Impasse During Cardiac Implantable Electronic Device Lead Extraction: Only Patience, Endurance and the Right Tools Can Bail You Out

A case of complex and arduous percutaneous cardiac implantable electronic device (CIED) lead extraction is presented that illustrates several aspects of technical challenges that may emerge during the procedure requiring a change of strategy, appropriate tool selection, and operator and patient endurance. Rhythmos 2018;13(4):78-80

Pulmonary manifestations of chronic liver disease: A comprehensive review

Hepatopulmonary syndrome (HPS) and porto-pulmonary hypertension (PoPH) represent relatively common pulmonary vascular complications of advanced liver disease. Despite distinct differences in their pathogenetic background, both clinical states are characterized by impaired arterial oxygenation and limited functional status, and are associated with increased pre-transplantation mortality. Accumulation of ascitic fluid in the pleural cavity, known as hepatic hydrothorax (HH), is another frequent manifestation of decompensated cirrhosis, which may cause severe respiratory dysfunction, depending on the volume of the effusion, the rapidity of its development and its resistance to therapeutic measures. Orthotopic liver transplantation constitutes the only effective treatment able to resolve the pulmonary complications of liver disease. A prioritization policy for liver transplantation has evolved over the past years regarding advanced stages of HPS, yielding favorable outcomes regarding post-transplantation survival and HPS resolution. In contrast, severe PoPH is associated with poor post-transplantation survival. Hence, liver transplantation is recommended only for patients with PoPH and an acceptable reduction in pulmonary pressure values, after receiving PoPH-targeted vasodilating therapy. This review focuses on basic pathogenetic and diagnostic principles and discusses the current therapeutic approaches regarding HPS, PoPH, and HH. © 2020 Hellenic Society of Gastroenterology

Novel echocardiographic markers in the diagnosis and severity assessment of the hepatopulmonary syndrome in patients with liver cirrhosis

