2024;121(12) – ABC CARDIOL

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Editorial

The Importance of Electrovectorcardiographic Assessment of Intraventricular Blocks and their Relationship with the Cardiac Cycle

Carlos Alberto Pastore

The impact of intraventricular conduction disorders on myocardial activation and ventricular function has long been debated. However, with the advent of cardiac resynchronization therapy, this topic has gained even more attention during the last two decades.^,

At that time, our team utilized surface electrocardiographic mapping and isochronal line maps to assess the mean activation time in three specific regions of the heart: the right ventricle (RV), the left ventricle (LV), and the anteroseptal region. This evaluation was conducted on patients with a left ventricular ejection fraction of less than 40%, who exhibited left bundle branch block (LBBB), and had a mean QRS duration of 180 ms.^, The cardiac electrical activation was evaluated in three groups of patients: 1) patients with native LBBB, 2) patients under RV pacing, and 3) patients under biventricular pacing (BVP). In individuals with LBBB, the RV and anteroseptal mean activation time were delayed compared to the LV, leading to a loss of synchrony. Similarly, the RV pacing group’s activation time extended beyond normal, with a more significant difference between the septal area and LV. LV and RV activation times were similar during BVP, and the septal activation approached the normal and native LBBB conditions. Those findings suggested that the prolonged RV electrical activation by BVP, which sometimes may go unnoticed in the presence of LBBB, could be a relevant criterion in selecting candidates for cardiac resynchronization therapy.^,

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Original Article

Impact of 3D Printing on Cardiac Surgery in Congenital Heart Diseases: A Systematic Review and Meta-Analysis

Davi Shunji Yahiro et al. Mariana de Paula Cruz Brenda Ficheira Coelho Ribeiro Luiza Meireles Teixeira … Maria Fernanda Ribeiro Mendes de Oliveira Aurea Lúcia Alves de Azevedo Grippa de Souza Ana Flávia Malheiros Torbey Juliana Serafim da Silveira Claudio Tinoco Mesquita

Abstract

Background

Congenital heart disease (CHD) poses significant challenges in surgical management due to the complexity of cardiac anatomy. Three-dimensional (3D) printing has emerged as a promising tool in preoperative planning, intraoperative guidance, and medical education for CHD surgeries.

Objectives

We aimed to systematically review the literature on the utilization and benefits of 3D printing technology in CHD surgical interventions.

Methods

A systematic search was conducted across PubMed and EMBASE for studies published up to February of 2024. We included controlled and uncontrolled studies investigating the surgical role of 3D printing in CHD patients. We conducted a single-arm meta-analysis estimating the proportion of change in treatment planning due to the use of 3D printed-models. Moreover, studies that compared 3D printing to conventional care were included into the meta-analysis. A p-value < 0.05 was considered statistically significant.

Results

A total of 21 studies met the inclusion criteria, comprising 444 patients undergoing CHD surgeries with 3D printing assistance. Preoperative planning aided by 3D models led to changing surgical decisions in 35 of 75 cases (51.8%; 95% CI 26.6-77.0%, I2=80.68%, p=0.001) and reduced total operative time in 22.25 minutes in favor of the 3D printing group (95%CI 49.95; 5.80 min, I2=0%, p=0.817) but without statistical significance. Albeit in a smaller sample, other endpoints (mechanical ventilation and ICU time) demonstrated some benefit from the technology but without statistical significance.

Conclusions

By providing personalized anatomical models, 3D printing may facilitate surgical planning and execution. More studies are needed to investigate the effects of 3D printing on reducing intervention, hospitalization, and mechanical ventilation times.

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Original Article

Twitter (X) as a Communication and Education Tool for Brazilian Cardiologists: Profile, Influence and Challenges

Aline Goneli de Lacerda et al. Luana de Oliveira Ribas Estephany de Jesus Ronaldo Ferreira de Araújo … Thaiane Moreira de Oliveira Claudio Tinoco Mesquita

Abstract

Background

Twitter (recently renamed to X) is a popular social media that can be used for health communication. There are few studies analyzing the profile of Brazilian cardiologists active on the platform.

