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Background Patients surviving a myocardial infarction have progressive cardiac dysfunction and ventricular remodeling. Mitral regurgitation is often diagnosed in these patients, and is a risk factor that portends poor prognosis. Whether such post-infarction mitral regurgitation magnifies adverse left ventricular remodeling is unclear, which was studied in an animal model. Methods Forty-one adult rats were induced with myocardial infarction by left coronary artery ligation and assigned to three groups: (group 1) myocardial infarction only; (group 2) myocardial infarction with severe mitral regurgitation introduced after 4 weeks; and (group 3) myocardial infarction with severe mitral regurgitation introduced after 10 weeks. Valve regurgitation was introduced by advancing a trans-apical, ultrasound guided needle into the mitral valve anterior leaflet. Animals were survived to 20 weeks from the index procedure, with biweekly cardiac ultrasound, and invasive hemodynamics and histology at termination. Results At 20 weeks, end diastolic volume was largest in the groups with mitral regurgitation, compared to the group without the valve lesion (group 1: 760.9±124.6μl, group 2: 958.0±115.1μl, group 3: 968.3±214.9μl). Similarly, end systolic volume was larger in groups with regurgitation (group 1: 431.2±152.6μl, group 2: 533.2±130.8μl, group 3: 533.1±177.5μl). In the infarction only group, left ventricular remodeling was maximal until 6 weeks and plateaued thereafter. In groups with mitral regurgitation, left ventricular remodeling was significantly elevated upon the onset of regurgitation and persisted. Conclusions Mitral regurgitation is a potent driver of adverse cardiac remodeling after a myocardial infarction, irrespective of the timing of its onset.

Background This study aimed to clarify the incidence and determinants of postoperative adverse events in patients with ischemic cardiomyopathy who achieved long-term durable mitral valve repair. Methods Between 1999 and 2015, 166 patients with chronic ischemic mitral regurgitation (MR) and left ventricular (LV) ejection fraction ≤40% underwent restrictive mitral annuloplasty. During follow-up (65±34 months), echocardiographic assessments were performed 809 times (mean, 4.9±2.4 times) and 20 patients who had developed postoperative recurrent MR (≥moderate) were excluded. Finally, 146 patients (68±9 years) whose MR was well controlled over time were included. Results A total of 61 mortalities and/or 27 readmissions for heart failure were observed in 76 patients (52%). Among hospital survivors, age (adjusted hazard ratio: 1.05; P=0.001), and estimated glomerular filtration rate (adjusted hazard ratio: 0.61; P=0.001) were identified as independent predictors of long-term mortality and/or readmission for heart failure. The degree of LV function recovery after surgery was comparable between patients with and without adverse events. However, the former group showed greater values for systolic pulmonary artery pressure, tricuspid regurgitation severity, inferior vena cava dimension, and plasma brain natriuretic peptide level throughout the follow-up period (group effect p Conclusions Approximately 50% of patients died or were hospitalized for heart failure even in the absence of recurrent mitral regurgitation during the 5-year follow-up, indicating that durable mitral repair does not always lead to favorable clinical outcomes. The adverse events might be related to volume overload secondary to impaired renal function and less favorable pulmonary hemodynamics.

Objective The study objective was to evaluate the short- and long-term outcomes of patients with ischemic cardiomyopathy after surgical ventricular restoration and to identify risk factors related to poor results. Methods Between August 2002 and April 2016, 62 patients affected by ischemic cardiomyopathy underwent surgical left ventricular restoration at our unit. Patients' mean age at operation was 63 years (39-79 years). Mean ejection fraction was 29.6%. The Surgical Treatment for Ischemic Heart Failure trial criteria have been used as indications for surgery. Fifty-seven patients (91%) received surgical myocardial revascularization. Mitral valve repair was performed in 39 patients (63%). The surgical technique consisted of the classic Dor operation or a different approach reducing the equatorial diameter of the left ventricle and avoiding the use of a patch. The data were analyzed retrospectively for perioperative results and short- and long-term clinical outcomes. Results One patient died of noncardiac causes within 30 days (1.6%). All-cause death occurred in 36 patients (58%) during follow-up (0.6-14.7 years; median follow-up time, 7.02 years), of whom 15 died of cardiac causes. Age, need for preoperative intra-aortic balloon pump, reduction less than 35% of postoperative left ventricular end-diastolic and end-systolic volumes, type of surgical technique, and ejection fraction less than 25% were identified as risk factors for late cardiac mortality. Perioperative levosimendan administration and presence of preoperative moderate to severe mitral regurgitation influenced early and intermediate-term outcomes, but no statistical relevance on long-term results was demonstrated. Conclusions Patients with ischemic dilative cardiomyopathy have favorable short- and long-term outcomes after ventricular restoration. Age, preoperative ejection fraction less than 25%, inadequate left ventricular surgical reverse remodeling, and type of surgical technique negatively affect long-term survival.

Objectives Myocardial autophagy has been recognized as an important factor in heart failure. It is not known whether changes in ventricular geometry by left ventriculoplasty influence autophagy in ischemic cardiomyopathy. We hypothesized that myocardial autophagy plays an important role in left ventricular (LV) redilation after ventriculoplasty. Methods Four weeks after ligation of the left anterior descending artery, ventriculoplasty or sham operation was performed. The animals were euthanized at 2 days (early) or 28 days (late) after the second operation. Ventricular autophagy was evaluated by protein expression of microtubule-associated protein light chain 3 II, an autophagosome marker. Cardiomyocyte area was assessed by histologic examination. LV function was evaluated by echocardiography. To examine the implications of autophagy, an autophagy inhibitor (3-methyladenine) was injected intraperitoneally for 3 weeks before sacrifice. Results The LV was reduced in size early and redilated late after ventriculoplasty. LV systolic function was improved early and later worsened after ventriculoplasty. Light chain 3 II expression decreased early after ventriculoplasty and increased in the late period. Myocyte area increased from the early to late stage after ventriculoplasty. Autophagic inhibition exaggerated the increased myocyte hypertrophy and LV redilation. Conclusions In a rat model of myocardial infarction, autophagy decreased early after ventriculoplasty and increased again during LV redilation. These results provide new insights into the mechanism underlying the late failure of ventriculoplasty.

Objectives This study aimed to determine the feasibility of using radioablation for arrhythmogenic a substrate modification. Background Stereotactic body radiation therapy (SBRT) is a promising therapy for ventricular tachycardia (VT) refractory to catheter ablation. Methods A total of 6 male patients (median age 72 years) with ischemic cardiomyopathy (left ventricular ejection fraction 20% [interquartile range (IQR): 16%-25%]) and VT refractory to antiarrhythmic medications and catheter ablations underwent SBRT to extensive scar substrate. In addition to electroanatomical mapping, 5 of 6 patients had computed tomography segmentation using MUSIC (Institut Hospitalo-Universitaire l’Institut de Rythmologie et Modelisation Cardiaque, Bordeaux, France). Regions of wall thinning Results The median planning target volume was 319 (IQR: 280-330) mL. Device-treated or sustained VT episodes were not significantly reduced by radioablation (median 42 [IQR: 19-269] to 29 [IQR: 0-81]; P = 0.438). However, a reduction in device shocks was observed from 12 (IQR: 3-19) to 0 (IQR: 0-1) (P = 0.046). Over a follow-up period of 231 (IQR: 212-311) days, 3 patients died of end-stage heart failure and 3 of 6 patients had possible adverse events (heart failure exacerbation, pneumonia, and an asymptomatic pericardial effusion). Conclusions Substrate modification using SBRT assisted by computed tomography segmentation is feasible for treatment of VT in patients with ischemic cardiomyopathy. Although a significant reduction in device shocks was observed, suboptimal VT burden reduction and significant mortality rate in this cohort of patients with advanced cardiomyopathy underscore the need to improve mechanistic understanding for antiarrhythmic effects to guide dosing and targeting of scar substrates.

