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The presence of bipolar low-voltage zone (LVZ) is a predictor of AF recurrence after PV isolation (PVI). However, changes of wavefront and bipole directions may cause different electrogram characteristics. We aimed to investigate whether using omnipolar maximum voltage (Vmax) map derived from high density (HD) Grid mapping catheter could assess LVZ and AF ablation outcome accurately. Fifty paroxysmal AF patients (27 males, 57.8 ± 9.5 years old) who underwent 3D mapping guided PVI were enrolled. Left atrial voltage mapping during sinus rhythm before ablation was performed. The significant LVZ (<0.5 mV with area > 5 cm2) were defined as sites by omnipolar Vmax, bipolar HD wave map, conventional bipolar electrograms acquired from electrode pairs along to and across to the catheter shaft. The primary end point was the first documented recurrence of any AF during follow-ups. PVI was performed in all patients, and there were 2 patients (4%) who also received additional non-PV triggers ablation. After a follow-up of 11.4 ± 5.4 months, recurrence of AF occurred in 12 patients (24%). The presence of a significant LVZ was less detected by omnipolar Vmax map, compared to HD wave map (24.0% vs. 58.0%, p = 0.001). LVZ detected by omnipolar Vmax map independently predicted the AF recurrence (odds ratio 16.91; 95% CI, 3.17–90.10; p = 0.001). LVZ detected by omnipolar Vmax map accurately predicts the AF recurrence following ablation in paroxysmal AF, compared to conventional bipolar and HD wave maps, suggesting the omnipolar Vmax map can precisely define the atrial substrate property. • The presence of bipolar low-voltage zone is a predictor of AF recurrence after pulmonary vein isolation. • Changes of wavefront and bipole directions may cause different electrogram characteristics. • The wavefront orientation-optimized voltage map by omnipolar technology may define the left atrium substrate more accurately. [ABSTRACT FROM AUTHOR]

Abstract Background CD4+ T cells are key players in regulating the inflammatory processes and physiological repair mechanisms engaged after acute myocardial infarction (AMI). Although signaling through the CD27-CD70 co-stimulatory pathway are known to be important in CD4+ T cell activation and proliferation in certain contexts, the role of the CD27-CD70 pathway in AMI remains unclear. Methods and results A total of 43 control subjects, 42 unstable angina patients, and 90 AMI patients were enrolled in the present study. The serum levels of soluble CD27 (sCD27) in patients were measured, revealing a significant increase in serum sCD27 levels in AMI patients within 24 h of the cardiac event, after which they decreased. Correlation analyses revealed that serum sCD27 was positively correlated with cardiac troponin I (c-TnI) (r = 0.267, P = 0.011). When anti-CD70 antibody was used to block the CD27-CD70 pathway in MI model mice, we found that this treatment increased left ventricular end-diastolic dimension (LVEDD) (P < 0.01) and left ventricular end-systolic dimension (LVESD) (P < 0.01), and decreased ejection fraction (P < 0.01). Flow cytometric analysis revealed that the percentage of regulatory T cells was lower in blocking antibody-treated mice (P < 0.01), while neutrophils levels were higher (P < 0.01). The number of CD31-positive endothelial cells (P = 0.026) and α -smooth muscle actin-positive arterioles (P < 0.01) were significantly down-regulated in anti-CD70 treated-AMI mice. The formation of the extracellular matrix (ECM) was also impaired. Conclusion Serum sCD27 may be a potential biomarker for AMI. Blockade of the CD27-CD70 pathway worsens cardiac dysfunction, aggravates left ventricular remodeling, and impairs scar healing after AMI, resulting in heart failure. Highlights • The circulating sCD27 was increased within 24 h post-MI in patients. • The sCD27 level was correlated with c-TnI. • Blockade of CD27-CD70 pathway enhanced inflammatory response and led to adverse ventricular remodeling. [ABSTRACT FROM AUTHOR]

Abstract The population of adults with congenital heart disease (ACHD) is increasing constantly due to medical, surgical and interventional successes and the input from advanced cardiovascular imaging. ACHD patients are at continuing risk of residua and sequelae related to their CHD contributing to significant morbidity and mortality. Consequently, lifelong expert surveillance is recommended for most patients. Healthcare providers are still working out how best to achieve this objective, how to train enough experts to provide high quality care, and how to organize the delivery of care. Echocardiography is crucial to clinical surveillance providing a comprehensive assessment of cardiac morphology, physiology, pathophysiology, and function. Thus it contributes significantly to the overall clinical management of ACHD patients. The International Society for Adult Congenital Heart Disease (ISACHD; www.isachd.org) is the leading organization of professionals worldwide dedicated to the pursuit of excellence in the care of ACHD patients. Recognizing the critical role of imaging in the diagnosis and management of ACHD, ISACHD established a task force to provide guidance on echocardiographic studies and reporting. The rationale is that standardization of echocardiographic imaging and reporting carries the potential to improve the overall quality of these exams around the world and facilitate collaborative multicenter research. The standardized ACHD protocols provided by the ISACHD task force (found in the appendices) include specific recommendations for data acquisition and reporting for each of the major adult congenital heart lesions. These protocols give a comprehensive and structured approach in the evaluation of ACHD patients and help to ensure excellent patient care. Highlights • Due to medical advances including imaging there is a growing population of adults with congenital heart diseases • Echocardiography is crucial to proactive clinical surveillance • ISACHD; www.isachd.org established a task force to provide this guidance on echocardiographic studies and reporting • The standardized echocardiography protocols provide recommendations for acquisition and reporting of specific ACHD lesions [ABSTRACT FROM AUTHOR]

Abstract Background Measures of left ventricular (LV) systolic and diastolic function are known predictors of mortality after repair of tetralogy of Fallot. We aimed to characterise LV reverse remodelling achievable with ramipril therapy. Methods and results A blinded post-hoc analysis of baseline and 6-month follow-up echocardiograms from the APPROPRIATE (ISRCTN: 97515585) randomised double-blinded placebo-controlled trial of ramipril therapy was performed in 64 patients: 32 in ramipril and 32 in placebo group. Tissue Doppler systolic and diastolic myocardial velocities, mitral inflow velocities and time intervals were measured. Left atrial area and left atrial emptying fraction were calculated. There was significant increase in long axis shortening mean (standard deviation); MAPSE [1.9 (4.2) mm vs −0.2 (3.7) mm; p = 0.030], peak lateral systolic velocity; S′ lateral [1.0 (2.0) cm/s vs −0.3 (2.2) cm/s; p = 0.025], peak lateral early diastolic velocity; E′ lateral [0.57 (2.4) cm/s vs −3.3 (3.9) cm/s; p < 0.001], transmitral to lateral mitral annular early diastolic velocity ratio; E/E′ lateral [−0.7 (1.9) vs 1.5 (1.9); p < 0.001] over the study period in the ramipril compared to the placebo group. Significantly higher measurements were observed in the ramipril arm of the subgroup of patients with right ventricular restrictive physiology in terms of peak late diastolic velocity; A [5.9 (13.5) cm/s vs −5.8 (12.5) cm/s; p = 0.041] and early to late diastolic transmitral velocity ratio; E/A [−0.18 (0.42) vs 0.23 (0.48); p = 0.037]. Conclusion Six months' ramipril treatment appears to limit progression of both diastolic and systolic LV function in adults late after tetralogy of Fallot repair. With increased appreciation that even subtle LV disease predicts tetralogy of Fallot outcomes, further clinical trials of drug therapies are justified. Highlights • Left ventricular (LV) function is a known predictor of mortality after tetralogy of Fallot repair. • We aimed to characterise LV reverse remodelling achievable with ramipril therapy. • 6-months' ramipril treatment limits progression of both diastolic and systolic LV function. [ABSTRACT FROM AUTHOR]