Objectives

To identify the profile of Brazilian cardiologists on Twitter (X), their online influence and reach, as well as their bios’ description.

Methods

A total of 1,083 accounts of Brazilian cardiologists were created between 2006 and 2021. Data were collected using the FollowerWonk tool and analyzed using the IRAMUTEQ software.

Results

Most profiles were of men (76.5%) and 0.8% was institutional profiles. Most profiles had less than 100 followers (71%) and low social authority (81.8%). The 20 most influential profiles were mostly of men (80%) and highly concentrated in the southeast of Brazil (68%).

Conclusions

Brazilian cardiologists prefer a personal and direct communication in social medias, rather than an institutional representation. There is a gender disparity among Brazilian cardiologists on Twitter (X), with a predominance of men. The most influential profiles were of men, and mostly located in the southeastern Brazil.

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Original Article

Impact of Intraventricular Blocks on Cardiac Cycle Dynamics: An Echocardiographic and Vectorcardiographic Analysis

Carlos Eduardo Duarte et al. Katia Regina Silva Luciene Dias de Jesus Henry Abensur Roberto Costa

Abstract

Background

Left bundle branch block (LBBB) causes delays that alter the mechanics of the ventricular cycle. The effect of other intraventricular blocks (IVB) remains little explored.

Objectives

To study the phases of the cardiac cycle (CC) and ventricular synchrony in different ventricular activation patterns.

Methods

Cross-sectional study with 328 consecutive individuals without structural heart disease, normal electrocardiogram or IVB, conducted in the period between August/2020 and January/2022. Echocardiogram and Vectorcardiogram were performed simultaneously to analyze the electromechanics of the CC. A one-way Analysis of Variance (ANOVA) with Bonferroni’s multiple comparison test was used, with a significance level of 5%.

Results

The age of the participants was 64.8±15.3 years, with 57.9% male and an ejection fraction of 67.0±6.8%. The electrocardiogram was normal for 32.3%, 18.6% had right bundle branch block (RBBB), 17.7% had left anterior fascicular block (LAFB), 15.6% had RBBB+LAFB, and 15.9% had LBBB. The echocardiogram showed an increased left ventricular pre-ejection by 18.7% (p<0.001) and 56.8% (p<0.001) in RBBB+LAFB and LBBB, respectively. There was a post-systolic myocardial contraction in all types of IVB and ventricular dyssynchrony in LBBB. Using the vectorcardiogram, initial activation of the R wave was increased by 17.4% in LAFB (p<0.001), 43.5% in RBBB+LAFB (p<0.001) and 47.4% in LBBB (p<0.001) and delayed final activation by 69.4% in LBBB (p<0.001), 73.6% in RBBB+LAFB (p<0.001) and 95.3% in RBBB (p<0.001).

Conclusion

All IVBs modified the CC; however, only LBBB and RBBB+LAFB significantly changed the left ventricular cycle, thereby evidencing the greater complexity of these disorders.

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Editorial

High-power, Short-duration Radiofrequency Ablation of Atrial Fibrillation: Point-by-Point or Catheter Dragging Technique?

Guilherme Fenelon

Pulmonary vein isolation (PVI) is universally accepted as the cornerstone of atrial fibrillation (AF) ablation. Current guidelines recommend electrical isolation of the pulmonary veins in all AF ablation procedures (Class I, level of evidence A). As of today, the most common methods to perform PVI are point-by-point radiofrequency (RF) guided by 3D mapping or the cryoballoon. Both are thermal energies, creating lesions by heating (RF) or freezing (cryoenergy) the tissue. Of note, it has been consistently demonstrated that RF ablation and cryoballoon ablation are equally effective and safe for treating patients with paroxysmal AF. However, cryoballoon ablation is more reproducible within groups than RF ablation. The outcomes of RF ablation are closely related to operator and center volumes. Furthermore, there can be significant variability in the number of ablation lesions created, the force applied by the tip of the catheter to the tissue—known as contact force—and the amount and duration of power delivery.