Background Diabetes mellitus (DM) may occur either pre-heart transplant (HT) or as new onset DM post-HT. We sought to define the contemporary incidence of post-HT DM, evaluate risk factors for post-HT DM, and assess the impact of post-HT DM on major outcomes. Methods The cohort included International Society for Heart and Lung Transplantation (ISHLT) Thoracic Organ Transplant Registry adult primary HT-alone recipients, transplanted January 1995-June 2017, who survived to 1 year post-HT. DM status was characterized as (1) No DM pre- or post-HT; (2) Pre-HT DM; or (3) Post-HT DM (onset within 5 years of HT). Cox proportional hazards models were constructed to identify risk factors for post-HT DM onset, as well as risk factors for post-HT severe renal dysfunction and death/retransplantation. Results Of 26 263 eligible subjects, 57% had no DM pre- or post-HT, 22% had pre-HT DM; 21% had new onset post-HT DM. Risk factors for the development of post-HT DM included use of tacrolimus or steroids at 1-year post-HT, as well as with higher recipient age, female sex, ischemic cardiomyopathy, higher body mass index (BMI), pre-HT dialysis, and pre-HT steroid use. Post-HT DM within 5 years was associated with increased subsequent severe renal dysfunction (hazard ratio, HR, 1.89; 95% CI 1.77, 2.01) and death/retransplantation (HR 1.38; 95% CI 1.32, 1.45), compared to patients without post-HT DM. Conclusions Post-HT DM is common, occurring in 21% of recipients within 5 years of HT. Post-HT DM is associated with increased risk of severe renal dysfunction and death or retransplantation.

Introduction Electromagnetic interference (EMI) from left ventricular assist devices (LVADs) can cause implantable cardioverter-defibrillator (ICD) oversensing. We sought to assess the frequency of inappropriate shocks/oversensing due to LVAD-related EMI and prospectively compare integrated (IB) versus dedicated bipolar (DB) sensing in patients with LVADs. Methods Single-center study in LVAD patients with Medtronic or Abbott ICDs between September 2017 and March 2020. We excluded patients that were pacemaker dependent. Measurements were obtained of IB and DB sensing and noise to calculate a signal-to-noise ratio (SNR). Device checks were reviewed to assess appropriate and inappropriate sensing events. Results Forty patients (age 52 ± 14 years, 75% men, 38% ischemic cardiomyopathy) were included with the median time between LVAD implantation and enrollment of 6.7 months [2.3, 11.4 months]. LVAD subtypes included: HeartWare (n=22, 55%), Heartmate II (n=10, 25%), and Heartmate III (n=8, 20%). Over a follow-up duration of 21.6 ± 12.9 months after LVAD implantation, 5% of patients (n=2) had oversensing of EMI from the LVAD (both with HeartWare LVADs and Abbott ICDs) at 4 days and 10.8 months after LVAD implantation. Both patients underwent adjustment of ventricular sensing with resolution of oversensing and no further events over 5 and 15 months of further follow-up. The SNR was similar between IB and DB sensing (50 [29-67] and 57 [41-69], p=0.89). Conclusion ICD oversensing of EMI from LVADs is infrequent and can be managed with reprogramming the sensitivity. There was no significant difference in the R-wave SNR with IB versus DB ICD leads. This article is protected by copyright. All rights reserved.

The aim of the research. To study levels of the apoptosis biomarkers annexin A5 (AnxA5) and Bcl‑2 and to identify the presence of correlations of structural and functional parameters of the myocardium with the level of the studied biomarkers in patients with ischemic cardiomyopathy (ICMP).Materials and methods. Patients with ICMP (n = 47) were examined as the main group. The control group included 30 somatically healthy individuals. Bcl‑2 and APA5 levels were determined in the blood serum by the enzyme immunoassay.Results. It was found that in the group of patients with ICMP. The level of AnxA5 was statistically significantly higher (p < 0.001), and the level of Bcl‑2 was statistically significantly lower (p < 0.001) than in the control group. Based on the results of the correlation analysis a noticeable close relationship on the Cheddock scale was revealed between levels of the studied apoptosis biomarkers and the values of the sphericity index of in diastole and systole of left ventricle (LV), final diastolic and systolic volume of LV and ejection fraction of LV. Between the other parameters of myocardial remodeling and levels of the studied biomarkers of apoptosis, the closeness of relationships on the Cheddock scale were weak and moderate.

Ischemic cardiomyopathy is a common but underestimated cause of heart failure. This study investigated the myocardial-protective effects of nicorandil on rats with ischemic cardiomyopathy. In the present study, ischemic cardiomyopathy rats model were used to evaluate the effects of nicorandil. Cardiac ultrasonography was employed to examine the changes of heart structure and heart function. Electron microscopy was employed to observe the changes of pathological ultrastructure of the myocardium. Western blot and enzyme-linked immunosorbent assays were employed to detect protein levels and Mitochondrial Ca2+ concentration. The heart color ultrasound and myocardial pathology of the rats in the nicorandil group were improved significantly, the mitochondrial Ca2+ concentration was decreased, the expressions of MFN-1, OPA-1, and Bcl were increased, and the expressions of the mitochondrial mitotic proteins DRP-1, VDAC1, CytC, and Bax were decreased in ICM rats' heart treatment with nicorandil, compared with ICM rats. Nicorandil can reduce myocardial pathological damage in ICM rats, which may be caused by promoting the opening of mitochondrial ATP-sensitive potassium channel and inducing the changes of mitochondrial dynamics to induce the reduction of myocardial cell apoptosis.

Background: Despite the low spatial resolution of 2D-multisegment late gadolinium enhancement (2D-MSLGE) sequences, it may be useful in uncooperative patients instead of standard 2D single segmented inversion recovery gradient echo late gadolinium enhancement sequences (2D-SSLGE). The aim of the study is to assess the feasibility and comparison of 2D-MSLGE reconstructed with artificial intelligence reconstruction deep learning noise reduction (NR) algorithm compared to standard 2D-SSLGE in consecutive patients with ischemic cardiomyopathy (ICM). Methods: Fifty-seven patients with known ICM referred for a clinically indicated CMR were enrolled in this study. 2D-MSLGE were reconstructed using a growing level of NR (0%,25%,50%,75%and 100%). Subjective image quality, signal to noise ratio (SNR) and contrast to noise ratio (CNR) were evaluated in each dataset and compared to standard 2D-SSLGE. Moreover, diagnostic accuracy, LGE mass and scan time were compared between 2D-MSLGE with NR and 2D-SSLGE. Results: The application of NR reconstruction ≥50% to 2D-MSLGE provided better subjective image quality, CNR and SNR compared to 2D-SSLGE (p < 0.01). The best compromise in terms of subjective and objective image quality was observed for values of 2D-MSLGE 75%, while no differences were found in terms of LGE quantification between 2D-MSLGE versus 2D-SSLGE, regardless the NR applied. The sensitivity, specificity, negative predictive value, positive predictive value and accuracy of 2D-MSLGE NR 75% were 87.77%,96.27%,96.13%,88.16% and 94.22%, respectively. Time of acquisition of 2D-MSLGE was significantly shorter compared to 2D-SSLGE (p < 0.01). Conclusion: When compared to standard 2D-SSLGE, the application of NR reconstruction to 2D-MSLGE provides superior image quality with similar diagnostic accuracy.