Background Vasovagal responses (VR) encountered during radiofrequency pulmonary vein isolation (PVI) in paroxysmal atrial fibrillation (PAF) suggest ablation of the atrial tissue subjacent to the ganglionic plexi (GP) and confer durability of PVI. Objective We hypothesized that VR during cryoballoon PVI (CB-PVI) in PAF can predict mid-term AF recurrence. Methods We enrolled 39 patients who underwent PVI using 2nd generation cryoballoon for PAF from November 2014 to July 2016. We evaluated the long term outcomes for those who had VR during index procedure. Results A total of 39 patients (76% male, mean age 57 ± 9 years) underwent CB-PVI for PAF and 66.67% (26/39) had VR. VR was frequently observed in the LSPV (100%), followed by RSPV (64%), LIPV (60%), and less frequently, RIPV (28%). Overall, the mean difference in the HR and SBP, and the relative differences in the HR and SBP were observed during CB-PVI in the LSPV (mean difference in HR, p  < 0.001; mean difference in SBP, p < 0.001; relative difference in HR, p < 0.001); relative difference in SBP, p < 0.001). After PVI, 22/26 (84.62%) and 5/13 (38.46%) of patients in the VR and NVR group, respectively, maintained SR at 14 ± 6 months follow-up. The Kaplan-Meier analysis showed statistical difference in favor of patients with VR during CB-PVI (log rank p  < 0.01) with a better mid-term outcome. Conclusion In a small cohort of patients, VR during CB-PVI in PAF is a surrogate marker for ablation of atrial tissue subjacent to the GP and predicts a favorable mid-term outcome for AF recurrence. [ABSTRACT FROM AUTHOR]

Background There are limited literatures regarding the non-pulmonary vein (NPV) triggers in long-standing persistent atrial fibrillation (LSPAF). The goal of the present study was to investigate the characteristics and long-term outcome of catheter ablation among these patients. Methods The study included 776 patients (age 53.59 ± 11.38 years-old, 556 males) who received catheter ablation for drug-refractory atrial fibrillation (AF). We divided these patients into 3 groups. Group 1 consisted of 579 patients with paroxysmal AF (PAF), group 2 consisted of 103 patients with persistent AF (PerAF) and group 3 consisted of 94 patients with long-standing persistent AF (LSPAF). The average follow-up duration was 28.53 ± 23.21 months. Results The clinical endpoint was the recurrence of atrial tachyarrhythmia. Among these 3 groups, higher percentages of male (93.6%, P < 0.001), NPV triggers (44.7%, P < 0.001), longer AF duration (6.65 ± 6.72 years, P = 0.029), larger left atrium diameter (44.44 ± 6.79 mm, P < 0.001), and longer procedure time (181.94 ± 70.02 min, P < 0.001) were noted in LSPAF. After the first catheter ablation, the recurrence rate of AF was highest in LSPAF (Log Rank, P < 0.001). Larger left atrium diameters (LAD) ( P = 0.006; HR: 1.063; CI: 1.018–1.111) and NPV triggers ( P = 0.035; HR: 1.707; 1.037–2.809) independently predicted AF recurrence in LSPAF. Conclusions Compared with PAF and PerAF, LSPAF had a higher incidence of NPV triggers and worse long-term outcome after catheter ablation. NPV triggers and LAD independently predicted AF recurrence after catheter ablation in LSPAF. [ABSTRACT FROM AUTHOR]

Background Heart failure (HF) causes atrial remodeling and increases the incidence of atrial fibrillation (AF). Renal denervation (RDN) has been shown to decrease the development of AF. This study aimed to identify the effects of RDN on the atrial arrhythmogenic substrates in HF. Methods Rabbits were classified into four groups: control (n = 9), RDN (n = 10), HF (n = 6) and HF-RDN (n = 9). Surgical and chemical RDN was approached through bilateral retroperitoneal flank incisions in RDN and HF-RDN. Rapid ventricular pacing of 400 bpm for 4 weeks was applied in HF and HF-RDN. After 4 weeks, the rabbits were sacrificed and atrial myocardium were harvested for Western blot and Trichrome stain. Results The bi-atrial effective refractory period (ERP) of HF was significantly longer compared with that of control and RDN. In right atrium, the ERP of HF was also significantly longer compared with that of HF-RDN, but there was no significant difference in left atrial ERP. In bi-atrium, ion channel protein expressions of CaV1.2, NaV1.5, Kir2.1 SERCA2 and NCX were similar among 4 groups. However, the degree of atrial fibrosis was extensive in bi-atrium of HF, when compared to that of control, RDN and HF-RDN. Conclusion The ERP of HF-RDN is partially shortened by RDN compared with that of HF. There are no differences ionic channel protein expressions in bi-atrium among all groups. The degree of atrial fibrosis is severe in HF, but not in HF-RDN, suggesting that RDN may regulate the atrial arrhythmogenic substrates in HF mostly through reverse structural remodeling. [ABSTRACT FROM AUTHOR]

Background Antipsychotic agents are well known for their arrhythmigenic effect on ventricular arrhythmia. Though a few case reports observed the occurrence of atrial fibrillation (AF) after antipsychotic exposure, information about their implication in AF is limited. Methods Based on the National Health Insurance Database in Taiwan, we conducted a nested case-control study to investigate the relationship between antipsychotics and AF. From 2001 to 2010, a total of 34,053 cases of AF and 34,919 matched controls were enrolled. Antipsychotic exposure was measured and binding affinity to neurotransmitter receptors was calculated. Both medical and psychiatric comorbidities were identified and adjusted in multivariate logistic regression analysis. Results Current antipsychotic use was associated with a 17% increased risk of AF relative to nonusers (adjusted OR: 1.17, 95% CI: 1.10–1.26). A dose-dependent relationship of antipsychotic exposure and AF risk was observed ( P for trend < 0.001). Antipsychotics with higher binding affinity to muscarinic M2 receptors were associated with a higher incidence of AF. In subgroup analysis, subjects with preexisting hypertension, diabetes, or coronary artery diseases were at greater risk of developing AF following antipsychotic exposure. Conclusion Antipsychotic exposure was associated with increased risk of AF, especially for agents with higher cardiac muscarinic receptor binding affinity. Physicians should monitor the occurrence of new-onset AF, and strictly control underlying medical risk factors while prescribing antipsychotic agents to high-risk populations. [ABSTRACT FROM AUTHOR]

Background The treadmill exercise test (TET) is one of the most common noninvasive diagnosis approaches for ischemic heart diseases, but potential reduction of TET accuracy among Chinese female patients was ignored by most studies, especially in perimenopause women. Hence, we aim to perform a systematic review and meta-analysis evaluating the TET diagnostic accuracy for Chinese women compared with coronary angiography (CAG). Methods PubMed, MEDLINE, EMBASE, CNKI and WANFANG (1990 to 2015) were performed to identify studies assessing the diagnostic accuracy of TET versus CAG. Random effects modeling strategies were used to produce summary receiver operating characteristic (SROC) curves, including overall estimates for sensitivity and specificity. Results A total of 19 studies involving 2396 Chinese females were included in our systematic review. TET has moderate levels of sensitivity (0.80) and specificity (0.65) to detect coronary artery stenoses in female patients with suspected coronary artery diseases, generating 0.79 of the area under the curve (AUC). In subgroup analyses, the pooled sensitivity of postmenopause and premenopausal/perimenopausal groups were 0.83 and 0.80, respectively. However, the postmenopause group has a higher pooled specificity: 0.68 versus 0.32 compared with premenopausal/perimenopausal women, and a higher corresponding AUC (0.81 versus 0.56). Conclusions TET may be used as a triage test for women with suspected and subclinical CAD. The positive results of TET should be treated with caution because of its higher false-positive, especially for premenopausal/perimenopausal women, and further confirmatory diagnosis is needed. However, patients with negative TET results could be precluded for further evaluation using CAG, and avoid unnecessary risk and economic burden to patients. [ABSTRACT FROM AUTHOR]