Ablation protocols have changed significantly during the last decade, particularly with respect to RF parameters. Conventional power settings were 20-35 W over 30-60 seconds. In recent years, high-power, short-duration (HPSD) protocols utilizing RF at power levels of 40-50 W for shorter durations have gained popularity.^– Indeed, the HPSD technique is associated with shorter times to achieve PVI and greater freedom from AF recurrences, albeit with a trend towards more asymptomatic cerebral emboli.^,

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Editorial

Nitrite Supplementation Attenuates Vascular Stiffness Independently of Physical Exercise

Alex Yuiti Ogura et al. Claudiane Maria Barbosa Silvio Assis de Oliveira-Junior

Exercise training is considered one of the most efficient non-pharmacological measures for reducing blood pressure and increasing the redox state in blood vessel walls. Indeed, regular exercise training can cause endothelial relaxation by increasing nitric oxide (NO) levels, with or without a reduction in the amount of reactive oxygen species (ROS). Excessive production and/or accumulation of ROS can result in redox imbalance, with decreased NO bioavailability and consequent endothelial dysfunction.^, In this regard, reduced NO release is one of the critical factors for the development of systemic arterial hypertension.^,

Importantly, NO is a diatomic gaseous signaling molecule that is water-soluble and can freely pass through the cell membrane. This peptide is essential in the regulation of several physiological actions in the body, being of utmost importance for vasodilation, immune response, neurotransmission, apoptosis, and genetic regulation. When released, NO diffuses from endothelial cells to vascular smooth muscle cells, promoting relaxation and vasodilation. Through this mechanism, NO can reduce vascular peripheral resistance and, consequently, decrease blood pressure. In the endogenous context, NO production results from the oxidation and cleavage of the guanidine group of L-arginine, with the release of NO and L-citrulline. Then, free NO is easily transformed into nitrite and nitrate, the current products are later recycled into NO and other forms of nitrogen oxidation, through the nitrate/nitrite/NO pathway.

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Editorial

The Role of 3D Printing in Cardiac Surgery for Congenital Heart Diseases

3D printing is revolutionizing various industries, enabling the creation of intricate, customized physical models by layering materials such as silicone or polymers based on digital designs. Among its diverse applications, healthcare has seen significant advancements with this technology.

In cardiology, the adoption of 3D modeling has lagged compared to other fields, primarily due to the challenge of depicting the heart’s complex, dynamic nature. This pattern mirrors the initial slow integration of computed tomography and magnetic resonance imaging into cardiac care — technologies that were first widely used in non-cardiac specialties before transforming cardiovascular diagnosis and management.^, Over the last decade, however, 3D printing has emerged as a transformative tool in cardiac surgery, enhancing visualization, preoperative planning, and patient outcomes.

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Editorial

Challenges and Perspectives of Cardiac Fibrosis Biomarkers: From Diagnosis to Clinical Application

Priscila Portugal dos Santos et al. Ricardo Luiz Damatto

As reported by Cheng-Mei et al. myocardial fibrosis is present in various cardiac diseases and can negatively impact the heart. It plays a central role in cardiac dysfunction and failure across different pathologies, serving as a strong predictor of poor clinical outcomes and mortality. However, it is essential to recognize that fibrosis is a complex and heterogeneous process, which can sometimes play a beneficial role, such as after a myocardial infarction. In this context, fibrosis acts as a reparative mechanism, replacing dead cardiomyocytes with scar tissue. This initial fibrotic response is crucial to prevent cardiac rupture, a severe and often fatal complication and one of the leading causes of death in patients with acute myocardial infarction.

