atrial fibrillation (AF). We conducted a retrospective cross-sectional analysis of 502 non-anticoagulated AF patients (median age, 66 (60–73) years, median CHA2DS2-VASc score, 3.0 (2.0–4.0)) with an estimated glomerular filtration rate (eGFR) ≥ 15 mL/min/1.73 m2. Endogenous thrombin potential (ETP), clot permeability (Ks), and clot lysis time (CLT), among others, were determined. Patients with stage 4 CKD (n = 87; 17.3%) had higher ETP and prolonged CLT compared with those with stage 3 CKD. In patients with stages 3 to 4 CKD (n = 180; 35.9%) N-terminal pro-B-type natriuretic peptide predicted low Ks (the lowest quartile, odds ratio [OR] per 100 pg/mL: 1.03, 95% confidence interval [CI]: 1.01–1.06) and prolonged CLT (the top quartile, OR per 100 pg/mL: 1.05, 95% CI: 1.02–1.08), but not high ETP. In the whole cohort, after adjustment for CHA2DS2-VASc score, stage 4 CKD, but not stage 3 CKD, predicted high ETP (OR: 9.06; 95% CI: 4.44−18.46) and prolonged CLT (OR: 3.58; 95% CI: 1.76–7.28), but not low Ks. compared to the reference eGFR category. This study is the first to demonstrate the prothrombotic and antifibrinolytic alterations in AF patients with stage 4 CKD, but not stage 3 CKD irrespective of clinical stroke risk factors

Infections of cardiac implantable electronic devices: Epidemiology, mechanisms, and preventive measures

Cardiac implantable electronic device (CIED) infections represent a complication associated with high morbidity and mortality. Despite enormous efforts to prevent them, the rates of infections continue to rise out of proportion to the reported increase in CIED implantation rates. Following extensive research of various prevention strategies and new technologies, several organizations have issued recommendations and consensus papers covering this topic. Our narrative review aims to provide a summary of the existing preventive strategies put forward by the European Heart Rhythm Association consensus and European Society of Cardiology guidelines and introduce the most recent developments in the field, including optimized surgical site management and appropriate periprocedural antithrombotic drug use. It also provides an overview of epidemiology, mechanisms, risk factors, and risk stratification approaches. It focuses on the pre-, intra-, and postprocedural actions that should be taken to mitigate CIED infection risks. Future directions in the prevention of CIED infections have also been addressed

Neuroimaging Studies of the Neural Correlates of Heart Rate Variability: A Systematic Review

Direct and indirect links between brain regions and cardiac function have been reported. We performed a systematic literature review to summarize current knowledge regarding the associations of heart rate variability (HRV) and brain region morphology, activity and connectivity involved in autonomic control at rest in healthy subjects. Both positive and negative correlations of cortical thickness and gray matter volumes of brain structures with HRV were observed. The strongest were found for a cluster located within the cingulate cortex. A decline in HRV, as well as cortical thickness with increasing age, especially in the orbitofrontal cortex were noted. When associations of region-specific brain activity with HRV were examined, HRV correlated most strongly with activity in the insula, cingulate cortex, frontal and prefrontal cortices, hippocampus, thalamus, striatum and amygdala. Furthermore, significant correlations, largely positive, between HRV and brain region connectivity (in the amygdala, cingulate cortex and prefrontal cortex) were observed. Notably, right-sided neural structures may be preferentially involved in heart rate and HRV control. However, the evidence for left hemispheric control of cardiac vagal function has also been reported. Our findings provide support for the premise that the brain and the heart are interconnected by both structural and functional networks and indicate complex multi-level interactions. Further studies of brain–heart associations promise to yield insights into their relationship to health and disease

Thromboembolism and bleeding in patients with atrial fibrillation and stage 4 chronic kidney disease: impact of biomarkers