Background BiVACOR is a novel total artificial heart (TAH) utilizing a single centrifugal magnetically levitated rotor with the ability to modulate pulsatile flow. The device has been successfully tested in a bovine model. We undertook a multicenter anatomical and virtual fitting study of the BiVACOR in patients undergoing heart transplantation. Methods 10 patients were recruited across two heart transplant centers. A sterilized 1:1 titanium model of the device was inserted into the patient's chest post heart explant, prior to implantation of the donor heart. Measurements were recorded in situ. The device was then removed. Following this, retrospective 3D reconstructions were created from computed tomography chest scans to simulate a virtual fitting. Results Mean age was 53 years (range 38-67). Mean BMI was 28 (range 20-37). Heart failure etiology was varied-with ischemic cardiomyopathy being the most common. Mean spine-to-sternum distance at the tenth thoracic vertebrae (T10) was 14 cm (range 11-18). Mean aorta to aortic Port distance was 0.2 cm (range 0-0.5). Mean pulmonary artery to pulmonary artery port distance was 4.2 cm (range 1-7). The device fitted suitably in all patients without gross distortion to the geometry between native vessel/chamber and port. Conclusions This study described the anatomical and virtual fitting of the BiVACOR TAH. The device fit well within the chest cavities of all 10 patients, who represented a variety of body morphologies and heart failure etiology.

BACKGROUND: Right heart catheterization for invasive hemodynamics has shown only modest correlation with clinical outcomes. We designed a novel hemodynamic variable that incorporates ventricular output and filling pressure. We anticipated that the aortic pulsatility index (API) would correlate with clinical outcomes in patients with heart failure. METHODS AND RESULTS: We retrospectively analyzed consecutive patients undergoing right heart catheterization with milrinone drug study at our institution (February 2013 to November 2019). The API was calculated as (systolic blood pressure – diastolic blood pressure)/pulmonary capillary wedge pressure. The primary outcome was freedom from advanced therapies, defined as the need for inotropes, temporary mechanical circulatory support, a left ventricular assist device, or orthotopic heart transplantation, or death at 30 days. A total of 224 patient encounters, age 57 years (48–66 years; 34% women; 31% ischemic cardiomyopathy) were included. In univariable analysis, lower baseline API was significantly associated with progression to advanced therapies or death at 30-days (odds ratio 0.43, 95% confidence interval 0.30–0.61; P < .001) compared with those on continued medical management. Receiver operator characteristic analysis specified an optimal cutpoint of 1.45 for API. A Kaplan–Meier analysis indicated an association of API with the primary outcome (79% for API ≥ 1.45 vs 48% for API < 1.45). In multivariable analysis, higher API was strongly associated with freedom from advanced therapies or death (odds ratio 0.38, 95% confidence interval 0.22–0.65, P ≤ .001), even when adjusted for baseline characteristics and routine right heart catheterization measurements. CONCLUSIONS: The API is a novel invasive hemodynamic measurement that is associated independently with freedom from advanced therapies or death at 30-day follow-up.

Objectives This study describes the clinical and electrophysiological characteristics of basal-septal ventricular tachycardias (VTs) in patients with structural heart disease (SHD). Background The basal septum is a common source of VT in patients with SHD. Methods Data from 312 consecutive patients with SHD undergoing catheter ablation of ventricular arrhythmias were reviewed. Results Thirty-three basal-septal VTs in 31 patients (mean age 67.4 ± 14.2 years, mean left ventricular ejection fraction [LVEF] 42% ± 15%) were identified. Patients with VTs with left ventricular basal-septal breakthrough were more likely to have ischemic cardiomyopathy and lower LVEF; patients with right ventricular basal-septal VT were more likely to have sarcoidosis or right ventricular cardiomyopathy of unknown significance, with higher LVEF. Atrioventricular block was present in 45% of patients and intraventricular block including persistent biventricular pacing in 77%. Unipolar scar was larger than bipolar scar (area 18.8% ± 19.4% vs 12.7% ± 14.6%; P Conclusions Basal-septal VTs in patients with SHD have a distinct clinical, electrocardiographic, and electrophysiological profile depending on the breakthrough site, accompanied by a deep intramural septal substrate that limits procedural success after catheter ablation.

In patients with ischemic cardiomyopathy and left ventricular aneurysm formation who are symptomatic despite optimal medical therapy, it is challenging to determine whether surgical ventricular reconstruction, heart transplantation, or left ventricular assist device (LVAD) implantation is the treatment of choice. This report describes the concept of surgical ventricular reconstruction with a specially prepared LVAD fixation ring to facilitate subsequent LVAD implantation if required. In the patient reported in this case, endoventricular circular LVAD ring plasty sufficiently reduced the ventricular volume, normalized the left ventricular geometry, and subsequently led to an improvement of left ventricular ejection fraction.

Background: The subcutaneous cardioverter-defibrillator (S-ICD) continues to be preferentially used in relatively young patients, with less advanced heart disease. Objective: We, therefore, studied the short and long-term efficacy and safety of the S-ICD in subgroups of patients, which are underreported at present. Methods: A total of 218 patients between November 2010 and February 2019 undergoing S-ICD with a follow up of at least 6 months implantation were included in a prospective registry. Mean follow up was 38 months. Results: The most common indication for S-ICD implantation was ischemic cardiomyopathy (n = 106, 49%). Complication rate needing invasive intervention was 9% (n = 21). Appropriate shock rate in patients with an S-ICD was 3.5%/year. A total of 30 inappropriate shocks (IAS) occurred in 19 patients (8.7%; 2.7%/year). The proportion of appropriate and inappropriate shock rates in patients with different cardiomyopathies shows remarkable variances. There were significant more IAS (3.6%/year vs. 1.7%/year, p =.048) in patients with non-ischemic cardiomyopathy versus patients with ischemic cardiomyopathy. Multivariate analysis identified, besides type of cardiomyopathy, atrial fibrillation (AF) as predictor for IAS. Conclusion: In this real-world prospective registry we analyzed S-ICD performance in the more traditional ICD patient. Patients with ischemic cardiomyopathy had significantly less inappropriate therapy compared to patients with non-ischemic cardiomyopathy and appear to be appropriate patients for this type of device.

Combined implantation of cardiac contractility modulation (CCM) with subcutaneous implantable cardioverter-defibrillator (S-ICD) appears a suitable option to reduce the amount of intracardiac leads and complications for patients. Here we report on a patient with ischemic cardiomyopathy carrying an S-ICD in which a CCM device was implanted. During crosstalk testing post-CCM implantation, the S-ICD misannotated QRS complexes and T waves. The problem was solved through reprogramming the CCM, while preserving S-ICD functionality and improving heart failure symptoms. In conclusion, S-ICD combined with CCM seems to be a good and safe option for patients when device interference is being ruled out.

Introduction: Congestive Cardiac Failure (CCF) is an anomalous clinical condition involving insufficient heart pumping and filling. Cardiac failure causes the heart to be unable to provide enough blood to meet the tissue's oxygen needs. Heart disease is the most common explanation why older people are admitted to hospitals or are in need of palliation. This puts a huge economic strain on the health care system. The dynamic, progressive nature of heart failure also leads to poor results, with hospital readmissions being the costliest. About half of those patient die within 5 years after diagnosis. Case presentation [1]: A male patient of 62years from Aarvi Naka was admitted to Medicine Intensive Care Unit (MICU), AVBRH on 11th January 2020 with a known case of Ischemic Cardiomyopathy which was diagnosed itself at AVBRH on 22nd October 2018 and a known case of diabetes and hypertension for 10 years. My patient was brought to AVBRH Emergency Unit on 11th January 2020 with a chief complaint of breathlessness for 2 days, sweating over both feet for 5 days and generalized weakness for 2 weeks. He was having difficulty in breathing for about 2 days which eventually become severe on 11th January 2020 evening and was brought immediately to AVBRH and got admitted on the same day. The patient was delirious and vomit two times on admission.