Aims: Cardiac function impairment in the setting of hepatopulmonary syndrome (HPS) in patients with end stage liver disease remains an issue of debate. The current study evaluated possible correlations between HPS and biventricular systolic function in patients with decompensated cirrhosis. Methods: Consecutive liver transplantation candidates with stable decompensated cirrhosis were prospectively evaluated. HPS was defined as the presence of an elevated alveolar-arterial oxygen gradient and intrapulmonary vasodilatation, detected by contrast enhanced echocardiography. HPS severity was determined based on arterial blood oxygen pressure values, while shunt size was assessed with a semi-quantitative method. Demographic, clinical and laboratory parameters were also prospectively collected. Results: In total, 130 patients (mean age 56.5, M/F: 94/36, MELD score 14.6±5.6) were enrolled, of whom 45 (34.6%) fulfilled the criteria for HPS diagnosis (mild: 57.7%, moderate: 33.3%, severe 4.4% and very severe 4.4%). Significantly lower absolute left ventricular (LV) global longitudinal strain (GLS) values (-21.62.3 vs -22.62.5 %, p= 0.041) were measured in patients with HPS compared to cirrhotic patients without HPS, while there was no statistically significant difference regarding right ventricular GLS (-22.13.3 vs -23.23.5%, p=0.061) between the two groups. Lower LV ejection fraction values were also recorded in the HPS group (53.93.5 vs 56.34.5%, p<0.01). No other echocardiographic parameter was correlated to HPS. Intrapulmonary shunt grading was correlated to HPS classification (χ2 = 19.8, p<0.01), with lower arterial oxygen values being recorded in higher stages of intrapulmonary shunt. Conclusion: In patients with cirrhosis, the presence of HPS is associated with worse LV contractile performance.Στόχος: Σκοπός της παρούσας μελέτης είναι η διερεύνηση των πιθανών συσχετισμών μεταξύ ηπατοπνευμονικού συνδρόμου (ΗΠΣ) και καρδιακής λειτουργίας σε ασθενείς με μη αντιρροπούμενη κίρρωση. Μέθοδοι: Ασθενείς με σταθερή μη αντιρροπούμενη κίρρωση που αξιολογήθηκαν στην κλινική μας ως υποψήφιοι για μεταμόσχευση ήπατος συμπεριελήφθησαν προοπτικά στη μελέτη. Ως ΗΠΣ ορίστηκε ως η παρουσία αυξημένης κυψελιδο-αρτηριακής διαφοράς οξυγόνου και ενδοπνευμονικών αγγειακών διατάσεων – ενδοπνευμονικού shunt α, που ανιχνεύθηκε από ηχωκαρδιογραφία ενισχυμένης σκιαγραφικής αντίθεσης. Η σοβαρότητα του ΗΠΣ προσδιορίστηκε με βάση την μερική πίεση αρτηριακού οξυγόνου, ενώ με τη χρήση μιας ημι-ποσοτικής μεθόδου αξιολογήθηκε ο βαθμός του ενδοπνευμονικού shunt. Συλλέχθηκαν δημογραφικά, κλινικά και εργαστηριακά δεδομένα. Αποτελέσματα: Συνολικά, στη μελέτη συμπεριελήφθησαν 130 ασθενείς (μέση ηλικία 56,5 έτη, Α / Γ: 94/36, MELD score 14.6 ± 5.6), εκ των οποίων 45 (34.6%) πληρούσαν τα κριτήρια διάγνωσης για τη διάγνωση ΗΠΣ (ήπιο: 57.7%, μέτριο: 33.3%, σοβαρό 4.4% και πολύ σοβαρό 4.4%). Σημαντικά χαμηλότερες απόλυτες τιμές ολικού γραμμικού strain (global longitudinal strain – GLS) της αριστερής κοιλίας καταγράφηκαν σε ασθενείς με ΗΠΣ σε σύγκριση με κιρρωτικούς ασθενείς χωρίς ΗΠΣ (-21.62,3 έναντι -22.62.5%, p = 0.041), ενώ δεν διαπιστώθηκε στατιστικά σημαντική διαφορά σχετικά GLS της δεξιάς κοιλίας μεταξύ των δύο ομάδων (-22.13.3 έναντι -23.23.5%, p = 0.061). Χαμηλότερες τιμές κλάσματος εξώθησης της αριστερής κοιλίας καταγράφηκαν επίσης στους ασθενείς με ΗΠΣ (53.9-3.5 έναντι 56.3-4.5%, ρ <0,01). Καμία άλλη ηχωκαρδιογραφική παράμετρος δεν συσχετίστηκε με την παρουσία του ΗΠΣ. Η σταδιοποίηση του ενδοπνευμονικού shunt συσχετίστηκε με την σταδιοποίηση της βαρύτητας του ΗΠΣ (χ2 = 19,8, p <0,01), με χαμηλότερες τιμές μερικής πίεσης αρτηριακού οξυγόνου να καταγράφονται σε υψηλότερα βαθμού ενδοπνευμονικού shunt. Συμπέρασμα: Σε ασθενείς με κίρρωση, η παρουσία ΗΠΣ σχετίζεται με μειωμένη συστολική απόδοση της αριστερής κοιλίας

Management of patients with concomitant coronary and carotid artery disease

Introduction: Ideal management of concomitant carotid and coronary artery occlusive disease remains under investigation. Although researchers have advocated the potential benefits of varying treatment strategies based on either concomitant or staged surgical treatment, there is no consensus in treatment guidelines. With emerging data suggesting favorable outcome of carotid artery stenting (CAS) compared to carotid endarterectomy (CEA) in patients with critical coronary artery disease, physicians must consider these diverging therapeutic options. Areas covered: This review presents current evidence regarding the prevalence of carotid stenosis in patients with coronary artery disease, the common pathophysiologic links with an emphasis on the diverse mechanisms of stroke in the coronary artery bypass grafting (CABG) setting and discusses the contemporary registries and observational studies comparing outcomes of various revascularization strategies in high-risk patients. Authors conducted a literature search in two bibliographic databases including papers published from 1983 until 2018 (PubMed, Scopus). Expert opinion: Symptoms should drive the need to intervene on carotid stenosis in patients undergoing coronary revascularization. Carotid artery stenting has gained significant ground, especially among those individuals considered of high surgical risk. PCI may be considered as an alternative option for the management of severe concurrent coronary disease

Effect of biologics on cardiovascular inflammation: Mechanistic insights and risk reduction

