Mammoth interatrial septal aneurysm in the ICE age

<p>Abstract</p> <p>Background</p> <p>Intracardiac echocardiography (ICE) is a useful imaging modality that is now being used more widely to assist in the percutaneous closure of atrial septal defects (ASD) and patent foramen ovales (PFO).</p> <p>Case presentation</p> <p>A 42 year old lady with a history of transient ischaemic attacks and migraine underwent percutaneous closure of an ASD. Intraprocedural ICE demonstrated a mammoth billowing multiperforated interatrial septal aneurysm in association with a secondum ASD.</p> <p>Conclusion</p> <p>ICE provides excellent adjuvant imaging during percutaneous closure of intracardiac shunts, in this case demonstrating a 'mammoth' interatrial septal aneurysm.</p

Echocardiographic assessment and percutaneous closure of multiple atrial septal defects

Atrial septal defect closure is now routinely performed using a percutaneous approach under echocardiographic guidance. Centrally located, secundum defects are ideal for device closure but there is considerable morphological variation in size and location of the defects. A small proportion of atrial septal defects may have multiple fenestrations and these are often considered unsuitable for device closure. We report three cases of multiple atrial septal defects successfully closed with two Amplatzer septal occluders

Resolving large-scale pressures on species and ecosystems: propensity modelling identifies agricultural effects on streams

1. Although agriculture is amongst the world's most widespread land uses, studies of its effects on stream ecosystems are often limited in spatial extent. National monitoring data could extend spatial coverage and increase statistical power, but present analytical challenges where covarying environmental variables confound relationships of interest. 2. Propensity modelling is used widely outside ecology to control for confounding variables in observational data. Here, monitoring data from over 3000 English and Welsh river reaches are used to assess the effects of intensive agricultural land cover (arable and pastoral) on stream habitat, water chemistry and invertebrates, using propensity scores to control for potential confounding factors (e.g. climate, geology). Propensity scoring effectively reduced the collinearity between land cover and potential confounding variables, reducing the potential for covariate bias in estimated treatment–response relationships compared to conventional multiple regression. 3. Macroinvertebrate richness was significantly greater at sites with a higher proportion of improved pasture in their catchment or riparian zone, with these effects probably mediated by increased algal production from mild nutrient enrichment. In contrast, macroinvertebrate richness did not change with arable land cover, although sensitive species representation was lower under higher proportions of arable land cover, probably due to greatly elevated nutrient concentrations. 4. Synthesis and applications. Propensity modelling has great potential to address questions about pressures on ecosystems and organisms at the large spatial extents relevant to land‐use policy, where experimental approaches are not feasible and broad environmental changes often covary. Applied to the effects of agricultural land cover on stream systems, this approach identified reduced nutrient loading from arable farms as a priority for land management. On this specific issue, our data and analysis support the use of riparian or catchment‐scale measures to reduce nutrient delivery to sensitive water bodies

The effect of sodium‐glucose co‐transporter 2 inhibitors on outcomes after cardiac resynchronization therapy

Aims: The trials upon which recommendations for the use of cardiac resynchronization therapy (CRT) in heart failure used optimal medical therapy (OMT) before sodium‐glucose co‐transporter 2 inhibitors (SGLT2i). Moreover, the SGLT2i heart failure trials included only a small proportion of participants with CRT, and therefore, it remains uncertain whether SGLT2i should be considered part of OMT prior to CRT. Methods and results: We compared electrocardiogram (ECG) and echocardiographic responses to CRT as well as hospitalization and mortality rates in consecutive patients undergoing implantation at a large tertiary centre between January 2019 to June 2022 with and without SGLT2i treatment. Three hundred seventy‐four participants were included aged 74.0 ± 11.5 years (mean ± standard deviation), with a left ventricular ejection fraction (LVEF) of 31.8 ± 9.9% and QRS duration of 161 ± 29 ms. The majority had non‐ischaemic cardiomyopathy (58%) and were in NYHA Class II/III (83.6%). These characteristics were similar between patients with (n = 66) and without (n = 308) prior SGLT2i treatment. Both groups demonstrated similar evidence of response to CRT in terms of QRS duration shortening, and improvements in LVEF, left ventricular end‐diastolic inner‐dimension (LVIDd) and diastolic function (E/A and e/e′). While there was no difference in rates of hospitalization (for heart failure or overall), mortality was significantly lower in patients treated with SGLT2i compared with those who were not (6.5 vs. 16.6%, P = 0.049). Conclusions: We observed an improvement in mortality in patients undergoing CRT prescribed SGLT2i compared with those not prescribed SGLT2i, despite similar degrees of reverse remodelling. The authors recommend starting SGLT2i prior to CRT implantation, where it does not delay implantation