We assessed image quality using a practical and time-efficient protocol for intravenous glucose loading and insulin injection prior to administration of 18F-fluorodeoxyglucose (18F-FDG) for PET myocardial viability evaluation in patients with ischemic cardiomyopathy, with and without type 2 diabetes mellitus. Methods: Metabolic preparation period (MPP) or optimal cardiac 18F-FDG uptake was determined from the time of intravenous infusion of 12.5 or 25 gram of 50% dextrose to the time of 18F-FDG injection. Cardiac 18F-FDG image quality was evaluated according to a 5-point scoring system (5=excellent to 1=non-diagnostic) by two independent observers. In cases of disagreement, consensus was achieved in a joint reading. Fifteen patients with ischemic cardiomyopathy, who underwent oral glucose loading and i.v. insulin administration, served as reference for MPP comparisons. Results: 59 consecutive patients (age: 63±10yrs, men n = 48 and women n = 11) underwent rest 99mTc-tetrofosmin SPECT/CT and 18F-FDG PET/CT for the evaluation of myocardial viability. FDG image quality was scored as excellent in 42%, very good in 36%, good in 17%, fair in 3%, and non-diagnostic in 2%. Comparing diabetic and non-diabetic patients, the quality scores were excellent in 29% vs. 76% , very good in 41% vs. 18%, good in 24% vs. 6%, fair in 4% vs. 0% , and non-diagnostic in 2% vs. 0%. The mean (±SD) quality score was 4.12±0.95 and overall it was better in non-diabetic than in diabetic patients (4.71±0.59 vs 3.88±0.96; p

Ischemic cardiomyopathy continues to be a major contributor to congestive heart failure, which places a significant burden on our healthcare system. Improving medications and different coronary revascularization strategies are the mainstays in the management of ischemic cardiomyopathy. Although medications and mechanical circulatory support are playing an ever-increasing role, cardiac transplantation remains the gold standard for treating advanced heart failure. Given the small number of available and suitable donor hearts, transplantation is limited for the majority of patients. Surgical ventricular restoration has repeatedly been suggested as a viable alternative in managing heart failure in select patients, as it is believed that surgically returning the ventricle to its original dimensions is possible and associated with favorable outcomes. The purpose of this manuscript is to comprehensively review the current literature on various surgical strategies for ventricular restoration. We also contextualize the published data with respect to ventricular function, volume, structure, arrhythmias, mitral regurgitation, and clinical outcomes.

Ischemic cardiomyopathy results from the combination of scar with fibrosis replacement and areas of dysfunctional but viable myocardium that may improve contractile function with revascularization. Observational studies reported that only patients with substantial amounts of myocardial viability had better outcomes following surgical revascularization. Accordingly, dedicated noninvasive techniques have evolved to quantify viable myocardium with the objective of selecting patients for this form of therapeutic intervention. However, prospective trials have not confirmed the interaction between myocardial viability and the treatment effect of revascularization. Furthermore, recent observations indicate that recovery of left ventricular function is not the principal mechanism by which surgical revascularization improves prognosis. In this paper, the authors describe a more contemporary application of viability testing that is founded on the alternative concept that the main goal of surgical revascularization is to prevent further damage by protecting the residual viable myocardium from subsequent acute coronary events.

Background LIVE (Less Invasive Ventricular Enhancement) with Revivent TC™ is an innovative therapy for symptomatic ischemic Heart Failure (HF). It is designed to reconstruct a negatively remodeled left ventricle (LV) after an anterior myocardial infarction (MI) by plication of the scar tissue. Its indications are specific and, as with any other structural heart intervention, the success of the procedure starts with appropriate patient selection. We aim to present the indications of the technique, crucial aspects in patient selection and individual case planning approach. Methods and Results After clinical evaluation, transthoracic echocardiography is the first imaging modality to be performed in a potential candidate for the therapy. However, definitive indication and detailed case planning rely on late gadolinium-enhanced cardiac magnetic resonance imaging or multiphasic contrast-enhanced cardiac computed tomography. These imaging modalities also assist with relative or absolute contra-indications for the procedure. Individual assessment is done to tailor the procedure to the specifics of the LV anatomy and location of the myocardial scar. Conclusion LIVE procedure is a unique intervention to treat symptomatic heart failure and ischemic cardiomyopathy after anterior MI. It is a highly customizable intervention that allows a patient-tailored approach, based on multimodality imaging assessment and planification.

INTRODUCTION AND OBJECTIVES The expression levels of microRNA-16-5p (miR-16) are upregulated in ischemic cardiomyopathy and in animal models of ischemic dilated cardiomyopathy (iDCM), inducing myocardial apoptosis. We investigated the role of miR-16 in the adaptive cellular response associated with endoplasmic reticulum (ER) stress and autophagy in the apoptotic iDCM environment. METHODS We quantified the miR-16 plasma levels of 168 participants-76 controls, 60 iDCM patients, and 32 familial DCM patients with the pathogenic variant of BAG3-by quantitative real-time polymerase chain reaction and correlated the levels with patient variables. The effects of intracellular miR-16 overexpression were analyzed in a human cardiac cell line. Apoptosis and cell viability were measured, as well as the levels of markers associated with ER stress, cardiac injury, and autophagy. RESULTS Plasma miR-16 levels were upregulated in iDCM patients (P=.039). A multivariate logistic regression model determined the association of miR-16 with iDCM clinical variables (P

Purpose of review As the number of patients with reduced ejection fraction secondary to ischemic cardiomyopathy (ICM) increases, coronary artery bypass grafting is being used with increasing frequency. In this review, we summarize the different operative considerations in this vulnerable patient population. Recent findings Preoperative optimization with mechanical circulatory support devices, especially in the setting of hemodynamic instability, can reduce perioperative morbidity and mortality. The advantage of advanced techniques, such as off-pump CABG and multiple arterial grafting remains unclear. Concomitant procedures, such as ablation for atrial fibrillation remain important considerations that should be tailored to the individual patients risk profile. Summary Despite improvements in perioperative care of patients undergoing CABG, patients with a reduced ejection fraction remain at elevated risk of major morbidity and mortality. Preoperative optimization and careful selection of intraoperative techniques can lead to improved outcomes.

In ischemic cardiomyopathy patients, cardiac sympathetic nervous system dysfunction is a predictor of sudden cardiac arrest (SCA). This study compared abnormal innervation and perfusion measured by [11C]meta-hydroxyephedrine (HED) vs [13N]ammonia (NH3), conventional uptake vs parametric tracer analysis, and their SCA risk discrimination. This is a sub-study analysis of the prospective PAREPET trial, which followed ischemic cardiomyopathy patients with reduced left ventricular ejection fraction (LVEF ≤ 35%) for events of SCA. Using n = 174 paired dynamic HED and NH3 positron emission tomography (PET) scans, regional defect scores (%LV extent × severity) were calculated using HED and NH3 uptake, as well as HED distribution volume and NH3 myocardial blood flow by kinetic modeling. During 4.1 years follow-up, there were 27 SCA events. HED defects were larger than NH3, especially in the lowest tertile of perfusion abnormality (P < .001). Parametric defects were larger than their respective tracer uptake defects (P < .001). SCA risk discrimination was not significantly improved with parametric or uptake mismatch (AUC = 0.73 or 0.70) compared to HED uptake defect scores (AUC = 0.67). Quantification of HED distribution volume and NH3 myocardial blood flow produced larger defects than their respective measures of tracer uptake, but did not lead to improved SCA risk stratification vs HED uptake alone.

The Revivent TC System (BioVentrix Inc, San Ramon, CA) enables a less invasive approach for left ventricular reshaping and scar exclusion in selected patients with ischemic cardiomyopathy. Although the system is designed to improve quality of life and to promote reverse remodeling, patients can still progress to end-stage heart failure requiring advanced therapies. This report describes a case of left ventricular assist device surgery in a patient 16 months after Revivent System implantation. The planning process and surgical technique proved to be complex. This case report can help provide guidance to advanced heart failure teams who encounter patients with the Revivent System who require left ventricular assist device support.