Background Aortic dilatation was frequently observed in patients with atrial fibrillation (AF) and non-pulmonary vein (PV) triggers are important for mapping and ablation of AF. We hypothesized that the aortic encroachment area over left atrium (LA) could contribute to the local substrate characteristics. Methods We studied 32 consecutive patients of AF (age = 57.34 ± 8.07, male = 30), including 26 paroxysmal and 6 persistent AFs. Anatomic relationship between LA and aorta, and electrophysiological characteristics of the encroachment areas were investigated. IRB approval was taken. Results The LA bipolar voltage (mean 0.49 ± 0.26 mV) was lower at aortic encroached area compared to global LA (mean 1.52 ± 0.48 mV) and it was statistically significant (p < 0.001). There was a linear correlation between the voltages of LA and distance from the aorta to the aortic encroachment area of LA (p < 0.001, R = 0.616). Non-PV triggers were observed in 34.37% (n = 11) of total patients. The initiation of AF in aortic encroached area was seen in 45.45% (n = 5) of non-PV trigger and 15.62% of total patients. All the patients were followed up for 6 months and 4 (14.81%) out of 27 patients without trigger at aortic encroached site of LA and 1 (20%) out of 5 patients with trigger at aortic encroached site of LA had recurrence of AF. Conclusion The aorta contributed to low voltages on its encroachment area over the anterior wall of LA. Non-pulmonary vein triggers originating from the aortic encroachment area were found in 15.62% of total patients. Careful evaluation of the anatomical relationship between LA and aorta is important during AF ablation for a better long term outcome. [ABSTRACT FROM AUTHOR]

Background Autonomic imbalance with increased sympathetic and decreased parasympathetic activities is observed in patients after myocardial infarction (MI). We aimed to investigate sleep-related changed in autonomic regulation in left coronary artery (LCA) ligation rats. Methods Wireless transmission of polysomnographic recording was performed in sham and LCA ligation male rats during normal daytime sleep with and without atenolol treatment. Spectral analyses of the electroencephalogram (EEG) and electromyogram (EMG) were evaluated to define active waking (AW), quiet and paradoxical sleeps (QS, PS). Cardiac autonomic activities were measured by analyzing the power spectrum of heart rate variability (HRV). EEG, EMG and HRV were recorded over 6 h for consecutive 3 days in all groups. Results In LCA ligation group, there were higher LF and LF/HF ratio on QS phase, but not AW and PS phases, compared to atenolol treated sham and LCA ligation groups, respectively. The HF component was not significantly changed on all groups in both sleep and awake phases. Sleep interruption was more frequent in LCA ligation rats compared to sham, and it was not found in LCA ligation with atenolol treatment group. Increased AW, PS and decreased QS time were noted in LCA ligation group, compared to sham and it was restored to baseline in LCA ligation with atenolol treatment group. Conclusions Our results demonstrate significant sleep fragmentations with sympathetic hyperactivity during QS stages after MI, and atenolol could restore the autonomic dysfunction and sleep disturbance. The finding explains the cause of sleep-related fetal arrhythmia and sudden cardiac death after MI. [ABSTRACT FROM AUTHOR]

Background Both extrinsic and intrinsic cardiac autonomic nervous systems are important for initiation and maintenance of atrial fibrillation (AF). We aimed to evaluate the effect of vagotomy on the activity of cardiac autonomic ganglionated plexi (GP) and the change of dominant frequency (DF) distribution in the left atrium (LA) during AF. Methods A mid-sternal thoracotomy was performed in 6 dogs. High frequency stimulation was applied to locate the GPs. There were four major LA GPs, which were located near the pulmonary vein ostia, and a superior vena cava-aorta (SVC-Ao) GP that was located near the superior vena cava-right atrial junction. Acetylcholine patch was applied on GPs to induce intrinsic vagal response. Vagal denervation was performed thereafter. An Ensite Array was deployed in the LA to record atrial signals before and after vagotomy during induced AF. Results The LA mean DF values (8.2 ± 0.1 vs. 7.6 ± 0.1 Hz, p = 0.002) were higher during GP activation before than after vagotomy. The maximal DF distribution was located at the primary GPs and the nearby secondary GPs during LA GPs activation and at the LA septum and right superior pulmonary vein during SVC-Ao GP activation before vagotomy. After vagotomy, the maximal DF distribution shifted to non-GP LA sites during activation of the GPs. Conclusions The findings suggest the important role of the extrinsic neural input in the activation and interaction of the intrinsic cardiac autonomic activity during cholinergic AF, whereas the non-GP LA sites were responsible for the AF induced without the physiological extrinsic neural input. [ABSTRACT FROM AUTHOR]

Abstract: Background and aims: Long-term competence of any aortic prosthesis is critical to its clinical durability. Bioprosthetic valves, and in particular the stentless type have been proposed to offer superior haemodynamic profiles with consequent potential for superior left-ventricular mass regression. These benefits however are balanced by the potential longevity of the implanted valve. The aims of this study were to assess medium-term Toronto aortic valve function and its effect on left-ventricular function. Methods: Between 1992 and 1996 86 patients underwent Toronto aortic valve replacement for aortic valve disease and were followed up annually. Prospectively collected data was analyzed for all patients where detailed echocardiographic follow-up was available. Echocardiographic studies were analyzed at 2±0.6 and 6±1.4 years after valve replacement. Data collected included left-ventricular systolic and diastolic dimensions, fractional shortening and left-ventricular mass. In addition, data on aortic valve and root morphology, peak aortic velocities, time velocity integral, stroke volume and the mechanism of valve failure where relevant, were also collected. Results: Complete echocardiographic data were available for eighty-four patients, age 69±9 years, 62 male. Additional coronary artery bypass grafting was performed in 38% of patients. Twelve (14%) valves had failed during follow-up, 7 (8%) requiring re-operation. Valve failure was associated with morphologically bicuspid native aortic valve (9/12), and progressive dilatation of the aortic sinuses, sino-tubular junction and ascending aorta (11/12). Left-ventricular mass index remained high (184±75 g/m2) and did not continue to regress between early and medium-term follow-up (175.8±77 g/m2). Conclusions: Although more than 90% of implanted Toronto aortic valves remained haemodynamically stable with low gradient at medium-term follow-up, young age and larger aortic dimensions in patients with valve failure suggest better outcome if used in the elderly with normal aortic root geometry. [Copyright &y& Elsevier]

Pulsed Wave Tissue Doppler (PWTD) recording of myocardial velocities has been widely used for assessing ventricular function but the output trace has finite thickness that leads to potential ambiguity in determining velocity and timing.To determine optimal method of measurement of PWTD traces by comparing them with those obtained from digitised M-mode recorded from the atrioventricular (AV) valve ring (septal, LV and RV free wall).We studied 100 subjects, 49 normal and 51 with coronary artery disease (15 patients with reduced left ventricular wall motion, mean systolic amplitude of LV free wall 0.8±0.3cm), mean age 53±15 years. We recorded AV ring motion using PWTD and M-mode echo techniques. PWTD velocity signals were measured separately at: outer, inner and mid-points of the envelope and compared with peak velocities obtained from digitised M-mode long axis.Peak systolic (S), early diastolic (E) and late diastolic (A) PWTD velocities at outer, inner and middle envelope correlated closely with the corresponding M-mode measurements at left, septal and right ventricular free wall. However, only the midpoint S and E wave PWTD signal velocities agreed numerically with those obtained by digitised M-mode velocities; S (left 6.56±1.80 vs. 6.54±1.91 cm/s N.S.); E (left 8.50±3.25 vs. 7.65±3.30 cm/s N.S.). Agreement was somewhat less satisfactory for A wave; left 7.40±2.13 vs. 6.23±2.09 cm/s p<0.05.Atrioventricular valve ring echo provides an excellent in vivo calibration model for validating tissue Doppler velocity estimates. Since the mid-point of the envelope of the tissue Doppler signal is the most closely related value to that of the digitised M-mode, it may be recommended as a convention for routine practice. [Copyright &y& Elsevier]

Background: Hong Kong has been experiencing a transition from a developing area to a developed area over the past few decades. The time trends of acute myocardial infarction (AMI) mortality would have implications for the future trends of AMI in Mainland China. Methods: Age-adjusted mortality rates during the period 1976–1999 were calculated by direct standardization with the world population using local mortality and population data. Log-linear regressions were used to estimate the annual percentage changes in mortality over different periods. Poisson regression models were used to explore the effects of age, calendar period and birth cohort. Results: A downward trend was observed for age-adjusted AMI mortality rate in both sexes in the 1990s, after the increasing trends in the 1970s and 1980s. The AMI mortality rate among men and women dropped by 36.4% and 37.4%, respectively. A negative annual percentage change was observed across all age groups in both sexes. Both the calendar period and the birth cohort showed significant effects on the changing AMI mortality rate, with the influence of period being stronger than the cohort, especially among males. Conclusion: Age-adjusted AMI mortality started to decrease during the last decade. Changing life styles and a reduction of coronary risk factors could have contributed, but the improvements in medical care and effective treatment for patients suffering from AMI should have an important role. [Copyright &y& Elsevier]