Cardiac fibrosis is characterized by the excessive accumulation of extracellular matrix (ECM) components, especially collagens, within the myocardium. Understanding this process involves more than just collagen quantity; the characterization of fibrosis also considers collagen quality, the ratio of different fiber types, and the degree of collagen cross-linking. Type I collagen, which predominates in cardiac and vascular ECM, contributes to tissue strength and stiffness due to its thick, dense structure. Type III collagen, being more flexible, aids in ECM compliance. Thus, myocardial elasticity is determined by the ratio of type I to type III collagen fibers.^, Moreover, the degree of covalent cross-linking among the constituent microfibrils is critical to collagen fiber rigidity, increasing their resistance to degradation and significantly contributing to tissue stiffening.^, Therefore, a comprehensive understanding of cardiac fibrosis, aimed at developing new therapies and diagnostic methods, requires evaluating collagen quantity, quality, and cross-linking levels.

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Editorial

Mitral Regurgitation after Acute Myocardial Infarction: A Multi-Faceted Condition

Carlos Henrique Miranda

There are two leading causes of mitral regurgitation (MR) after acute myocardial infarction (AMI). First, the partial or complete papillary muscle rupture leads to MR; in this case, surgical repair is mandatory. Fortunately, the prevalence of this condition is low, around 0.05%. Second, the valve and the subvalvular apparatus are normal, and the MR results from leaflet tethering and regional left ventricular dilatation. The primary mechanism is the separation and excess angulation of the papillary muscle related to the regional wall motion in the myocardial infarction area. This second presentation is called the “functional” phenotype. This functional MR is a common echocardiographic finding after AMI. A recent investigation showed a mild MR in 76%, moderate MR in 21%, and severe MR in 3% of the patients after AMI. Vyas et al. found a significant MR (moderate + severe) prevalence of 7.21% after non-ST elevation myocardial infarction (NSTEMI). An important aspect to highlight is that most previous studies analyzed MR prevalence in all types of myocardial infarction together or ST-elevation AMI alone. The actual prevalence of MR in NSTEMI was unknown, and this study showed a considerable MR prevalence in this setting.

According to other previous studies,^, this recent investigation showed that significant MR worst the patients’ prognosis, increasing the risk of death, pulmonary edema, heart failure, and cardiogenic shock. There are no doubts about the clinical impact of the MR after AMI. The more significant problem is that the mortality associated with this complication has not changed for decades, and there are still many doubts about the better management of these patients. Another feature deserves to be commented on: the clinical repercussions of severe MR are much more documented than those of moderate MR, and this classification is critical in making decisions about the treatment. In this recent investigation, the researchers analyzed the moderate and severe MR together, called significant MR; it was understandable because of the small sample size of severe MR; however, in the clinical setting, these two classifications have entirely different outcomes during the follow-up.

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Editorial

The Use of Twitter (X) by Brazilian Cardiologists: A Call to Action

Sergio Emanuel Kaiser

The prominently influential media outlet currently known as X (Formerly “Twitter”) was originally conceived as a microblogging platform intended to broadcast short status updates, amenable to immediate delivery to friends and followers. However, it has sparked a revolution in the way information is shared, opinions are expressed, and connections that are made in real-time. With its short-message format, the platform enables instant communication between individuals thousands of miles apart with just a few taps on a smartphone screen.

In the framework of machine-learning driven algorithms, highly emotional texts and images drive engagement, spread rapidly, and amplify visibility for embedded ads or sponsored messages. Profit expectations for the platform’s owners, therefore, rely on the efficiency of these algorithms to generate engagement, regardless of the accuracy and authenticity of the shared information. By 2023, sponsored (and tailored) ads accounted for 74% of the platform’s revenue.

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Editorial

Digital Health – A Tool of Empowerment and Gender Equality?

Larissa Neto Espíndola et al. Alexandra Maria Monteiro Grisolia Gláucia Maria Moraes de Oliveira

Over the last years, advances in digital technology (DT) have revolutionized various sectors, and health is not an exception. Digital tools including monitoring devices, telemedicine platforms and even wearables have enabled individuals to be responsible for their self-care.