The impact of a provider-driven assessment and treatment algorithm based on remote OptiVol (Medtronic, Minneapolis, MN, USA) fluid index levels on hospitalizations for congestive heart failure (CHF) remains unknown. We implemented a physician-guided screening and educational strategy for elevated OptiVol fluid index levels measured on remote implantable cardioverter-defibrillator (ICD) monitoring and assessed clinical outcomes over a five-year period. Patients with CHF and a left ventricular ejection fraction (LVEF) of 40% or less with a previously implanted ICD underwent monthly remote monitoring from January 2015 to November 2019. An OptiVol fluid index of 60 Ω-days or more triggered a protocol-based CHF screening and therapy adjustment according to clinical presentation. Among 279 patients included in the study, 228 (81%) were male and 205 (73%) had ischemic cardiomyopathy. The average LVEF was 29% (± 7.3%). A total of 6,616 monthly transmissions were reviewed over five years; of those, 575 (8.7%) were associated with elevated OptiVol fluid index levels in 178 (64%) patients, and clinical follow-up data were available in 459 of 575 (80%) cases. Following abnormal OptiVol fluid levels on remote monitoring, CHF hospitalization occurred in 10 of 459 (2.2%) patient cases. In conclusion, monthly remote monitoring of OptiVol fluid index levels with a health care provider-guided CHF screening and an educational approach to abnormal OptiVol fluid index levels were associated with a low CHF hospitalization rate. This compared favorably to prior similar studies, and randomized controlled prospective studies evaluating similar algorithms are warranted.

Background Adaptive cardiac resynchronization therapy (aCRT) is known to have clinical benefits over conventional CRT, but the mechanisms are unclear. Objective Compare effects of aCRT and conventional CRT on electrical dyssynchrony. Methods A prospective, double-blind, 1:1 parallel-group assignment randomized controlled trial in patients receiving CRT for routine clinical indications. Participants underwent cardiac computed tomography and 128-electrode body surface mapping. The primary outcome was change in electrical dyssynchrony measured on the epicardial surface using noninvasive electrocardiographic imaging before and 6 months post-CRT. Ventricular electrical uncoupling (VEU) was calculated as the difference between the mean left ventricular (LV) and right ventricular (RV) activation times. An electrical dyssynchrony index (EDI) was computed as the standard deviation of local epicardial activation times. Results We randomized 27 participants (aged 64 ± 12 years; 34% female; 53% ischemic cardiomyopathy; LV ejection fraction 28% ± 8%; QRS duration 155 ± 21 ms; typical left bundle branch block [LBBB] in 13%) to conventional CRT (n = 15) vs aCRT (n = 12). In atypical LBBB (n = 11; 41%) with S waves in V5-V6, conduction block occurred in the anterior RV, as opposed to the interventricular groove in strict LBBB. As compared to baseline, VEU reduced post-CRT in the aCRT (median reduction 18.9 [interquartile range 4.3–29.2 ms; P = .034]), but not in the conventional CRT (21.4 [-30.0 to 49.9 ms; P = .525]) group. There were no differences in the degree of change in VEU and EDI indices between treatment groups. Conclusion The effect of aCRT and conventional CRT on electrical dyssynchrony is largely similar, but only aCRT harmoniously reduced interventricular dyssynchrony by reducing RV uncoupling., Graphical abstract

Introduction Left ventricular (LV) thrombus is a complication of acute myocardial infarction and is associated with systemic thromboembolism. We describe a trans-aortic endoscopic approach to the removal of an LV thrombus in a patient undergoing concurrent coronary artery bypass grafting and aortic valve replacement. Case presentation A 47 year old male presented following an embolic middle cerebral artery stroke and underwent transthoracic echocardiography demonstrating a mobile LV thrombus. Additional investigation revealed a moderately stenosed bicispid aortic valve, two vessel coronary artery disease and ischemic cardiomyopathy. The patient underwent early surgery to reduce the risk of further embolic episodes. A trans-aortic approach was utilized with videoscopy and single shafted instrumentation to aide in removal of the thrombus. The patient then underwent aortic valve replacement and coronary artery bypass grafting. Conclusion We report an alternative technique for the removal of a left ventricular thrombus in a patient undergoing concurrent coronary and aortic valve surgery. The transaortic video-assisted approach provided excellent visualisation of the apex and near complete removal of the thrombus without damaging the surrounding trabeculae. The main benefit of this technique is sparing of LV tissue, thereby preserving left ventricular function.

Aim: In our study, we evaluated the prognostic value of four calculated inflammatory ratios in patients with colorectal cancer. Material and methods: A six-year retrospective study was conducted on subjects admitted for colorectal cancer at "Prof. Dr. Octavian Fodor" Regional Institute of Gastroenterology and Hepatology Cluj-Napoca, Romania, from January 2014 until September 2019. The medical charts of patients diagnosed with colorectal cancer were used as the source of raw data and for the calculation of four ratios (neutrophil-to-lymphocyte ratio-NLR, derived neutrophil-to-lymphocyte ratio-dNLR, platelet-to-lymphocyte ratio-PLR, and systemic immune-inflammation index-SII), considered as prognostic markers related to mortality in colorectal cancer. Results: One thousand six hundred and eighty-eight patients, with ages ranging from 17 to 98 years, were evaluated. NLR and dNLR displayed significantly higher values among patients who died (NLR: 4.2 for deceased vs. 3.4 for alive, P-value=0.0224; dNLR: 2.7 for deceased vs. 2.3 for alive, Pvalue= 0.0566). Ischemic cardiomyopathy (odds ratio (OR)=2.70), liver cirrhosis (OR=7.84), postoperative complications (OR=2.39), and neutrophil-to-lymphocyte ratio (OR=1.08) proved to be significant prognostic factors for the primary outcome, independent of age and gender. Conclusions: Patients with high NLR, postoperative complications, ischemic cardiomyopathy an d/or liver cirrhosis are the candidates to a less favorable outcome among subjects with colorectal cancer regardless the age and gender.

The prevalence of Heart Failure (HF) has increased over time. Ischemic heart failure accounts for 50% of HF, which results from ischemic coronary heart diseases such as Myocardial Infarction (MI). Conventionally, reduction of cardiac load and revascularization partially increase cardiomyocyte survival and preserve cardiac functions. Nevertheless, how to improve cardiomyocyte rescue and prevent HF progression remain as challenges. Mesenchymal Stem Cells (MSCs) are multipotent stem cells that give rise to various lineages. The administration of MSCs promotes cardiomyocyte survival and improves cardiac functions in animal models of MI and patients with ischemic cardiomyopathy. However, after injection, MSCs persist for a very short time, indicating that the prolonged protective effects of MSCs on cardiomyocytes may be mediated by paracrine functions of MSCs, such as exosomes. In this review, we focus on MSC-derived exosomes in cardiomyocyte protection to facilitate future applications of exosomes in HF treatment.