The combined procedure of catheter ablation and left atrial appendage closure (LAAC) aims to simultaneously control the heart rhythm and reduce the risk of strokes in patients with atrial fibrillation (AF). The study aims to evaluate the procedural safety and long-term outcome of the combined procedure in a large patient cohort. Clinical data of AF patients who underwent the combined procedure was retrospectively analyzed. Procedural and imaging follow-up parameters were compared between the transesophageal echocardiography-guided standard process and fluoroscopy-guided modified process, and between the single-seal WATCHMAN and dual-seal LACBES devices. Long-term outcomes included all-cause mortality, thromboembolic events, major bleeding, and recurrence of atrial tachyarrhythmias. A total of 1114 patients were included. The rates of procedure-related major complications were comparable between the standard and modified processes (3.7% vs. 2.2%, p = 0.219), except for a higher incidence of respiratory depression in standard process group (0.9% vs 0%, p = 0.037), and between WATCHMAN and LACBES devices (2.4% vs. 3.3%, p = 0.535). The follow-up imaging evaluation revealed a high rate of satisfactory seals (99.7%) and a low rate of device related thrombus (1.9%), which were similar between two process groups and devices. The follow-up of over 1960 patient-years revealed low rates of mortality, thromboembolism, and nonprocedural major bleeding (1.8, 3.2, and 0.9 per 100 patient-years, respectively). Recurrent atrial tachyarrhythmias was observed in 23.9% patients. The results supported the safety and long-term efficacy of the combined procedure of catheter ablation and LAAC. Fluoroscopy-guided LAAC device implantation may be considered in experienced centers. • The safety of the combined procedure of catheter ablation and left atrial appendage closure was acceptable. • Despite a longer fluoroscopy time, the fluoroscopy-guided process had lower risks of respiratory depression and a shorter procedure time and required less workers than the transesophageal echocardiography-guided process. • Long-term event rates of the combined procedure were low, including mortality, thromboembolic events, and major bleeding events. [ABSTRACT FROM AUTHOR]

Infective endocarditis (IE) is a potentially lethal disease for adults with congenital heart disease (ACHD). Staphylococcus aureus (SA) is one of the commonest pathogens, identified in patients with ACHD and IE. This study aims to analyse the epidemiology, clinical characteristics and in-hospital management of IE due to SA (SAIE) in ACHD. This is a single center retrospective study on documented episodes of SAIE in ACHD patients, treated at the Royal Brompton Hospital between 1999 and February 2020. Thirty-seven ACHD patients had an episode of SAIE (mean age 35.5 ± 14.9 years). More than half (51.3%), had a cardiac lesion of at least moderate complexity, with left ventricular outflow tract lesions being the most frequent. Twenty-four (64.9%) patients had a history of at least one previous open-heart surgery, and prosthetic material was used in 20 patients. A predisposing event was identified in 11 episodes (29.7%). Surgery was performed during the same admission in 24 (64.9%) patients, with early surgery (≤ 7 days from admission) performed in 12 patients. Early operation was associated with a shorter in-hospital stay compared to a later operation during the same admission or medical management [28.5 (IQR 23) vs. 43.5 (IQR 30) days, P = 0.028]. In-hospital mortality was 8.1%. Renal dysfunction at admission was associated with in-hospital multiorgan complications and/or death (OR 7.50, 95% CI, 1.18–47.67, P = 0.03). SAIE remains a life-threatening complication, necessitating cardiac surgery in the majority of ACHD patients. Ongoing educational investment on prevention and timely SAIE detection is warranted. [Display omitted] • Staphylococcus aureus infective endocarditis (SAIE) is a life-threatening complication in adults with congenital heart disease (ACHD). • Almost two thirds of ACHD patients infected with SAIE in our cohort required surgery during admission. • In-hospital mortality due to SAIE was 8.1% in this cohort. • Ongoing educational investment on how to prevent and timely detect SAIE is warranted. [ABSTRACT FROM AUTHOR]

Based solely on pre-ablation characteristics, previous risk scores have demonstrated variable predictive performance. This study aimed to predict the recurrence of AF after catheter ablation by using artificial intelligence (AI)-enabled pre-ablation computed tomography (PVCT) images and pre-ablation clinical data. A total of 638 drug-refractory paroxysmal atrial fibrillation (AF) patients undergone ablation were recruited. For model training, we used left atria (LA) acquired from pre-ablation PVCT slices (126,288 images). A total of 29 clinical variables were collected before ablation, including baseline characteristics, medical histories, laboratory results, transthoracic echocardiographic parameters, and 3D reconstructed LA volumes. The I-Score was applied to select variables for model training. For the prediction of one-year AF recurrence, PVCT deep-learning and clinical variable machine-learning models were developed. We then applied machine learning to ensemble the PVCT and clinical variable models. The PVCT model achieved an AUC of 0.63 in the test set. Various combinations of clinical variables selected by I-Score can yield an AUC of 0.72, which is significantly better than all variables or features selected by nonparametric statistics (AUCs of 0.66 to 0.69). The ensemble model (PVCT images and clinical variables) significantly improved predictive performance up to an AUC of 0.76 (sensitivity of 86.7% and specificity of 51.0%). Before ablation, AI-enabled PVCT combined with I-Score features was applicable in predicting recurrence in paroxysmal AF patients. Based on all possible predictors, the I-Score is capable of identifying the most influential combination. • AI analysis of pre-ablation images and clinical data forecasts AF recurrence risk. • AI with I-Score boosts AF recurrence prediction, surpassing traditional techniques. • I-Score selection enhances AI efficiency and accuracy in predicting AF relapse. • The study introduces I-Score in cardiology, optimizing complex predictor analysis. [ABSTRACT FROM AUTHOR]

Background and purpose This study aims to investigate whether changes in lifestyle, added to the antihypertensive treatment, could translate to changes in cardiovascular (CV) morbidity and mortality in hypertensive patients. Methods Between October 2007 and November 2008, men or women (50–79 years) were enrolled randomly in this study when their BP was 140/90–179/109 mmHg with a 2-weeks run-in stage firstly. All participants had at least one additional CV risk factor, indicated by a history of stroke, myocardial infarction (MI), etc. Results 12,245 (90.4%) patients were eligible for our analysis. We assigned them to the lifestyle intervention group (5225) or to control group (7020). In the end of the study, weight loss at least 1 kg of the participants of the intervention group of accounted for 33.2%, control group was 24.9 (P < 0.001). Salt intake more than 6 g of the participants accounted for 29.4% in the intervention group, 38.4% in the control group (P < 0.001). The composite CV events which include non-fatal stroke, MI and CV death, happened in 133 (2.2%) participants of intervention group and 177 (2.4%) in the control group. However, the improvement of composite CV events reduced 55% (adjusted HR = 0.45, 95% CI: [0.32,0.63]), and decreased by 55% (HR = 0.45, 95% CI: [0.37,0.63]) for all CV events. Conclusions The effect of advised only lifestyle intervention used in our study is minor for CV prevention. However, the effect of improvement of lifestyle on CV prevention is indisputable even in hypertensives who receive a-hypertension drug treatment. [ABSTRACT FROM AUTHOR]