These technological innovations are particularly transformative for women, contributing to overcome a historical barrier to access to health care (now in the palm of their hands), and also to promote health and prevention of disease progression. The recent World Health Organization report highlights that digital health technologies can improve essential health information and the access to vital services, and support maternal health, thereby promoting gender equality, and women’s autonomy in their care, especially in places where the access is inhibited by socioeconomical and cultural barriers.

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Research Letter

Percutaneous Patent Ductus Arteriosus Closure in a Conjoined Twin: Case Report

Paulo Correia Calamita et al. Jonathan Guimarães Lombardi Mayra Rosana Palmeira Barreto Orlando Carlos Barbosa … Maurício Lopes Prudente Zacarias Calil Hamu Giulliano Gardenghi

Abstract

Conjoined twin patients with patent ductus arteriosus and hemodynamic repercussions have a worse prognosis. In the present case report, we demonstrate the first successful percutaneous closure of the ductus arteriosus with the Piccolo© device (Abbot Structural Heart, Plymouth, MN, USA) in this type of clinical situation.

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Case Report

A Rare Encounter: Case of Cardiac Angioma in an Adult Patient

Inês Conde et al. Rodrigo Silva Nuno Antunes Vitor Hugo Pereira Catarina Quina-Rodrigues

Introduction

Cardiac masses encompass a wide spectrum of etiologies, including primary tumors, both benign and malignant, metastatic tumors, and non-neoplastic lesions.^, The differential diagnosis of cardiac masses is challenging due to overlapping clinical presentations, diverse imaging characteristics, heterogeneity among different mass types, limited clinical experience, and the rarity of some of these conditions.^, This clinical case presents an intriguing scenario involving a cardiac mass, highlighting the complexities in its diagnosis and management.

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Research Letter

Relevant and Independent Scientific Publications: The Path of Systematic Reviews and Meta-Analyses

Camila Mota Guida et al. Rhanderson Cardoso

According to the Association of American Medical Colleges (AAMC), in 2023, the average number of publications per candidate accepted into medical residency programs in the United States was six for internal medicine, eight for neurology, nine for general surgery, and 19 for otolaryngology.Similarly, in countries such as Brazil, the United Kingdom, and Australia, publications are an important criterion in medical residency or postgraduate program evaluations.

In the United States, there is an established culture of participation in research projects among aspiring physicians even before entering medical school. Additionally, North American medical students commonly use the summer break between their first and second years to work in basic, translational, or clinical research laboratories to strengthen their applications for competitive residencies.

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Original Article

Examining the Role of Exercise Training in Enhancing Life for Adult Congenital Heart Disease: Systematic Review

Tugba Siyah et al. Naciye Vardar Yagli Ilker Ertugrul Hayrettin Hakan Aykan Melda Saglam

Abstract

Background

Current guidelines advise exercise for most congenital heart disease patients (CHD). However, physical activity remains low in CHD individuals, with limited research on exercise’s effects in adults.

Objectives

The aim of this study is to evaluate the safety and efficacy of exercise training on exercise capacity and quality of life in adult congenital heart disease (ACHD) patients.

Methods

We searched PubMed/Medline, Cochrane Library, Web of Science, and Scopus through December 2022 for randomized controlled trials assessing aerobic and resistance training effects on exercise capacity and quality of life in ACHD. Out of 3,517 citations, ten eligible articles were included.

Results

Meta-analysis of the included randomized controlled trials (286 participants) found no significant change in peak oxygen consumption or quality of life in ACHD with exercise training (pooled mean difference = 0.33 ml/kg/min [95% CI, -0.88 to 1.54 ml/kg/min]; p = 0.60; I²= 3%). However, the increase in maximum workload was significant (pooled mean difference = 8.86 watts [95% CI, 0.78 to 16.93], p = 0.03, I² = 0%).

Conclusions

Our review confirms that exercise training increases the maximum workload in ACHD patients. However, the lack of a standardized protocol among exercise interventions in this population may have contributed to the absence of a significant change in peak VO₂ and quality of life observed in the conducted studies. The heterogeneity of exercise programs could be a contributing factor to the inconsistency of the results. In this context, the implementation of standardized exercise protocols in future research, particularly with larger sample sizes, is crucial to enhance the comparability of outcomes. Well-designed randomized controlled trials studying structured exercise training in ACHD patients will provide clearer insights.