Background: Chronic kidney disease (CKD) is considered a risk factor for thromboembolic and bleeding events in patients with atrial fibrillation (AF). Aims: We sought to assess predictors of clinical outcomes among AF patients with advanced CKD. Methods: In a prospective cohort study, we enrolled 180 AF patients with stage 4 CKD, defined as estimated glomerular filtration rate of 15–29 ml/min/1.73 m2, on vitamin K antagonists (n = 90), and non-vitamin K antagonists oral anticoagulants (n = 90). We assessed biomarkers, including growth differentiation factor-15, cystatin C, and high-sensitivity cardiac troponin T, and prothrombotic state parameters, including plasma fibrin clot permeability (Ks).Results: The median age of the patients was 71.0 (64.0–75.0) years (men 65.0%). The median estimated glomerular filtration rate was 24.0 (21.0–25.0) ml/min/1.73 m2 while the median CHA2DS2-VASc score was 3.0 (2.0–4.0). Age (hazard ratio [HR], 1.11; 95% confidence interval [CI], 1.02–1.20) and decreased Ks (HR, 0.55; 95% CI, 0.34–0.90) were associated with thromboembolic events (n = 18; 4.7% per year). Previous bleeding (HR, 3.21; 95% CI, 1.22–8.45), growth differentiation factor-15 (HR, 1.48; 95% CI, 1.29–1.69), cystatin C (HR, 9.24; 95% CI, 2.15–39.67), and high-sensitivity cardiac troponin T (HR, 1.30; 95% CI, 1.14–1.48) were independent predictors of major or clinically relevant non-major bleeding (n = 27; 7.1% per year). After adjustment for age and comorbidities, only cystatin C (HR, 3.95; 95% CI, 1.08–14.37) predicted mortality (n = 25; 6.5% per year).Conclusions: Novel biomarkers might be useful in risk stratification of thromboembolic and bleeding events in AF patients with stage 4 CKD receiving oral anticoagulants

Transcatheter Aortic Valve Implantation and Cardiac Conduction Abnormalities: Prevalence, Risk Factors and Management

Over the last decades, transcatheter aortic valve implantation (TAVI) or replacement (TAVR) has become a potential, widely accepted, and effective method of treating aortic stenosis in patients at moderate and high surgical risk and those disqualified from surgery. The method evolved what translates into a noticeable decrease in the incidence of complications and more beneficial clinical outcomes. However, the incidence of conduction abnormalities related to TAVI, including left bundle branch block and complete or second-degree atrioventricular block (AVB), remains high. The occurrence of AVB requiring permanent pacemaker implantation is associated with a worse prognosis in this group of patients. The identification of risk factors for conduction disturbances requiring pacemaker placement and the assessment of their relation to pacing dependence may help to develop methods of optimal care, including preventive measures, for patients undergoing TAVI. This approach is crucial given the emerging evidence of no worse outcomes for intermediate and low-risk patients undergoing TAVI in comparison to surgical aortic valve replacement. This paper comprehensively discusses the mechanisms, risk factors, and consequences of conduction abnormalities and arrhythmias, including AVB, atrial fibrillation, and ventricular arrhythmias associated with aortic stenosis and TAVI, as well as provides insights into optimized patient care, along with the potential of conduction system pacing and cardiac resynchronization therapy, to minimize the risk of unfavorable clinical outcomes

Predictive risk models for forecasting arrhythmic outcomes in Brugada syndrome: A focused review

Brugada syndrome (BrS) is a rare disorder characterized by coved or saddle-shaped ST-segment elevation in the right precordial leads on the electrocardiogram. Risk stratification in BrS remains challenging. A number of clinical, electrocardiographic, programmed ventricular stimulation and genetic risk factors have been identified as important predictors of future major arrhythmic events. There is a positive association between the number of risk factors and arrhythmic events. Hence, a multi-parametric approach would provide comprehensive risk assessment and more accurate risk stratification, assisting in therapeutic decisions making, including implantable cardioverter-defibrillator placement or identification of low-risk individuals. However, the extent to which each variable influences the risk and non-linear interactions between the different risk variables make risk stratification challenging. This paper aims to provide a focused review of the multi-parametric risk models for BrS risk stratification published in the literature. [Abstract copyright: Copyright © 2022 Elsevier Inc. All rights reserved.