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This clinical consensus statement reviews the use of inotropic support in patients with advanced heart failure. The current guidelines only support use of inotropes in the setting of acute decompensated heart failure with evidence of organ malperfusion or shock. However, inotropic support may be reasonable in other patients with advanced heart failure without acute severe decompensation. The clinical evidence supporting use of inotropes in these situations is reviewed. Particularly, patients with persistent congestion, systemic hypoperfusion, or advanced heart failure with need for palliation, and specific situations relevant to implantation of left ventricular assist devices or heart transplantation are discussed. Traditional and novel drugs with inotropic effects are discussed and use of guideline‐directed therapy during inotropic support is reviewed. Finally, home inotropic therapy is described, and palliative care and end‐of‐life aspects are reviewed in relation to management of ongoing inotropic support (including guidance for maintenance and weaning of chronic inotropic therapy support). [ABSTRACT FROM AUTHOR]

Objective: Peripartum cardiomyopathy (PPCM) diagnosis made by excluding identifiable causes of heart failure (HF) and occurs end of the pregnancy or during the postpartum period of five months. It presents a clinical HF spectrum with left ventricular systolic dysfunction. Background: The purpose of this study is to retrospectively evaluate the clinical characteristics, cardiac magnetic resonance (CMR) imaging features, and end‐points consisting of left ventricle recovery, left ventricular assist device implantation, heart transplantation, and all‐cause mortality. Method: Outpatient HF records between 2008 to 2021 were screened. Thirty‐seven patients were defined as PPCM. Twenty‐five patients had CMR evaluation at the time of diagnosis, and six patients were re‐evaluated with CMR. Results: The mean age was 30.5 ± 5.6 years, and the mean LVEF was 28.2% ± 6.7%. In 13(35.7%) patients, LVEF recovered during the follow‐up course. The median recovery time was 281(IQR [78–358]) days. LVEF on CMR was 35.3 ± 10.5, and three patients exhibited late gadolinium enhancement(LGE) patterns. Sub‐endocardial and mid‐wall uptake pattern types were detected. 18(75%) patients met the Petersen left ventricle non‐compaction cardiomyopathy(LVNC) criteria. Patients with NC/C ratio lower than 2.3 had lower LVEDVi and LVESVi (124.9 ± 35.4, 86.4 ± 7.5, p =.003; 86.8 ± 34.6, 52.6 ± 7.6, p =.006), respectively. The median follow‐up time was 2129 (IQR [911–2634]) days. The primary endpoint‐free 1‐year survival was 88.9% (event rate 11.1%), and 5‐year survival was 75.7% (event rate 24.3%). Conclusion: In a retrospective cohort of PPCM patients, 35.7% of patients' LVEF recovered, and the primary end‐point of free‐5‐year survival was 75%. Twenty‐five patients were assessed with CMR; three of four met the Petersen CMR‐derived LVNC at initial evaluation. [ABSTRACT FROM AUTHOR]

Aims: Left ventricular non‐compaction cardiomyopathy (LVNC) is a poorly understood entity resulting in heart failure. Whether it is a distinct form of cardiomyopathy or an anatomical phenotype is a subject of discussion. The current diagnosis is based on morphologic findings by comparing the compacted to non‐compacted myocardium. The study aimed to compare demographic and prognostic variables of patients with dilated cardiomyopathy (DCM) and LVNC. Emphasis was given to cardiac magnetic resonance (CMR) imaging analysis. Data on survival were also assessed. Methods and results: We retrospectively evaluated the characteristics and outcomes of 262 non‐ischaemic cardiomyopathy patients with LVNC and DCM phenotypes. Petersen's CMR criteria of non‐compacted to the compacted myocardial ratio 2.3 were used to diagnose LVNC. The primary endpoint was a composite endpoint of major adverse cardiovascular events comprising cardiovascular‐related death, left ventricular assisted device implantation, or heart transplantation. A total of 262 patients with CMR data were included in the study. One hundred fifty‐five patients who fulfilled CMR criteria were diagnosed as LVNC. CMR findings revealed that LVNC patients had higher left ventricular end‐diastolic (137.2 ± 51.6, 116.8 ± 44.6, P = 0.002) and systolic volume index (98.4 ± 49.5, 85.9 ± 42.7, P = 0.049). Cardiac haemodynamics, cardiac output (5.61 ± 2.03, 4.96 ± 1.83; P = 0.010), stroke volume (73.9 ± 28.8, 65.1 ± 25.1; P = 0.013), and cardiac index (2.85 ± 1.0, 2.37 ± 0.72; P < 0.0001), were higher in LVNC patients. Of all the 249 patients, 102 (40.9%) patients demonstrated late gadolinium enhancement (LGE). According to Petersen's criteria, the Kaplan–Meier survival outcome did not reveal significant differences (hazard ratio [HR]: 1.53, 95% confidence interval [CI]: [0.89–2.63], P = 0.11). The presence or pattern of LGE did not show significant importance for endpoint‐free survival. Most of the sub‐epicardial LGE pattern was found in LVNC patients (94.4%). When receiver operator characteristics analysis was applied to NC/C ratio to discriminate the primary endpoint, a higher NC/C ratio of 2.57 was associated with adverse events (HR: 1.90, 95% CI: [1.12–3.24], P = 0.016). Conclusions: Our study questions the criteria being used for the diagnosis of LVNC. Further evaluation of CMR variables and association of these findings with demographic variables and survival is mandatory. [ABSTRACT FROM AUTHOR]