Ablation of ventricular tachycardias (VTs) in patients with structural heart disease (SHD) has been associated with advanced heart failure and poor survival.This matched case-control study sought to assess the difference in survival after left ventricular assist device (LVAD) implantation and/or heart transplantation (HTX) in SHD patients undergoing VT ablation. From the initial cohort of 309 SHD patients undergoing VT ablation (187 ischemic cardiomyopathy, mean age 64 ± 12 years, ejection fraction of 34 ± 13%), 15 patients received an LVAD and nine patients HTX after VT ablation during a follow-up period of 44 ± 33 months. Long-term survival after LVAD did not differ from the matched control group (p = 0.761), although the cause of lethal events was different. All post-HTX patients survived during follow-up.In this matched case-control study on patients with SHD undergoing VT ablation, patients that received LVAD implantation had similar survival compared to the control group after 4‑year follow-up, while the patients with HTX had a significantly better outcome.EINFüHRUNG: Die Ablation ventrikulärer Tachykardien (VT) bei Patienten mit struktureller Herzerkrankung wird mit fortgeschrittener Herzinsuffizienz und schlechter Überlebensprognose assoziiert.Diese gematchte Fall-Kontroll-Studie untersuchte den Einfluss einer linksventrikulären Assist-Device(LVAD)-Implantation und/oder einer Herztransplantation (HTX) auf die Überlebensprognose von Patienten mit struktureller Herzerkrankung und stattgehabter VT-Ablation. Von den initial 309 Patienten, die für eine VT-Ablation eingewiesen wurden (187 mit ischämischer Kardiomyopathie, mittleres Alter 64 ± 12 Jahre, Ejektionsfraktion 34 ± 13 %), erhielten 15 ein LVAD und 9 eine HTX während des Follow-ups von 44 ± 33 Monaten. Die Langzeitüberlebensraten nach LVAD-Implantation waren ähnlich wie in der gematchten Kontrollgruppe (p = 0,761), aber die Todesursachen waren unterschiedlich. Alle Patienten nach HTX überlebten bis zum Ende des Follow-ups.In unserer Studie zu Patienten mit struktureller Herzerkrankung und stattgehabter VT-Ablation zeigten die Patienten mit LVAD-Implantation nach 4 Jahren Follow-up ähnliche Überlebensraten wie die Kontrollgruppe, während Patienten mit HTX ein deutlich besseres Langzeitergebnis hatten.

Background Heart failure (HF) is associated with highly significant morbidity, mortality, and health care costs. Despite the significant advances in therapies and prevention, HF remains associated with poor clinical outcomes. Understanding the contractile force and kinetic changes at the level of cardiac muscle during end-stage HF in consideration of underlying etiology would be beneficial in developing targeted therapies that can help improve cardiac performance. Objective Investigate the impact of the primary etiology of HF (ischemic or non-ischemic) on left ventricular (LV) human myocardium force and kinetics of contraction and relaxation under near-physiological conditions. Methods and results Contractile and kinetic parameters were assessed in LV intact trabeculae isolated from control non-failing (NF; n = 58) and end-stage failing ischemic (FI; n = 16) and non-ischemic (FNI; n = 38) human myocardium under baseline conditions, length-dependent activation, frequency-dependent activation, and response to the β-adrenergic stimulation. At baseline, there were no significant differences in contractile force between the three groups; however, kinetics were impaired in failing myocardium with significant slowing down of relaxation kinetics in FNI compared to NF myocardium. Length-dependent activation was preserved and virtually identical in all groups. Frequency-dependent activation was clearly seen in NF myocardium (positive force frequency relationship [FFR]), while significantly impaired in both FI and FNI myocardium (negative FFR). Likewise, β-adrenergic regulation of contraction was significantly impaired in both HF groups. Conclusions End-stage failing myocardium exhibited impaired kinetics under baseline conditions as well as with the three contractile regulatory mechanisms. The pattern of these kinetic impairments in relation to NF myocardium was mainly impacted by etiology with a marked slowing down of kinetics in FNI myocardium. These findings suggest that not only force development, but also kinetics should be considered as a therapeutic target for improving cardiac performance and thus treatment of HF.

Objectives The aim of this study was to investigate the regional distribution of novel 18F-labeled positron emission tomographic (PET) tracer flubrobenguane (FBBG) (whose longer half-life could enable more widespread use) to assess myocardial presynaptic sympathetic nerve function in humans in comparison to [11C]meta-hydroxyephedrine (HED). Background The sympathetic nervous system (SNS) is vitally linked to cardiovascular regulation and disease. SNS imaging has shown prognostic value. HED is the most commonly used PET tracer for evaluation of sympathetic function in humans, but widespread clinical use is limited because of the short half-life of 11C. Methods A total of 25 participants (n = 6 healthy; n = 14 ischemic cardiomyopathy, left ventricular [LV] ejection fraction [EF] = 34 ± 5%; and n = 5 nonischemic cardiomyopathy, EF = 33 ± 3%) underwent 2 separate PET imaging visits 8.7 ± 7.6 days apart. On 1 visit, participants underwent dynamic HED PET imaging. On a different visit, participants underwent dynamic FBBG PET imaging. The order of testing was random. HED and FBBG global innervation (retention index [RI] and distribution volume [DV]) and regional denervation (% nonuniformity) were quantified to assess regional presynaptic sympathetic innervations. Results FBBG RI (r2 = 0.72; ICC = 0.79; p Conclusions FBBG and HED yield equivalent global and regional distributions in both patients with and without ischemic cardiomyopathy. 18F-labeled PET tracers, such as FBBG, are critical for widespread distribution necessary for multicenter clinical trials and to maximize patient impact.

Cardiomyopathy can have different aetiologies. Patient may present with typical symptoms of acute heart failure or ischemic chest pain, depending on the underlying aetiologies. It is the responsibility of the treating physician to find out the cause as prompt treatment could possibly alter the prognosis of the patient, but at the same time bearing in mind other possible diagnosis apart from the one which is obvious. In this case, we present a lady who came with breathlessness and no chest pain. She was tachycardic and tachypnoeic upon arrival and her electrocardiogram (ECG) showed ischemic changes in the inferior and lateral leads. Bedside echocardiogram showed dilated left ventricle. Her cardiac biomarker was raised, making an ischemic event unlikely to be excluded. She eventually succumb to her illness. The objective of this case report was to highlight the importance of keeping an open mind about the differential diagnoses available, knowing that the conditions could have overlap features.

Selection of the ideal surgical procedure for coronary revascularization in patients with severe cardiac dysfunction at times may represent a challenge. In recent years, with the advent of surgical large microaxial pumps, e.g., Impella 5.0 (Abiomed Inc., Boston, USA), specific support and effective unloading of the left ventricle has become available. In the interventional field, good results have been achieved with smaller microaxial pumps in the setting of so-called protected percutaneous coronary intervention. In this study, we would like to share our early experience with surgical coronary revascularization under the sole support of Impella 5.0, omitting the use of heart–lung machine in three cases of severe cardiac dysfunction due to complex ischemic heart disease. Effective circulatory support intraoperatively and postoperatively speaks in favor of this technique in selected patients.

Aims The goal of our study was to investigate the heterogeneity of cardiac macrophages (CMφs) in mice with transverse aortic constriction (TAC) via single-cell sequencing and identify a subset of macrophages associated with heart injury. Methods and results We selected all CMφs from CD45+ cells using single-cell mRNA sequencing data. Through dimension reduction, clustering and enrichment analyses, CD72hi CMφs were identified as a subset of proinflammatory macrophages. The pseudotime trajectory and ChIP-Seq analyses identified Rel as the key transcription factor that induces CD72hi CMφ differentiation. Rel KD and Rel-/- bone marrow chimera mice subjected to TAC showed features of mitigated cardiac injury, including decreased levels of cytokines and ROS, which prohibited cardiomyocyte death. The transfer of adoptive Rel-overexpressing monocytes and CD72hi CMφ injection directly aggravated heart injury in the TAC model. The CD72hi macrophages also exerted proinflammatory and cardiac injury effects associated with myocardial infarction (MI). In humans, patients with heart failure exhibit increased CD72hi CMφ levels following dilated cardiomyopathy (DCM) and ischemic cardiomyopathy (ICM). Conclusion Bone marrow-derived, Rel-mediated CD72hi macrophages play a proinflammatory role, induce cardiac injury and, thus, may serve as a therapeutic target for multiple cardiovascular diseases. Translational perspective Heart failure (HF) imposes an enormous clinical and economic burden worldwide and presents limited therapeutic approaches. Given the close association between inflammation and adverse outcomes, proinflammatory immune cells are considered potential therapeutic targets for HF treatment. The present studies identified a specific macrophage subset associated with myocardial injury, which may provide an alternative approach for treating cardiovascular diseases.