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Original Article

Females are Associated with Lower Risks of Long-Term Mortality in Patients Undergoing Off-Pump Coronary Artery Bypass Grafting

Chen Bai et al. Jiangang Wang Qing Ye Cheng Zhao

Abstract

Background

In patients who underwent off-pump coronary artery bypass grafting (OPCABG), females were reported to have lower rates of in-hospital mortality rate and postoperative atrial fibrillation than males. However, the association between gender and long-term prognosis following OPCABG is rarely reported.

Objective

This study aims to determine if women benefit more from OPCABG than men by comparing the difference in the risk of long-term all-cause mortality in patients with coronary chronic total occlusion (CTO).

Methods

This is an observational, retrospective cohort study conducted in adult patients (≥18 years) with coronary CTO undergoing OPCABG at our hospital from January 2011 to December 2014. A multivariate Cox proportional hazards model was employed to assess the association of gender with the risk of all-cause mortality. A p-value of <0.05 was considered statistically significant.

Results

Totally 1,256 participants were enrolled, among which 321 (25.6%) were females and 935 (74.4%) were males. During a maximum follow-up of 10 years, the all-cause mortality rate in women was significantly lower than that in men (10.3% vs. 24.3%, p<0.01). Multivariate Cox regression analysis indicated that women were significantly associated with a lower risk of all-cause mortality (HR=0.30, 95% CI: 0.20-0.44; p<0.01) after controlling for potential confounding factors.

Conclusion

Women benefit more from OPCABG surgery than men, as they have a lower risk of long-term all-cause mortality in patients with coronary CTO.

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Original Article

High Power Short Duration Atrial Fibrillation Ablation: Long-Term Predictors of Success and Recurrence – A Multivariate Analysis

Fabricio Vassallo et al. Christiano Cunha Lucas Corsino Eduardo Serpa … Aloyr Simões Jr Dalton Hespanhol Carlos Volponi Lovatto Dalbian Gasparini Luiz Fernando Barbosa Andre Schmidt

Abstract

Background

Point-by-point ablation with a high-power short-duration (HPSD) technique in atrial fibrillation (AF) ablation is used worldwide. Little data is available with the HPSD and dragging technique (DT).

Objective

To perform a multivariate analysis of clinical and procedural predictors of success and recurrence in HPSD with DT.

Methods

214 patients in the first AF ablation in sinus rhythm were prospectively enrolled. DT with radiofrequency power of 50 W and contact force (CF) of 10–20 g and 5–10 g at a flow rate of 40 mL/min were applied on the anterior and posterior walls, respectively. Statistical significance was defined as p < 0.05.

Results

143 (66.8%) males, paroxysmal AF (PAF) in 124 (57.9%), with 61.1±12.3 years and followed for 32.8±13.2 months. After 90 days, AF occurred in 43 (20.1%) patients, 19 (15.3%) from PAF, and 24 (26.7%) in persistent AF (PersAF). Multivariate analysis indicated as clinical predictors of recurrence: age ≥ 65 years (p=0.006); obesity [body mass index > 30 (p=0.009)]; CHA₂DS₂VASC score ≥ 3 (p=0.003); and PersAF (p=0.045). The procedural predictor of recurrence was a heart rate increase < 10% (p=0.006). Predictors of success were an increase in heart rate ≥ 30% (p=0.04) and < 60 min in left atrium time (LAT) (p=0.007).

Conclusion

AF ablation with DT and HPSD clinical and procedural predictors of recurrence were ≥ 65 years, obesity, a CHA₂DS₂VASC ≥ 3, PersAF, and a heart rate increase of < 10% after ablation. Success predictors were an increase of ≥ 30% in heart rate and low LAT (< 60 min).