Left ventricular assist device (LVAD) implantation via left lateral thoracotomy with outflow cannula anastomosis to the descending aorta is an alternative technique that avoids anterior mediastinal planes and requires a single incision. This study compares changes in exercise capacity following LVAD implantation with outflow cannula anastomosis to the descending aorta versus ascending aorta. Adult patients who received a continuous flow centrifugal LVAD implantation and completed both pre‐ and postimplantation cardiopulmonary exercise tests (CPETs) and or 6‐minute walk tests (6MWT) were included. Change in CPET parameters (maximum oxygen intake: vO2max, oxygen uptake efficiency ratio: OUES, ventilatory efficiency ratio: vE/vCO2Slope) and 6MWT distance were compared between ascending and descending aorta anastomosis groups. Ascending and descending aorta anastomosis cohorts included 59 and 14 patients, respectively. Pre‐ and postimplantation CPETs were performed 63 ± 12 days before and 216 ± 17 days following implantation. The improvement in CPET parameters (vO2max, OUES, vE/vCO2Slope) or 6MWT distance was not significantly different between the ascending and descending aorta anastomosis groups. This study found no significant difference in the improvement of CPET parameters or 6MWT distance between LVAD implantation via thoracotomy with outflow cannula anastomosis to descending aorta and standard implantation via sternotomy with outflow cannula anastomosis to ascending aorta. [ABSTRACT FROM AUTHOR]

This article updates the Heart Failure Association of the European Society of Cardiology (ESC) 2007 classification of advanced heart failure and describes new diagnostic and treatment options for these patients. Recognizing the patient with advanced heart failure is critical to facilitate timely referral to advanced heart failure centres. Unplanned visits for heart failure decompensation, malignant arrhythmias, co-morbidities, and the 2016 ESC guidelines criteria for the diagnosis of heart failure with preserved ejection fraction are included in this updated definition. Standard treatment is, by definition, insufficient in these patients. Inotropic therapy may be used as a bridge strategy, but it is only a palliative measure when used on its own, because of the lack of outcomes data. Major progress has occurred with short-term mechanical circulatory support devices for immediate management of cardiogenic shock and long-term mechanical circulatory support for either a bridge to transplantation or as destination therapy. Heart transplantation remains the treatment of choice for patients without contraindications. Some patients will not be candidates for advanced heart failure therapies. For these patients, who are often elderly with multiple co-morbidities, management of advanced heart failure to reduce symptoms and improve quality of life should be emphasized. Robust evidence from prospective studies is lacking for most therapies for advanced heart failure. There is an urgent need to develop evidence-based treatment algorithms to prolong life when possible and in accordance with patient preferences, increase life quality, and reduce the burden of hospitalization in this vulnerable patient population. [ABSTRACT FROM AUTHOR]