To evaluate the prognostic influence of the presence of right ventricular myocardial infarction (RVMI) on patients with inferior ST-segment elevation myocardial infarction (STEMI) in the contemporary reperfusion era. 9308 patients with inferior STEMI were included from the prospective, nationwide, multicenter China Acute Myocardial Infarction Registry, including 1745 (18.75%) patients with RVMI and 7563 (81.25%) patients without RVMI. The primary outcome was two-year all-cause mortality. The secondary outcome was major adverse cardiac and cerebrovascular event (MACCE) defined as a composite of all-cause mortality, recurrent MI, revascularization, stroke, and major bleeding. After two-year follow up, there were no significant differences between inferior STEMI patients with or without RVMI in all-cause mortality (12.0% vs 11.3%; adjusted HR: 1.05; 95% CI: 0.90 to 1.24; P = 0.5103). Inferior STEMI with RVMI was associated with higher risk of MACCE (25.6% vs 22.0%; adjusted HR: 1.17; 95% CI: 1.05 to 1.31; P = 0.0038), revascularization (10.3% vs 8.1%; adjusted HR: 1.23; 95% CI: 1.03 to 1.48; P = 0.0218), and major bleeding (4.6% vs 2.7%; adjusted HR: 1.56; 95% CI: 1.18 to 2.07; P = 0.0019). Primary percutaneous coronary intervention (PCI) and thrombolysis were independent predictors to decrease all-cause mortality. For patients who received timely reperfusion, RVMI involvement did not increase all-cause mortality, whereas for those who did not undergo reperfusion, RVMI increased all-cause mortality (20.3% vs 15.7%; HR: 1.34; 95% CI: 1.10 to 1.63). RVMI did not increase all-cause mortality for inferior STEMI patients in contemporary reperfusion era, whereas the risk was increased for patients with no reperfusion treatment. • RVMI did not increase all-cause mortality for patients with inferior STEMI in the contemporary reperfusion era; • RVMI increased all-cause mortality for inferior STEMI patients without reperfusion treatment; • Early recognition of RVMI and timely reperfusion may improve the prognosis of inferior STEMI patients with RVMI. [ABSTRACT FROM AUTHOR]

Background The safety and efficacy of everolimus-eluting stent (EES) versus zotarolimus-eluting stent (ZES) are controversial both in randomized controlled clinical trials (RCTs) and observational studies. The aim of this study was to assess the safety and efficacy of EES versus ZES. Methods Pubmed, Embase, Cochrane database and www.clinicaltrials.gov updated to Mar 2014 with safety [major adverse cardiac events (MACE)], all-cause mortality, non-fatal myocardial infarction (MI), stent thrombosis (ST) and efficacy [target vessel revascularization (TVR), target lesion revascularization (TLR), target vessel failure (TVF), target lesion failure (TLF)] endpoints and follow-up of ≥ 12 months were identified. Results Data from 11,778 patients in 8 RCTs and 34,850 patients in 26 observational studies were included. In RCT studies, no evidence indicating that EES was safer or more efficacious than ZES. In observational studies, EES associated with a significantly lower risk for MACE (RR: 0.56, 95% CI: 0.46–0.69), ST (RR: 0.59, 95% CI: 0.45–0.78), TVR (RR: 0.61, 95% CI: 0.47–0.79), TLR (RR: 0.57, 95% CI: 0.38–0.83) and TLF (RR: 0.69, 95% CI: 0.50–0.93). The pooled data of RCTs and observational studies showed that compared to ZES, EES associated with a significant lower risk for MACE (RR: 0.65, 95% CI: 0.54–0.78), ST (RR: 0.66, 95% CI: 0.52–0.83), TVR (RR: 0.72, 95% CI: 0.58–0.89), TLR (RR: 0.63, 95% CI: 0.49–0.82) and TLF (RR: 078, 95% CI: 0.62–1.00). Conclusions In RCTs, EES and ZES showed comparable safety and efficacy, while in observational studies or pooled data, EES was safer and more efficacious than ZES. [ABSTRACT FROM AUTHOR]

Aortic coarctation (AoCoa) is a congenital stenosis of aorta, which often co-exists with other congenital heart defects. Many studies have shown the importance of regular follow-up in these patients however there is scarcity of knowledge relating to the impact of left ventricle inflow lesions (LVIT) and left ventricle outflow track lesions (LVOT). The aim of this study is to evaluate the impact of isolated AoCoa with LVIT and/or LVOT on haemodynamic, morbidity and mortality. We have retrospectively analysed clinical data of all adult AoCoa patients who underwent echocardiography between 2010-2018 in our centre. Outcome measures included death, number of hospitalisations for cardiac causes, development of cardiac arrhythmia, new prescription of HF medication. A total of 406 AoCoa patients were included and were followed for a median 4.2 years. At baseline, 38% patients had AoCoa alone, 54% patients had LVOT, 3% patients had LVIT, and 5% patients had mixed LVIT and LVOT, including patients with Shone syndrome. Patients with mixed LVIT and LVOT had the highest mortality of the four groups and the highest heart failure-related morbidity. Moreover, they were the most prone to have a higher indexed LA volume compared to patients with no LVOT (p=0.0001). During follow-up, 13 patients died, of which 21% patients were from the mixed LVIT and LVOT group. AoCoa patients with a combination of LVIT and LVOT including Shone complex are associated with a significantly higher morbidity and mortality compared to AoCoa alone. • Impact of LVIT and LVOT, alone or in combination, on mortality, HF-related morbidity, hospitalisation and diastolic dysfunction in AoCoa patients. • AoCoa patients with combined LVIT and LVOT have a worse morbidity and mortality. [ABSTRACT FROM AUTHOR]

Background: Patients with congenitally corrected transposition of the great arteries (ccTGA) are at high risk of heart block requiring subpulmonary left ventricular (LV) pacing. Long-term right ventricular (RV) pacing in congenitally normal hearts is associated with LV dysfunction. We examined the effects of univentricular subpulmonary LV pacing on the systemic RV in a ccTGA cohort. Methods: ccTGA patients with two echocardiographic studies at least 6months apart were included. Records of 52 patients, 22 with pacing, were retrospectively reviewed. Seven patients with biventricular pacing were included for comparison. Results: The LV-Paced Group experienced deterioration in the RV fractional area change (RVFAC) (28.7±10.0 vs. 21.9±9.1%; P =0.003), systemic atrioventricular valve regurgitation (P =0.019) and RV dilatation (end-diastolic area 32.7±8.7 vs. 37.2±9.0cm2; P =0.004). There was a corresponding deterioration in NYHA class (P =0.013). Multivariate Cox regression analysis showed that pacing was an independent predictor of deteriorating RV function and RV dilation (hazard ratio 2.7(10–7.0) and 4.7(1.1–20.6) respectively). None of these parameters changed significantly in the Un-paced Group. The CRT Group showed improvement in RVFAC (22.0% to 30.7% (P =0.030) and NYHA class (P =0.030), despite having lower baseline RVFAC (22.0±5.7 vs. 31±9.7%; P =0.025) and greater dyssynchrony (RV total isovolumic time 13.4±2.1 vs. 9.3±4.2s/min; P =0.016) when compared to the Un-Paced Group. Conclusions: Univentricular subpulmonary LV pacing in patients with ccTGA predicted deterioration in RV function and RV dilatation over time associated with deteriorating NYHA class. Alternative primary pacing strategies such as biventricular pacing may need consideration in this vulnerable group already highly prone to mortality from systemic RV failure. [ABSTRACT FROM AUTHOR]

Background: Sudden cardiac death (SCD) occurs commonly after heart transplantation (HTX). The utilization of surface electrocardiography (ECG) to assess post-HTX SCD has not been investigated thoroughly. This study aimed to investigate the specific changes in surface ECG in HTX patients with SCD. Methods: A total of 227 HTX patients (age 48±14y/o, mean donor age 34±14y/o, 173males) were followed up regularly at the outpatient clinic. Twelve-lead ECG's were recorded during 1–2 monthly visits. Serial ECG parameters and relevant clinical data were collected and analyzed. Results: During the follow-up period of 96±51months, SCD occurred in 28 (12.3%) patients. The baseline ECG parameters were comparable between patients with and without SCD. Important ECG trends of rising rest heart rates and prolongation of corrected QT (QTc) and JT (JTc) intervals were observed prior to development of SCD. After adjustment for other clinical variables, the independent predictors for SCD were older donor age (p=0.014, OR 1.05, 95% CI 1.01–1.09), faster heart rate (p=0.006, OR 1.06, 95% CI 1.02–1.1) and longer JTc interval (p=0.015, OR 1.03, 95% CI 1.01–1.06). SCD occurred in 71.4% patients presenting with all three risk predictors. Conclusions: Besides older donor age, important ECG signs, including prolongation of the JTc interval and increased heart rate during post HTX follow up, could predict SCD. [ABSTRACT FROM AUTHOR]