Background The implantable cardiac defibrillator is the cornerstone of prevention of sudden cardiac death in non‐ischemic cardiomyopathy. The Selvester score, which is frequently investigated in ischemic cardiomyopathy, has not been investigated in the field of non‐ischemic cardiomyopathy. Aim The aim of this study was to evaluate the Selvester score for determining appropriate implantable cardiac defibrillator shocks in non‐ischemic cardiomyopathy patients. Materials and methods In all, 131 non‐ischemic cardiomyopathy patients were included in the study. A simplified Selvester score was calculated from ECG data. Patients were divided into two groups according to whether they received ICD shock. Results Of the patients, 28.2% received appropriate implantable cardiac defibrillator shock. The Selvester score was significantly higher in patients receiving appropriate shock when compared to patients with no implantable cardiac defibrillator shocks (8.8 ± 4.6 vs 7.2 ± 3.3, P = .040). The median QRS duration was significantly longer in patients receiving appropriate shock than in patients with no shocks (130.14 ± 35.08 ms vs 120.12 ± 20.57 ms, P = .045). We determined that the cutoff value for the Selvester score to predict ICD shocks was 6.5 with a sensitivity of 72.0% and a specificity of 83% (AUC = 0.717; %95 GA: 0.627‐0.807, P, Selvester score was higher in patients receiving appropriate shock than in patients who did not recieve any implantable cardiac defibrillator shock. In the selection of patients undergoing implantable cardioverter defibrillator for primer prevention of sudden cardiac death with nonischemic cardiomyopathy, the Selvester score may be used in addition to left ventricular ejection fraction.

Background The aging population is an increasing concern in Western hospital systems. The aim of this study was to describe the main characteristics and hospitalization patterns in inpatients aged 85 years or more in Spain from 2000 to 2015. Methods Retrospective observational study analyzing data from the minimum basic data set, an administrative registry recording each hospital discharge in Spain since 1997. We collected administrative, economic and clinical data for all discharges between 2000 and 2015 in patients aged 85 years and older, reporting results in three age groups and four time periods to assess differences and compare trends. Results There were 4,387,326 discharges in very elderly patients in Spain from 2000 to 2015, representing 5.32% of total discharges in 2000–2003 and 10.42% in 2012–2015. The pace of growth was faster in older age groups, with an annual percentage increase of 6% in patients aged 85–89 years, 7.79% in those aged 90–94 years, and 8.06% in those aged 95 and older. The proportion of men also rose (37.30 to 39.70%, p The proportion of patients that died during hospital admission decreased from 14.64% in 2000–2003 to 13.83% in 2012–2015 (p Some of the most frequent primary diagnoses became even more frequent relative to the total number of primary diagnoses, such as heart failure (7.84 to 10.62%), pneumonia (6.36 to 7.36%), other respiratory diseases (3.87 to 8.49%) or other alterations of urinary tract (3.08 to 5.20%). However, there was a relative decrease in the proportion of femoral neck fractures (8.07 to 6.77%), neoplasms (7.65 to 7.34%), ischemic encephalopathy (6.97 to 5.85%), COPD (4.23 to 3.15%), ischemic cardiomyopathy (4.20 to 8.49%) and cholelithiasis (3.07 to 3.28%). Conclusions Discharges in the very elderly population are increasing in both relative and absolute terms in Spanish hospitals. Within this group, discharged patients are getting older and more frequently male. The mean length of stay and the proportion of patients that died during hospital admission are decreasing. Acute-on-chronic organ diseases, neoplasms, acute cardiovascular diseases, and infections are the most common causes of discharge.

Background MR feature-tracking (FT) is a novel technique that quantitatively calculates myocardial strain and can assess myocardial viability. Purpose To evaluate the feasibility of FT at rest and with low-dose dobutamine (LDD), visual assessment of contractility with LDD and left ventricle (LV) end-diastolic wall thickness (EDWT) in the assessment of viability in ischemic cardiomyopathy (ICM) patients compared to delayed gadolinium enhancement (DGE). Study type Prospective. Subjects Thirty ICM patients and 30 healthy volunteers. Field strength/sequences A 1.5 T with balanced steady-state free precession (bSSFP) cine and phase-sensitive inversion prepared segmented gradient echo sequences. Assessment LDD (5 μg/kg/min and 10 μg/kg/min) was administered in the patient group. LV was divided into 16 segments and MR-FT was derived from bSSFP cine images using dedicated software. Viable segments were defined as those with a dobutamine-induced increase in resting MR-FT values >20%, a dobutamine-induced increase in systolic wall thickening ≥2 mm by visual assessment, ≤50% fibrosis on DGE, and resting EDWT ≥5.5 mm. Statistical tests One-way analysis of variance (ANOVA), two-sampled t-test, paired samples t-test, and receiver operating characteristic (ROC) curve analysis. A P value Results Resting peak global circumferential (Ecc) and radial (Err) strains were significantly impaired in patients compared to controls (-11.7 ± 7.9 vs. -20.1 ± 5.7 and 19.7 ± 13.9 vs. 32.7 ± 15.4, respectively). Segments with no DGE (n = 354) and ≤ 50% (n = 38) DGE showed significant improvement of both Ecc and Err with LDD while segments with >50% DGE (n = 88) showed no improvement. In comparison to viable and nonviable segments identified by reference-standard DGE, the sensitivity, specificity, and diagnostic accuracy of the four methods were: 74%, 92%, and 89%, respectively, for Ecc; 70%, 89%, and 86%, respectively, for Err; 67%, 88%, and 84% for visual assessment; and 39%, 90%, and 80% for EDWT. Data conclusion Quantitative assessment of MR-FT, along with EDWT and qualitative visual assessment of myocardial contractility with LDD, are feasible alternative methods for the assessment of myocardial viability with moderate sensitivity and high specificity. Level of evidence 1 TECHNICAL EFFICACY: Stage: 2.

The PAINESD risk score was developed in 2015 as a tool to stratify the risk of acute hemodynamic decompensation during ventricular tachycardia (VT) ablation in structural heart disease patients and further then used for post procedure 30-day mortality prediction. The original cohort however did not include Chagas disease (ChD) patients. We aim to evaluate the relevance of the score in a ChD population. The PAINESD risk score gives weighted values for specific characteristics (chronic obstructive pulmonary disease, age > 60 years, ischemic cardiomyopathy, New York Heart Association [NYHA] functional class 3 or 4, ejection fraction less than 25%, VT storm, and diabetes). The score was applied in a retrospective cohort of ChD VT ablations in a single tertiary center in Brazil. Data were collected by VT study reports and patient record analysis at baseline and on follow-up. Between January 2013 and December 2018, 157 VT catheter ablation procedures in 121 ChD patients were analyzed. Overall, 30-day mortality was 9.0%. Multivariate analysis correlated NYHA functional class (HR 1.78, 95% CI 1.03–3.08, P 0.038) and the need for urgent surgery (HR 31.5, 95% CI 5.38–184.98, P < 0.001), as well as a tendency for VT storm at presentation (HR 2.72, 95% CI 0.87–8.50, P 0.084) as risk factors for the primary endpoint. The median PAINESD risk score in this population was 3 (3–8). The area under the receiver operating characteristic (ROC) curve was 0.64 (95% CI 0.479–0.814). The PAINESD risk score did not perform well in predicting 30-day mortality in ChD patients. Pre-procedure NYHA functional class and the need for urgent surgery due to refractory pericardial bleeding were independently associated with increased 30-day mortality. Prospective studies are needed to take final conclusions in Chagas disease when using PAINESD score.