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Original Article

Short-term Oral Nitrite Administration Decreases Arterial Stiffness in Both Trained and Sedentary Wistar Rats

Thiago Pereira Souza et al. Lidieli Pazin Tardelli Rafael Antunes Nicoletti André Mourão Jacomini … Gabriel Francisco de Mello Martins Lucas Cézar Pinheiro José Eduardo Tanus-Santos Sandra Lia do Amaral Anderson Saranz Zago

Abstract

Background

Nitric Oxide (NO) plays an important role in blood pressure (BP) regulation, acting directly on peripheral vascular resistance through vasodilation. Physical training (via eNOS/NO) and intake of nitrite have been considered major stimuli to increase NO.

Objective

We examined the effects of oral nitrite administration and aerobic exercise training on BP and arterial stiffness in Wistar rats.

Methods

Thirty-nine (39) young male Wistar rats were divided into the following groups (n = 9 or 10 per group): Sedentary-Control (SC), Sedentary-Nitrite (SN), Trained-Control (TC), and Trained-Nitrite (TN). They were submitted to aerobic physical training on treadmills for 8 weeks (50-60% of physical capacity, 1h/day, 5 days/week) or kept sedentary. In the last 6 days of training, oral nitrite was administered (15 mg/Kg by gavage). BP, arterial stiffness, and plasma and tissue nitrite concentrations were assessed after the training and oral nitrite administration period. The significant level was defined as p < 0.05.

Results

Oral administration of nitrite was effective in reducing arterial stiffness values (TN, -23%; and SN, -15%). Both groups that had only one type of intervention showed lower systolic BP compared with control (TC vs. SC, -14.23; and SN vs. SC, – 12.46).

Conclusion

We conclude that short-term oral administration for 6 days and an aerobic physical training program promote several hemodynamic benefits in male Wistar rats, such as improvements in arterial stiffness and BP. These responses suggest that physical training and sodium nitrite supplementation can be alternatives for the prevention and treatment of hypertension.

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Original Article

NSTEMI and Ischemic Mitral Regurgitation: Incidence and Long-Term Clinical Outcomes with Respect to Management Strategy

Pooja Vyas et al. Radhakishan Dake Kewal Kanabar Iva Patel … Ashish Mishra Vishal Sharma Tirth Nathwani Kunal Parwani Mital Rathod

Abstract

Background

The optimal treatment for ischemic mitral regurgitation (IMR) in patients of non-ST elevation myocardial infarction (NSTEMI) is a debated topic.

Objective

To evaluate the long term outcome on patients with NSTEMI and IMR, particularly emphasizing the comparison of treatments in those with moderate to severe MR.

Methods

We enrolled patients with NSTEMI and classified non/trivial to mild regurgitation as insignificant IMR and moderate to severe regurgitation as significant IMR. Furthermore, patients with substantial IMR were assessed for long-term clinical outcomes with respect to different management strategies. A test was considered statistically significant based on the probability value p<0.05.

Results

From a total of 4,189 patients of NSTEMI, significant IMR was found in 7.21% of patients. A significantly higher number of patients with death (1.21% vs. 13.24%, p<0.0001), cardiogenic shock (0.46% vs. 13.24%, p<0.0001) and heart failure (1.03% vs. 11.59%, p<0.0001) were found during hospitalization in patients with significant IMR. At a 2-year follow-up, a higher event rate was observed in the significant IMR group. Patients with significant IMR re-vascularized either by percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG), or CABG+ mitral valve (MV) surgery showed substantial improvement in MR grade ( 32.65% vs. 6% vs. 16.98%, p<0.0001) and LVEF (27.55% vs. 1% vs. 1.89%, p<0.0001) at 1 year follow up and significantly improved outcomes were identified compared to refused revascularization and medical management group with (-5.10% vs. 15% vs. 13.21%, p=0.04) mortality, (-33.67% vs. 61% vs. 73.58%, p<0.0001) readmission, and (-15.31% vs. 27% vs. 33.96%, p=0.01) heart failure at 2 years follow up.