To evaluate the performance of a single‑lead, 14-day continuous electrocardiogram (ECG) patch for the detection of arrhythmias compared to conventional 24-h monitoring. This prospective clinical trial enrolled patients suspected of arrhythmias but not diagnosed by 12‑lead ECGs. Each patient underwent a 24-h Holter and 14-day ECG patch simultaneously. Seven types of arrhythmias were classified: supraventricular tachycardia (SVT, repetitive atrial beats >4 beats), irregular SVT without P wave (>4 beats), AF/AFL (irregular SVT without P wave ≥30 s), pause ≥3 s, atrioventricular block (AVB; Mobitz type II, third-degree, two to one or high degree AVB), ventricular tachycardia (VT), and polymorphic VT. A total of 158 patients were recruited (mean wear time:12.3 ± 3.2 days). The overall arrhythmia detection rate was higher with 14-day ECG patches (59.5%) compared to 24-h Holter (19.0%, P < 0.001). Up to 87.2% of arrhythmias recorded with 14-day ECG patches were not associated with symptoms. The 14-day ECG patch was associated with higher detection rates compared to the 24-h Holter in patients with SVT (52.5% versus 15.8%, P < 0.001), irregular SVT without P wave (12.7% versus 4.4%, P = 0.002), AF/AFL (9.5% versus 3.8%, P = 0.042), and critical arrhythmias (pause ≥3 s, AVB, VT, polymorphic VT) (16.5% versus 2.5%, P < 0.001). The 14-day ECG patch detected more than 2 types of arrhythmias in 5.1% of patients. No serious adverse events in patients wearing the 14-day ECG patch were reported. The 14-day ECG patch outperformed 24-h Holter to detect overall, asymptomatic, critical and multiple arrhythmias. It is safe and has the potential to identify individuals with hidden arrhythmias, especially those with critical arrhythmias. • The 14-day ECG patch outperformed 24-h Holter in identifying hidden arrhythmias. • The extended 14-day recording time is needed for detection of critical arrhythmias. • A light and easy-to-wear 14-day ECG patch is safe and has no serious adverse event. [ABSTRACT FROM AUTHOR]

Comprehensive echocardiography assessment of right ventricular (RV) impairment has not been reported in critically ill patients with COVID-19. We detail the specific phenotype and clinical associations of RV impairment in COVID-19 acute respiratory distress syndrome (ARDS). Transthoracic echocardiography (TTE) measures of RV function were collected in critically unwell patients for associations with clinical, ventilatory and laboratory data. Ninety patients (25.6% female), mean age 52.0 ± 10.8 years, veno-venous extracorporeal membrane oxygenation (VVECMO) (42.2%) were studied. A significantly higher proportion of patients were identified as having RV dysfunction by RV fractional area change (FAC) (72.0%,95% confidence interval (CI) 61.0–81.0) and RV velocity time integral (VTI) (86.4%, 95 CI 77.3–93.2) than by tricuspid annular plane systolic excursion (TAPSE) (23.8%, 95 CI 16.0–33.9), RVS' (11.9%, 95% CI 6.6–20.5) or RV free wall strain (FWS) (35.3%, 95% CI 23.6–49.0). RV VTI correlated strongly with RV FAC (p ≤ 0.01). Multivariate regression demonstrated independent associations of RV FAC with NTpro-BNP and PVR. RV-PA coupling correlated with PVR (univariate p < 0.01), as well as RVEDAi (p < 0.01), and RVESAi (p < 0.01), and was associated with P/F ratio (p 0.026), PEEP (p 0.025), and ALT (p 0.028). Severe COVID-19 ARDS is associated with a specific phenotype of RV radial impairment with sparing of longitudinal function. Clinicians should avoid interpretation of RV health purely on long-axis parameters in these patients. RV-PA coupling potentially provides important additional information above standard measures of RV performance in this cohort. • Critical COVID-19 patients in ICU are reliant on echocardiography to identify cardiac complications. • There is a high incidence of RV radial dysfunction in this group. • RV radial impairment correlates with markers of cardiac stress. • Conventional echocardiographic measures of longitudinal function may miss the extent of RV impairment. • RV-PA coupling provides additional information on RV performance in critically ill patients with COVID-19. [ABSTRACT FROM AUTHOR]

We aim to characterize the nature and magnitude of the prospective association between education and incident heart failure (HF) in the Atherosclerosis Risk in Communities (ARIC) Study and investigate any causal relevance to the association between them. The final sample size was 12,315 in this study. Baseline characteristics between education levels were compared using 1-way ANOVA test, the Kruskal-Wallis test, or the χ2 test. We used the Kaplan-Meier estimate to compute the cumulative incident of HF by education levels and the difference in estimate was compared using the log-rank test. Cox hazard regression models were used to explore the association between education levels and incident HF. Two-sample Mendelian randomization (MR) based on publicly available summary-level data from genome-wide association studies (GWASs) was used to estimate the causal influence of the education and incident HF. During a median follow-up of 25.1 years, 2453 cases (19.9%) of incident HF occurred. After multiple adjustments in the final model, participants in the intermediate and advanced education levels were still associated with 18% and 21% decreased rate of incident HF separately. In MR analysis, we detected a protective causal association between education and HF (P = 0.005). Participants with higher education levels were associated with a decreased rate of incident HF. There was a causal association between education and HF. • Education is well known for its inverse association with cardiovascular diseases. • Participants with higher education levels were associated with decreased rate of incident heart failure (HF). • Mendelian randomization (MR) analyses supported a protective causal association between education and HF. [ABSTRACT FROM AUTHOR]

The study aimed to assess the relation between echocardiographic parameters of subpulmonary left ventricular (LV) size and function, and the severity of heart failure in patients with a systemic right ventricle (SRV). A total of 157 patients (89 post Mustard/Senning operations, 68 with congenitally corrected transposition of great arteries [ccTGA]) were included. The size and function of the SRV and subpulmonary LV were assessed on the most recent echocardiographic exam. Clinical data were collected from the electronic records. The majority (133, 84.7%) were in NYHA functional class 1–2. Median BNP concentration was 79.5[38.3–173.3] ng/l, and 100 (63.7%) patients were receiving heart failure therapy. Both LV and SRV fractional area change (FAC) differed significantly between patients with NYHA class 1–2 vs 3–4 (48[41.5–52.8]% vs 34[28.6–38.6]%, p < 0.0001 and 29.5[23–35]% vs 22[20–27]%, p < 0.0001, respectively), but LV FAC had a higher discriminative power for functional class >2 than SRV FAC (AUC 0.90, p < 0.0001 vs 0.79; p < 0.0001, respectively). A LV FAC cut-off value <39.2% had the highest accuracy in identifying patients with NYHA class 3–4 (sensitivity 83% and specificity 88%). In multivariable logistic regression analysis, LV FAC and SRV FAC independently associated to NYHA class 3–4 (OR 0.80 [95%CI 0.72–0.88], p < 0.0001 and OR 0.85 [95%CI 0.76–0.96], p = 0.007, respectively). Subpulmonary LV systolic dysfunction is associated with NYHA functional class 3–4 in patients with ccTGA or after Mustard or Senning operation. Careful evaluation of the subpulmonary LV should be a part of the routine assessment of patients with a SRV. • Dysfunction of subpulmonary left ventricle (LV) is independently associated with NYHA class 3–4; • LV fractional area change (FAC) is more accurate than systemic right ventricle FAC in predicting heart failure symptoms; • LV FAC rather than MAPSE provides a reasonably accurate echocardiographic quantification of subpulmonary LV; • subpulmonary LV function requires accurate assessment during routine follow up. [ABSTRACT FROM AUTHOR]