Background Right ventricular ( RV) function has great impact on the survival of heart transplantation recipients; therefore, careful evaluation is of high clinical importance. However, there is no standard conventional echocardiographic parameter to assess RV systolic function. Herein, we evaluated the correlation between echocardiographic parameters of RV systolic function and ejection fraction assessed by cardiac magnetic resonance imaging ( MRI RVEF) in heart transplantation recipients. Method and Results Forty-three patients with at least 6-month heart transplantation history were included in this study. Each patient had conventional echocardiography and cardiac MRI evaluation, followed by endomyocardial biopsy and right heart catheterization, which were performed in six hours. Echocardiographic parameters of RV systolic function, RV fractional area change ( RV FAC), tricuspid annular plane systolic excursion ( TAPSE), RV myocardial performance index, and RV global longitudinal strain, were compared with MRI RVEF ( P values were <0.001, <0.3, <0.9, and <0.4, respectively). RV FAC was the only parameter to strongly correlate with MRI RVEF ( r=0.747, P<0.001); and RV FAC 48.5% value had 90.5% sensitivity and 90.5% specificity to predict the pathologic reference value of MRI RVEF ≤50% ( AUC:0.96; 95% CI, 0.908-1.013). Conclusion To our knowledge, this is the first prospective study to evaluate the correlation between the echocardiographic parameters for RV systolic function and MRI RVEF in heart transplantation recipients. RV FAC is the only parameter to correlate well with MRI RVEF, and its routine use in the follow-up of heart transplantation recipients should be considered. [ABSTRACT FROM AUTHOR]

Significant mitral regurgitation (MR) is thought to decrease after left ventricular assist device (LVAD) implantation, and therefore repair of mitral valve is not indicated in current practice. However, residual moderate and severe MR leads to pulmonary artery pressure increase, thereby resulting in right ventricular (RV) dysfunction during follow-up. We examined the impact of residual MR on systolic function of the right ventricle by echocardiography after LVAD implantation. This study included 90 patients (mean age: 51.7 ± 10.9 years, 14.4% female) who underwent LVAD implantation (HeartMate II = 21, HeartWare = 69) in a single center between December 2010 and June 2014. Echocardiograms obtained at 3-6 months and over after implantation were analyzed retrospectively. RV systolic function was graded as normal, mild, moderate, and severely depressed. MR (≥moderate) was observed in 43 and 44% of patients at early and late period, respectively. Systolic function of the RV was severely depressed in 16 and 9% of all patients. Initial analysis (mean duration of support 174.3 ± 42.5 days) showed a statistically significant correlation between less MR and improved systolic function of RV ( P = 0.01). Secondary echocardiographic analysis (following a mean duration of support of 435.1 ± 203 days) was also statistically significant for MR degree and RV systolic dysfunction ( P = 0.008). Residual MR after LVAD implantation may cause deterioration of RV systolic function and cause right-sided heart failure symptoms. Repair of severe MR, in selected patients such as those with severe pulmonary hypertension and depressed RV, may be considered to improve the patient's clinical course during pump support. [ABSTRACT FROM AUTHOR]

Background Right ventricular ( RV) dysfunction is a major determinant of outcomes in patients with pulmonary arterial hypertension ( PAH), although the optimal measure of RV function is poorly defined. We evaluated the utility of RV free-wall speckle tracking strain as an assessment tool for RV function in patients with PAH who are already under specific treatment compared with conventional echocardiographic parameters and investigated the relationship of RV free-wall strain with clinical hemodynamic parameters of RV performance. Methods Right ventricular free-wall strain was evaluated in 92 patients (Group-1 and Group-4 pulmonary hypertension) who were on PAH-specific treatment for at least 3 months. Right atrial ( RA) area, RV FAC, TAPSE, tricuspid S, functional class, 6-minute walking distance, and NT-pro BNP were studied. The mean duration of follow-up was 222±133 days. Results All patients were under PAH-specific treatment, and mean RV free-wall strain was −13.16±6.3%. RV free-wall strain correlated well with functional class ( r=.312, P=.01), NT-pro BNP ( r=.423, P=.0001), RA area ( r=.427, P=.0001), FAC ( r=−.637, P=.0001), TAPSE ( r=−.524, P=.0001), tricuspid S ( r=−.450, P=.0001), 6-minute walking distance ( r=−.333, P=.002). RV free-wall strain significantly correlated with all follow-up adverse events, death, and clinical right heart failure ( RHF) ( P=.04, P=.03, P=.02, respectively). According to the receiver operator characteristic analysis, the cutoff value for RV free-wall strain for the development of clinical RHF was −12.5% (sensitivity: 71%, specificity: 67%) and for all cardiovascular adverse events (death included) was −12.5% (sensitivity: 54%, specificity: 64%). Conclusion Assessment of RV free-wall strain is a feasible, easy-to-perform method and may be used as a predictor of RHF, clinical deterioration, and mortality in patients already under PAH-specific treatment. [ABSTRACT FROM AUTHOR]