It is increasingly recognized that atherosclerosis and consequently cardiovascular disease (CVD) are closely linked with inflammatory processes. The latter is in the center of the pathogenic mechanism underlying autoimmune rheumatic diseases (ARD). It follows then, that optimal control of inflammation in ARDs may lead to a decrease of the accompanied CVD risk. Major trials (eg, CANTOS, CIRT), aimed at examining the possible benefits of immunomodulatory treatments in CVD, demonstrated conflicting results. On the other hand, substantial evidence is accumulating about the possible beneficial effects of biologic disease modifying antirheumatic drugs (bDMARDs) in patients with ARDs, parti-cularly those with rheumatoid arthritis (RA). It seems that bDMARDs (some more than others) alter the lipid profile in RA patients but do not adversely affect, in most cases, the TC/HDL ratio. Favorable effects are noted for arterial stiffness and endothelial function. This is reflected in the lower risk for CVD events, seen in observational studies of RA patients treated with bDMARDs. It should be stressed that more data exist for the TNF-inhibitors than for other bDMARDs, such as tocilizumab, abatacept and rituximab. As regards the spondyloarthropathies (SpA), data are less robust. For TNF-inhibitors, effects appear to be on par with those seen in RA but no conclusions can be drawn for newer biologic drugs used in SpA (eg, IL-17 blockers). Finally, there is accumulating evidence for a beneficial effect of immunosuppressive treatment in cardiac inflammation and function in several ARDs. Introduction of newer therapeutic options in clinical practice seem to have a positive impact on CVD in the setting of ARD. This is probably due to better control of inflammation, but direct improvement in vascular pathology is also a valid hypothesis. Most data are derived from observational studies and, therefore, randomized controlled trials are needed to assess the possible favorable effect of bDMARDs on CVD outcomes. © 2021 Fragoulis et al

Review article: Update on current and emergent data on hepatopulmonary syndrome

Hepatopulmonary syndrome (HPS) is a frequent pulmonary complication of end-stage liver disease, characterized by impaired arterial oxygenation induced by intrapulmonary vascular dilatation. Its prevalence ranges from 4% to 47% in patients with cirrhosis due to the different diagnostic criteria applied among different studies. Nitric oxide overproduction and angiogenesis seem to be the hallmarks of a complicated pathogenetic mechanism, leading to intrapulmonary shunting and ventilation-perfusion mismatch. A classification of HPS according to the severity of hypoxemia has been suggested. Contrast-enhanced echocardiography represents the gold standard method for the detection of intrapulmonary vascular dilatations which is required, in combination with an elevated alveolar arterial gradient to set the diagnosis. The only effective treatment which can modify the syndrome’s natural history is liver transplantation. Although it is usually asymptomatic, HPS imparts a high risk of pretransplantation mortality, independently of the severity of liver disease, while there is variable data concerning survival rates after liver transplantation. The potential of myocardial involvement in the setting of HPS has also gained increasing interest in recent research. The aim of this review is to critically approach the existing literature of HPS and emphasize unclear points that remain to be unraveled by future research. © The Author(s) 2018. Published by Baishideng Publishing Group Inc. All rights reserved

Chrononutrition in Cardiometabolic Health

In recent years, a healthy balanced diet together with weight reduction has risen to the forefront of minimizing the impact of cardiovascular disease. There is evidence that metabolic processes present circadian rhythmicity. Moreover, the timing of food consumption exerts a powerful influence on circadian rhythms. In this context, the subject of chrononutrition, described as the alignment of timing of food intake to the rhythms imposed by the circadian clock, has attracted considerable interest for possible beneficial effects on cardiovascular health. Current human studies suggest that chrononutrition-based dietary interventions could reduce the risk for cardiovascular disease by improving weight control, hypertension, dyslipidemia, and diabetes. However, meta-analysis of randomized control trials in this topic present varying and somehow conflicting results. Even the traditional association of breakfast skipping with adverse cardiovascular outcomes is nowadays controversial. Therefore, long-term and fairly consistent studies on the effect of chrononutrition on cardiovascular outcomes are needed. The purpose of this review is to provide concise evidence of the most recent literature involving the effects of chrononutrition and the specific chrononutrition-based dietary interventions, in particular time-restricted eating, on body weight and other cardiovascular disease risk factors