Severe TR is associated with impaired prognosis while limited interventional options available. The purpose of this observational first-in-human experience with the K-Clip™ transcatheter tricuspid annular reconstruction system is to investigate its feasibility, safety as well as short-term clinical impact on patients with severe functional tricuspid regurgitation (TR). In this compassionate-use, prospective, multi-center, single-arm study , 15 patients with severe symptomatic functional TR were treated with the K-Clip™ system and followed up at 30 days after discharge. Feasibility endpoints consisted of safety (major clinical cardiovascular events (MACEs), echocardiographic, clinical and functional endpoints. All the 15 patients (9 males, 72.67 ± 9.42 years of age) successfully received implants and no MACEs were reported throughout the study at 30 days. Between baseline and 30 days, echocardiography showed remarkable reduction of tricuspid annular circumference and area by 14.30% and 25.96%. Improvement of ≥ + 2 grade and ≥ +3 grade TR was presented in 9/15(60.00%) and 4/15(26.67%) respectively while 10/15(66.67%) of patients had ≤ moderate TR. Clinical evaluation indicated that 86.67% of patients were finally in NYHA functional class I or II (p<0.001) and overall Kansas City Cardiomyopathy Questionnaire score improved from 62.28 ± 18.97 to 77.90 ± 11.70 (p = 0.016). Our first-in-human results of the transcatheter tricuspid annular reconstruction using the K-Clip™ system demonstrated initial favorable procedural success, acceptable safety and remarkable TR reduction in consistent with significant clinical improvement. Larger-scaled prospective trials with longer follow-up duration are warranted to further determine whether these promising findings could be promoted to a broader population in the long term. • We summarize the compassionate-use experience with K-Clip™ annuloplasty system in 15 compassionate patients with severe tricuspid regurgitation. • K-Clip™ annuloplasty system demonstrated high technical success, acceptable safety as well as significant clinical improvement in the reduction of TR. • Larger prospective studies with long-term follow-up are needed to determine its durable efficacy in TR reduction and impacts on clinical outcomes. [ABSTRACT FROM AUTHOR]

Abstract: Background: The effects of low K+ on post-ischemic reperfused heart cells are not clearly understood. Calcium overload is one of the major causes for myocardial reperfusion injury, the present study was to investigate the role of intracellular calcium oscillations in the effects of reperfusion with low K+ on rat myocytes. Methods: Ischemic myocytes were reperfused with Tyrode solution containing K+ at 5.4 (control) or 3.0 mM (low K+) for 10 min. the changes of intracellular calcium was recorded by spectrofluorometry. The exclusion of trypan blue by myocytes served as indices of viability. Measurements of cell length, reverse-mode Na+–Ca2+ exchanger (NCX) and Na+, K+ ATPase activity were performed. Results: Compared to control, myocytes reperfused with low K+ had greater number of calcium oscillations and reverse-mode NCX activity, which were accompanied with decreased cell length recovery and cell viability. Reperfusion with KB-R7943, an inhibitor of reverse-mode NCX, attenuated the effects of low K+ on all the parameters. Inhibition of Na+, K+ ATPase with Ouabain increased the susceptibility to calcium oscillations in myocytes reperfused with low K+, which was accompanied with cell length shortening and decreased cell viability. Reperfusion with K+ at 9.0 mM, which activated Na+, K+ ATPase, attenuated calcium oscillations, protected cell length recovery, and increased cell viability. Conclusions: These results suggest that increased calcium oscillations mediate the exacerbating reperfusion injury with low K+ on myocytes, and inhibition of Na+, K+ ATPase activity and increase of reverse-mode NCX activity contribute to these effects. [Copyright &y& Elsevier]

Abstract: Background: Pregnant women with heart disease (HD) are at an increased risk for maternal and neonatal adverse events. However, the effect of pregnancy on clinical status and ventricular function in women with HD has not been examined in a controlled study. Methods and results: Ninety-three women with HD were studied longitudinally. Of these, fifty-three underwent clinical and echocardiographic evaluation before and 1.5±1.1 years after pregnancy (pregnancy group), whereas forty served as controls matched for age (28.6±4.6 versus 28.5±6.6, p =0.88), diagnosis, and length of follow-up (2.9±1.4 versus 2.6±1.1, p =0.23). NYHA functional class remained unchanged in both groups during follow-up. End diastolic and end systolic dimensions and shortening fraction of the morphologic left ventricle also remained unchanged. Furthermore, systemic and subpulmonary ventricular function remained unchanged in the pregnancy and control groups on semiquantitative analysis. Pregnancy, however, was associated with a persisting increase in subpulmonary ventricular size in patients with tetralogy of Fallot (ToF) which was not present in tetralogy controls. Furthermore, diagnosis of ToF was the only predictor of an increase in subpulmonary ventricular size after pregnancy on univariate logistic regression analysis (OR 8.8[95% CI 1.9–41.1], p =0.006). Conclusions: In this longitudinal controlled study amongst women with HD no deleterious midterm effects of pregnancy on clinical status and right and left ventricular function were found. However, pregnancy was associated with a persisting increase in subpulmonary ventricular size, attributable to patients with repaired ToF. This may have prognostic implications and merits further investigation. [Copyright &y& Elsevier]

Abstract: Background: The search for optimal sedation for transesophageal echocardiography (TEE) continues. We hypothesized that the ultra-short acting opioid remifentanil combined with very low-dose midazolam would provide a better sedation and recovery profile compared to midazolam alone. Methods: 41 consecutive outpatients scheduled for TEE received either IV midazolam (group M, 2.5 mg bolus plus 1 mg increments repeated as needed, n =18) or a combination of a low-dose IV bolus of midazolam (0.5 mg) plus an infusion of remifentanil (group RM, 0.1 mcg/kg/min, reduced to 0.08 mcg/kg/min after probe insertion, n =23). All patients received topical pharyngeal anesthesia with 2 puffs of lidocaine 4% spray. We recorded BP, SpO2, HR, time-to-discharge (modified Aldrete score of 13), duration of procedure, resource utilization, complications, ease of probe introduction, ease and quality of the procedure. Patients'' satisfaction with sedation was assessed using the Iowa Satisfaction with Anesthesia Scale (ISAS). Results: Mean dose of midazolam in group M was 3.7±1.3 mg. Median time-to-discharge was significantly reduced in the RM group compared with the M group (5 (5–10) vs. 30 (5–240) min, p <0.0001), with 22 of the 23 group RM patients ready for “street discharge” within 5 min of removal of the TEE probe. Ease of probe insertion (p =0.001), resource utilization (p =0.0001), patient satisfaction (p =0.03) and overall ease and quality of the procedure (p =0.0001) were significantly better in the RM group than in the M group. No episodes of desaturation were observed. Conclusions: This is the first report of the use of an ultra-short acting opioid, remifentanil, combined with a low-dose of midazolam, as a sedative technique for outpatient TEE. In this pilot, non-randomized prospective study, remifentanil plus low-dose midazolam provided better sedation than our current practice of higher bolus doses of midazolam alone. This novel approach is associated with improved procedure tolerance, faster recovery and minimal resource utilization. A randomized, controlled study is under way to verify our preliminary results. [Copyright &y& Elsevier]

Abstract: Background: Bosentan, a dual-endothelin receptor antagonist, is an established treatment for pulmonary arterial hypertension. We hypothesized that bosentan is safe and well tolerated in patients with Eisenmenger physiology. Methods: In this pilot open-label study, we primarily examined safety and tolerability of oral bosentan. Patients were recruited from our adult congenital heart clinic following informed consent. Baseline and 3-month assessment included WHO functional class, resting oxygen saturations, 6-min walk test, transthoracic echocardiography and respiratory mass spectrometry. Patient clinical status and liver enzymes were closely monitored throughout. Results: All 10 study patients (42±4 years; eight female) tolerated bosentan well. No major adverse events or significant liver enzyme elevations were observed. All but one patient felt better; none felt worse. Four patients experienced transient leg oedema. Resting oxygen saturations (83±5 versus 80±5%; P=0.011) and the distance travelled in the 6-min walk test (348±112 versus 249±117 m; P=0.004) increased relative to baseline. Changes in echocardiographic parameters (maximum aortic forward flow velocity 1.3±0.1 versus 1.1±0.2 ms, P=0.013; pulmonary arterial acceleration time 66±10 versus 58±12 m/s, P=0.02) and pulmonary blood flow (3.45±1.2 versus 2.58±1.0 L/min, P=0.008) suggested improved pulmonary haemodynamics by study end. Other echocardiographic changes suggested improved right ventricular systolic function (septal amplitude 1.0 versus 1.1 cm, P=0.048; systolic tissue Doppler velocity 4.8 versus 2.3 cm s−1, P=0.002) by study end. Conclusions: Bosentan was safe and well tolerated in adults with Eisenmenger physiology both at initiation and after 3 months of oral therapy. Clinical status of patients and pulmonary haemodynamics appeared to improve, and this warrants further investigation. [Copyright &y& Elsevier]