Pulmonary hypertension ( PH) is considered as a risk factor for morbidity and mortality in patients undergoing heart transplantation. Recently, left ventricular assist device ( LVAD) implantation has been increasingly used in reducing pulmonary artery pressure ( PAP) in patients with PH unresponsive to medical therapy. Herein, we aimed to compare the efficacy of continuous-flow and pulsatile-flow blood pumps on the improvement of PH in mechanical circulatory support patients. Twenty-seven patients with end-stage heart failure who underwent LVAD implantation surgery were enrolled. Fifteen of them (55.6%) had continuous-flow pump (HeartWare Ventricular Assist System, HeartWare, Inc., Miramar, FL, USA), and 12 of them (44.4%) had pulsatile pump (Berlin Heart EXCOR ventricular assist device, Berlin Heart AG, Berlin, Germany). The efficacy of LVADs on the improvement of PH was compared between continuous-flow and pulsatile pumps by the evaluation of systolic PAP, tricuspid annular plane systolic excursion ( TAPSE), right ventricular systolic motion ( RVSM), right ventricular ejection fraction ( RVEF), and grade of tricuspid insufficiency ( TI) for each of the study participants. All of the 15 patients who underwent continuous-flow blood pump implantation surgery (Group 1) were male with a mean age of 46.9 ± 11.7 years, and in pulsatile-flow blood pump implanted participants (Group 2), the mean age was 40.6 ± 16.8 years, all of whom were also male ( P = 0.259). Mean follow-up was 313.7 ± 241.3 days in Group 1 and 448.7 ± 120.7 days in Group 2 ( P = 0.139). In Group 1, mean preoperative and postoperative systolic PAP were measured as 51.7 ± 12.2 mm Hg and 22.2 ± 3.4 mm Hg, respectively, while those in Group 2 were 54.5 ± 7.5 mm Hg and 33.9 ± 6.4 mm Hg, respectively. A significantly greater decrease in systolic PAP was noticed in patients with continuous-flow blood pumps ( P = 0.023); however, no statistically significant difference was found when we considered the change in TAPSE between study groups ( P = 0.112). A statistical significance in the alteration of RVEF, RVSM, and the grade of TI during study visits was not found between the study groups ( P = 0.472, P = 0.887, and P = 0.237, respectively). Although the two studied types of LVADs were found to be effective in reducing PAP in heart transplantation candidates with PH, lesser postoperative systolic PAP values were achieved in patients who underwent continuous-flow pump implantation surgery. [ABSTRACT FROM AUTHOR]

Sinus of Valsalva aneurysms mostly remain silent. Here, we report a case with sinus of Valsalva aneurysm which caused right ventricular outflow obstruction and ruptured into the main pulmonary artery in the setting of DeBakey type I aortic dissection (Echocardiography 2011;28:E60-E63) Sinus of Valsalva aneurysms mostly remain silent. Here, we report a case with sinus of Valsalva aneurysm which caused right ventricular outfl ow obstruction and ruptured into the main pulmonary artery in the setting of DeBakey type I aortic dissection. [ABSTRACT FROM AUTHOR]

Background: The most cardiovascular physiological and pathophysiological events show a circadian rhythm. It is thought that the autonomic nervous system and biologic factors play a key role in the pathogenesis of vasovagal syncope (VVS). In this study, we investigated the circadian and infradian variation of VVS. Methods: A prospective consecutive series of 246 patients (142 women; mean age 36 ± 7 years) with recurrent syncope and with a positive head-up tilt testing (HUT) were included in this study. The daily and weekly distributions of the syncopal episodes were investigated. The assessments of episodes were done according to the days of the week and three time periods of the day (6 a.m.–12 noon, 12 noon–6 p.m., 6 pm–12 midnight). Results: According to the results of HUT, 76 patients (31%) had cardioinhibitory, 62 patients (25%) had vasodepressor, and 108 patients (44%) had mixed type of VVS. During the initial passive phase, 40% of patients (99/246) showed positive response. Time to syncope was 20 ± 2 minutes during HUT. The mean number of syncopal episodes was 4 ± 2/years. In all, 1,070 episodes were evaluated. The distribution of the episodes in 6-hour intervals was significantly different from uniform occurrence (38%, 33%, and 29%, respectively) (P = 0.02). The frequency of episodes was higher in the morning (P = 0.045) and in the middle of the week (P = 0.046). A significant difference was found between week and weekend days in terms of the frequency of episodes (75.5% vs 24.5%, P = 0.01). Conclusion: VVS may show a circadian and infradian rhythm. [ABSTRACT FROM AUTHOR]