Conclusion

Higher mortality and admission rates were observed in patients with significant IMR compared to those with in-significant IMR. Notably, significant IMR patients who underwent PCI, CABG, or CABG+MV surgery showed improved outcomes compared to non-revascularized counterparts.

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Original Article

Potential Biomarkers in Myocardial Fibrosis: A Bioinformatic Analysis

Wang Cheng-Mei et al. Gang Luo Ping Liu Wei Ren Sijin Yang

Abstract

Background

Myocardial fibrosis (MF) occurs throughout the onset and progression of cardiovascular disease, and early diagnosis of MF is beneficial for improving cardiac function, but there is a lack of research on early biomarkers of MF.

Objectives

Utilizing bioinformatics techniques, we identified potential biomarkers for MF.

Methods

Datasets related to MF were sourced from the GEO database. After processing the data, differentially expressed genes were screened. Differentially expressed genes were enriched, and subsequently, protein-protein interaction (PPI) was performed to analyze the differential genes. The associated miRNAs and transcription factors were predicted for these core genes. Finally, ROC validation was performed on the core genes to determine their specificity and sensitivity as potential biomarkers. The level of significance adopted was 5% (p < 0.05).

Results

A total of 91 differentially expressed genes were identified, and PPI analysis yielded 31 central genes. Enrichment analysis showed that apoptosis, collagen, extracellular matrix, cell adhesion, and inflammation were involved in MF. One hundred and forty-two potential miRNAs were identified. the transcription factors JUN, NF-κB1, SP1, RELA, serum response factor (SRF), and STAT3 were enriched in most of the core targets. Ultimately, IL11, GADD45B, GDF5, NOX4, IGFBP3, ACTC1, MYOZ2, and ITGB8 had higher diagnostic accuracy and sensitivity in predicting MF based on ROC curve analysis.

Conclusion

Eight genes, IL11, GADD45B, GDF5, NOX4, IGFBP3, ACTC1, MYOZ2, and ITGB8, can serve as candidate biomarkers for MF. Processes such as cellular apoptosis, collagen protein synthesis, extracellular matrix formation, cellular adhesion, and inflammation are implicated in the development of MF.

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Original Article

In Vivo Anti-Inflammatory Activity of D-Limonene in a Rat Model of Monocrotaline-Induced Pulmonary Hypertension: Implications to the Heart Function

Jorge Lucas Teixeira-Fonseca et al. Diego Jose Belato y Orts Polyana Leal da Silva Michael Ramon de Lima Conceição … Hernan Hermes Carlos R. Prudencio Danilo Roman-Campos

Abstract

Background

D-limonene (D-L) is the major monocyclic monoterpene in citrus plants with anti-inflammatory properties. Pulmonary hypertension (PH) can cause right heart dysfunction and increases the risk of death, partially due to inflammatory response in the heart.

Objective

To evaluate the possible protective effect of D-L on cardiac function in a rat model of monocrotaline-induced PH (MCT-PH).

Methods

Electrocardiogram was monitored in vivo. Masson Trichrome technique was deployed to verify fibrosis in the heart. Contractility function of isolated atrial tissue was studied using organ bath chamber. Real-time quantitative PCR was applied to quantify inflammation in the right ventricle.

Results

The MCT-PH group showed electrical and structural heart remodeling, with the presence of fibrosis in the cardiac tissue and in vivo electrocardiographic changes. Treatment with D-L partially prevented the development of tissue fibrosis and the increase in P wave duration in the MCT-PH group. The contraction and relaxation velocity of isolated right and left atrium were accelerated in CTR and MCT-PH animals treated with D-L. Finally, D-L was able to prevent the abnormal expression of the key inflammatory cytokines (interleukin 1-β, interleukin 6 and tumor necrosis factor-α) in the right ventricle of MCT-PH animals. D-L was able to enhance the production of the anti-inflammatory cytokine Interleukin-10.

Conclusion

Our results showed that in vivo administration of D-L partially prevented the molecular, structural and functional remodeling of the heart in the MCT-PH model with attenuation of the inflammatory response in the heart.

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