Background: The exact location of a Q wave myocardial infarction has an important effect on overall left ventricular function. Objectives: To assess the effect of localization of Q wave infarction on left ventricular minor and long axis function, with particular reference to electromechanical disturbances. Methods: We studied 72 patients with Q wave myocardial infarction; 35 anterior, age 61±15 years and 37 inferior, age 62±12 years. ECG intervals were automatically measured by Hewlett-Packard Pagewriter and LV dimension and filling velocities studied by transthoracic echocardiography and simultaneous phonocardiogram. Findings were compared with 21 controls of similar age. Results: Heart rate and all ECG intervals were similar in the two patient groups and controls. QRS axis was more to the left in patients with inferior MI. Normal septal q wave was absent in lead V5 and V6 in 33/35 (94%) patients with anterior MI and in only 3/37 (8%) with inferior MI, p<0.001. LV minor axis dimensions were enlarged vs. normal (p<0.001) in the two patient groups and to a greater extent in anterior MI compared with inferior MI, p<0.05. Isovolumic relaxation time was prolonged only in-patients with an inferior MI, p<0.01. Long axis amplitude was globally reduced (p<0.001) in the two patient groups as were shortening and lengthening velocities (p<0.001). The onset of septal long axis shortening with respect to the q wave was delayed by 30 and 40 ms in inferior MI and anterior MI and that of lengthening with respect to A2 by 20 and 30 ms, respectively, compared to normal (p<0.001 for both). Post ejection shortening was localized to the septal long axis in 32/35 patients with anterior MI but was generalized involving all three LV long axes in inferior MI, p<0.001. Transmitral Doppler flow velocities and the frequency of mild mitral regurgitation were similar in the two groups. Conclusion: These results confirm a close association between anterior Q wave infarction, septal incoordination and absent septal q waves. The global incoordinate long axis behaviour in inferior Q wave MI may be due to significant papillary muscle dysfunction, and results in significant shape change in early diastole. This disturbance in electromechanical behaviour might play an important role in the differing outcomes between the two different sites of myocardial infarction. [Copyright &y& Elsevier]

MiRNA-1, Acute myocardial infarction, Therapeutic targets, Cardioprotection. [Extracted from the article]

Catheter ablation is an effective treatment for atrioventricular nodal reentrant tachycardia (AVNRT). However, the characteristics of extremely late (>3 years) recurrences of AVNRT after a successful initial ablation are not fully elucidated. We aimed to explore the electrophysiological characteristics of extremely late recurrences of AVNRT after a successful ablation. From 1991 to 2018, 3311 patients (mean age: 48.7 ± 17.4 years; men: 1328 [40.1%]) who underwent catheter ablation for AVNRT were investigated. Baseline characteristics of the patients, recurrence status, and detailed electrophysiological parameters of the index and repeat ablation procedures were obtained for analysis. After a mean follow-up period of 129.5 ± 58.0 months, 65 (2.0%) patients underwent repeat ablation for recurrences of AVNRT, of whom 17 (0.5%) presented with extremely late recurrences. The incidence of transient AV block was significantly higher in patients with extremely late recurrences (5.9%) than in those without recurrences (1.9%) but lower than that in patients with recurrences within <3 years (12.5%, P <.001). In addition, among patients with extremely late recurrences of AVNRT, the atrial–His bundle interval was significantly longer (99.1 ± 23.4 vs. 76.5 ± 13.1 ms, P <.01) and the need for intravenous isoproterenol and/or atropine for the induction of AVNRT (88.2% vs. 47.1%, P =.03) was higher in the repeat ablation procedure than in the index ablation procedure. Recurrences of AVNRT can occur 3 years after a successful initial ablation. The electrophysiological features of the index and repeat ablation procedures differed between patients with extremely late recurrences of AVNRT and those with recurrences within <3 years. • Recurrences of AVNRT can occur 3 years after a successful initial ablation. • Higher incidence of transient AV block in patients with recurrences of AVNRT • Late recurrences of AVNRT had significantly longer AH interval. • Late recurrences of AVNRT had higher need for isoproterenol for the induction. [ABSTRACT FROM AUTHOR]

Atrial fibrillation (AF) is associated with increased risks of dementia and hospitalization. Whether catheter ablation (CA) for AF might reduce such risks remains unclear. We aimed to investigate the effects of CA on dementia and hospitalization risks during a very long-term follow-up. We studied a total of 787 AF patients receiving CA for AF treatment from 2003 to 2012 (AF CA group). The propensity score of this group was matched to another two cohorts: (a) AF patients without CA (AF no CA, n = 787) and (b) control patients without AF (n = 770). New onset of dementia of each subject was identified by ICD-9-CM codes, and information on hospitalization for AF was based on medical records. The Cox proportional hazards model was used to determine the hazard ratios (HRs) for events. During 9.0 ± 2.6 year's follow-up, a total of 139 dementia events and 732 AF-related hospitalizations have occurred. AF CA group has lower incidence of dementia than AF no CA group (adjusted HR: 0.44, p = 0.005). AF related hospitalizations were also lower in the AF CA group than that in AF no CA group (adjusted HR: 0.72, p < 0.05). In AF patients aged >65 years, CA reduced the risk of dementia compared to those without CA (adjusted HR: 0.46, p = 0.03). In a 9-year follow-up, we found that CA had reduced the risk of dementia and hospitalization in AF patients, compared with those without CA. Such reduction in the risk of dementia was particularly clear in older AF patients (aged >65 years). • Catheter ablation (CA) in atrial fibrillation (AF) patients reduced the long-term risk of dementia and hospitalization. • The risk of dementia was similar between AF patients receiving CA and those without history of AF. • CA in AF patients has a lower risk of dementia than AF patients without CA, particularly in older patients aged >65 years. • The dementia risk was higher in CA patients with AF hospitalization occurred ≤ 5 years than those without hospitalization. [ABSTRACT FROM AUTHOR]

Patients with atrial fibrillation (AF) may be at higher risk for cancer, possibly due to the presence of coexisting risk factors. In this study, we investigate the magnitude and predictors of this potential risk within a population-based study. The study cohort included 332,555 AF patients aged ≥20 years without past history of cancer. Standardized incidence ratio (SIR) was used as a measure of relative risk, comparing observed cancer incidence among patients with AF with that expected based on cancer incidence in the Taiwanese population. During the observation period, 22,911 incident cancers occurred with an incidence of 1.65%/year. Compared with the general population, AF patients had a significantly higher cancer risk with a SIR of 1.37 (95%CI = 1.36–1.39). Patients with new-onset AF had an elevated cancer risk which was highest within 1 year (SIR = 2.30; 95%CI, 2.25–2.36) and persisted beyond 10 years after AF was diagnosed (SIR = 1.18; 95%CI, 1.11–1.25). Age ≥ 65 years, male gender, hypertension, diabetes, chronic obstructive pulmonary disease (COPD) and liver cirrhosis were significantly associated with development of cancers among AF patients. The hazard ratio of cancers increased from 1.40 (95%CI = 1.28–1.53) for patients having 1 risk factor to 5.14 (95%CI = 4.03–6.06) for patients with 6 risk factors, in comparison to those without any risk factors. In the nationwide cohort study, we show that AF patients had a higher risk of cancer. Age, male gender, hypertension, diabetes, COPD and liver cirrhosis are important risk factors of cancer among AF patients. Prompt and detailed examinations may be considered for incident AF patients with multiple risk factors to early detect the occult malignancy. • The incidence of cancer was 1.65%/year for patients with atrial fibrillation (AF). • Compared to general population, AF patients had a higher risk of cancer. • Several clinical factors could predict the developments of cancers for AF patients. [ABSTRACT FROM AUTHOR]