Objective: The relationship between myocardial bridging (MB) and ischemic heart disease is still controversial. In this study, we aimed to evaluate the existing atherosclerosis and noninvasive endothelial function of brachial artery in patients with MB. Methods: The present study included 50 patients (group I) who had MB in left anterior descending (LAD) on coronary angiography. All of the coronary artery segments were evaluated by intravascular ultrasound (IVUS). Endothelial function was assessed with measurement of flow-mediated dilatation (FMD) and nitrate-dependent dilatation in the brachial artery. The study also included 30 healthy control subjects (group II). Patients in the group I were further subdivided into two subgroups based on the findings on IVUS: group IA included 20 patients without atherosclerotic lesions and group IB included 30 patients with atherosclerotic coronary artery disease in addition to MB. Results: FMD values were found to be significantly lower in the patients with MB (group I) than in the control (6.4 ± 3% vs 11 ± 4%, P <0.001). In regard to FMD values in subgroups, FMD was 7 ± 2% in the group IA and 5.8 ± 1% in the group IB (P = 0.023). On IVUS, atherosclerotic plaque was found proximal to the bridge in the same coronary artery segment in addition to MB in 75% of the patients in group I (group IB). No atherosclerotic plaque was found in within or distal segments of MB. Conclusion: Endothelial function is impaired in patients with MB and there is an increased tendency for atherosclerosis proximal to the bridge in the patients with MB. Endothelial dysfunction is more severe in the patients with atherosclerosis proximal to the bridge. [ABSTRACT FROM AUTHOR]

Background:Two different studies were conducted to evaluate the value of T wave in V1 taller than T wave in V6 (TV1 > TV6) pattern as an indicator of coronary artery disease. Method: In the first study 5,300 resting ECGs were examined and the criterion was found in 283 patients. All of these patients were examined with echocardiography. In the second study, ECG tracings and coronary angiograms of another 500 patients were evaluated. Results:In the first study, in 59 of 283 patients left ventricular hypertrophy was detected and these patients were excluded from the study. There were ST segment-T wave changes and/or Q wave on ECG suggesting coronary ischemia or myocardial infarction in 160 of the 224 patients. TV1, > TV6 criterion was the sole finding in 64 of the 224 patients. All of the 224 patients underwent coronary angiography and coronary artery disease was detected in 185 patients; 134 of the 160 patients (83.3%) and 51 of 64 patients (80%) had one-vessel or multivessel disease. There was no significant difference among the groups regarding coronary artery disease. Left anterior descending artery was involved in all of the 185 patients. In the second study, 408 patients were found to have coronary disease involvement and 92 patients showed normal or insignificant coronary disease. Sixty-six of the 408 patients with coronary disease and four of 92 patients were found to have the TV1 > TV6 pattern. Sensitivity of the criterion was 16.1%, specificity was 95.6%, and accuracy was 94.2%. Conclusions: According to these results, it is concluded that TV1 > TV6 with or without other ECG findings is a good criterion suggesting coronary artery disease, especially left anterior descending artery involvement in patients without left ventricular hypertrophy. A.N.E. 1999;4(4):397-400 [ABSTRACT FROM AUTHOR]

An isolated congenital left ventricular diverticulum, which is characterized by the local failure of the ventricular muscle during embryologic development, is a rare cardiac abnormality that may be found in isolated form or in the accompaniment of other cardiac abnormalities. Clinically, it has been reported to follow an asymptomatic course in the majority of cases; however, it may cause heart failure, arrhythmia, or chest pain in some patients. [ABSTRACT FROM AUTHOR]

Aspergillus aortitis following cardiac surgery has an important role among the cardiac infections as almost all affected cases result in death. Survival of the patient with Aspergillus aortitis is dependent on early initiation of aggressive medical and surgical treatment. Transesophageal echocardiography proved very useful in the diagnosis of this uncommon case of aortitis. In this paper, we present a patient with aortitis caused by Aspergillus niger that hasn't been reported previously diagnosed by transesophageal echocardiography following cardiac surgery. [ABSTRACT FROM AUTHOR]