Nonischemic cardiomyopathies encompass a broad spectrum of myocardial disorders with mechanical or electrical dysfunction without evidence of ischemia. There are five broad variants of nonischemic cardiomyopathies; hypertrophic cardiomyopathy (Variant 1), restrictive or infiltrative cardiomyopathy (Variant 2), dilated or unclassified cardiomyopathy (Variant 3), arrhythmogenic cardiomyopathy (Variant 4), and inflammatory cardiomyopathy (Variant 5). For variants 1, 3, and 4, resting transthoracic echocardiography, MRI heart function and morphology without and with contrast, and MRI heart function and morphology without contrast are the usually appropriate imaging modalities. For variants 2 and 5, resting transthoracic echocardiography and MRI heart function and morphology without and with contrast are the usually appropriate imaging modalities. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Background Ventricular tachycardia (VT) catheter ablation success may be limited when transcutaneous epicardial access is contraindicated. Surgical ablation (SurgAbl) is an option, but ablation guidance is limited without simultaneously acquired electrophysiological data. Objective We describe our SurgAbl experience utilizing contemporary electroanatomic mapping (EAM) among patients with refractory VT storm. Methods Consecutive patients with recurrent VT despite antiarrhythmic drugs (AADs) and prior ablation, for whom percutaneous epicardial access was contraindicated, underwent open SurgAbl using intraoperative EAM guidance. Results Eight patients were included, among whom mean age was 63 ± 5 years, all were male, mean left ventricular ejection fraction was 39% ± 12%, and 2 (25%) had ischemic cardiomyopathy. Reasons for surgical epicardial access included dense adhesions owing to prior cardiac surgery, hemopericardium, or pericarditis (n = 6); or planned left ventricular assist device (LVAD) implantation at time of SurgAbl (n = 2). Cryoablation guided by real-time EAM was performed in all. Goals of clinical VT noninducibility or core isolation were achieved in 100%. VT burden was significantly reduced, from median 15 to 0 events in the month pre- and post-SurgAbl (P = .01). One patient underwent orthotopic heart transplantation for recurrent VT storm 2 weeks post-SurgAbl. Over mean follow-up of 3.4 ± 1.7 years, VT storm–free survival was achieved in 6 (75%); all continued AADs, although at lower dose. Conclusion Surgical mapping and ablation of refractory VT with use of contemporary EAM is feasible and effective, particularly among patients with contraindication to percutaneous epicardial access or with another indication for cardiac surgery.

Background: Implantable cardioverter defibrillators (ICDs) are effective in preventing arrhythmic sudden cardiac death in patients with tetralogy of Fallot (TOF). Although ICD therapies for malignant ventricular arrhythmias can be life-saving, shocks could have deleterious consequences. Substrate-based ablation therapy has become the standard of care to prevent recurrent ICD shocks in patients with ischemic cardiomyopathy. However, the efficacy and safety of this invasive therapy in the prevention of recurrent ICD shocks in patients with TOF has not been well evaluated. Methods: Records of a total of 47 consecutive TOF patients (mean age: 43.1 ± 13.2 years, male sex: n = 34 [72.3%]) who underwent ICD implantation for secondary prevention between 2000 and 2018 were reviewed. Results: Twenty (42.6%) patients underwent invasive therapy (radiofrequency catheter ablation, n = 8; surgical ablation with pulmonary valve replacement, n = 12) before ICD implantation. Twenty-seven patients (57.4%) were managed noninvasively. During follow-up (median 80.5 [interquartile range, 28.5-131.0] months), 2 (10.0%) patients in the invasive group and 10 (37.0%) patients in the noninvasive group received appropriate ICD shocks (P = 0.036). Logistic regression analysis showed that invasive therapy was associated with a decreased risk of ICD shocks by 81.1% (odds ratio, 0.189; 95% confidence interval, 0.036-0.990; P = 0.049). Furthermore, invasive therapy was associated with decreased risk of the composite outcomes of ICD shock, death, cardiac transplantation, and hospital admission (odds ratio, 0.090; 95% confidence interval, 0.025-0.365; P = 0.013) compared with noninvasive therapy. Conclusions: Invasive substrate modification therapy was associated with a lower likelihood of ICD shocks and improvement of long-term outcomes in TOF patients. Résumé: Contexte: Les défibrillateurs cardioverteurs implantables (DCI) sont efficaces pour prévenir la mort cardiaque subite provoquée par une arythmie chez les patients présentant une tétralogie de Fallot (TF). Bien que le traitement des arythmies ventriculaires malignes par DCI puisse sauver des vies, les chocs administrés peuvent avoir des conséquences délétères. L’ablation du substrat est devenue le traitement de référence pour prévenir l’administration à répétition de chocs par DCI chez les patients atteints d’une cardiomyopathie ischémique. L’efficacité et l’innocuité de ce traitement invasif pour prévenir l’administration de chocs répétés chez les patients présentant une TF n’ont toutefois pas été bien évaluées. Méthodologie: Nous avons examiné les cas consécutifs de 47 patients présentant une TF (âge moyen : 43,1 ± 13,2 ans; hommes : n = 34 [72,3 %]) ayant reçu un DCI en prévention secondaire entre 2000 et 2018. Résultats: Au total, 20 (42,6 %) patients ont subi un traitement invasif (ablation par cathéter par radiofréquence, n = 8; ablation chirurgicale et remplacement de la valve pulmonaire, n = 12) avant l’implantation d’un DCI. Vingt-sept patients (57,4 %) ont été pris en charge de façon non invasive. Au cours de la période de suivi (durée médiane de 80,5 [intervalle interquartile : 28,5 à 131,0] mois), 2 (10,0 %) patients du groupe ayant subi une intervention invasive et 10 (37,0 %) patients du groupe ayant subi une intervention non invasive ont reçu un choc approprié par DCI (p = 0,036). Les résultats de l’analyse par régression logistique montrent que le traitement invasif est associé à une réduction du risque de choc par DCI de 81,1 % (rapport des cotes : 0,189; intervalle de confiance à 95 % : de 0,036 à 0,990; p = 0,049). En outre, le traitement invasif est associé à une réduction du risque de survenue d’un des événements du paramètre d’évaluation composé, soit un choc administré par DCI, le décès, une transplantation cardiaque ou une hospitalisation (rapport des cotes : 0,090; intervalle de confiance à 95 % : de 0,025 à 0,365; p = 0,013) par rapport au traitement non invasif. Conclusions: La modification invasive du substrat a été associée à une probabilité plus faible de choc administré par DCI et à une amélioration des résultats à long terme chez les patients présentant une TF.

Background and Aims: Cardiovascular comorbidities are common in patients with COVID-19 and these patients are at higher risk of morbidity and mortality. It is not known if the presence of cardiovascular co-morbid conditions poses independent risk or whether this is mediated by other factors. Methods: This is a retrospective follow up study done at Shahid Gangalal National Heart Centre (SGNHC). The main objective of this study was to study the clinical profile, baseline comorbidities, and outcome of cardiac patients and health care worker diagnosed with COVID 19. This study retrospectively evaluated case records of all cardiovascular disease (CVD) patients admitted at SGNHC with COVID 19 cases from 1st case diagnosed on July at SGNHC till September 2020. Results: During this study period, 90 patients with COVID 19 with cardiovascular disease were admitted. The mean age of the study population was 52.3±19 years with 65.6% being male. Among the study population 52 (57.8%) had past history of cardiovascular disease, hypertension in 18 (20%) cases, diabetes in 8 (8.9%) cases. Among the patients with cardiovascular diagnosis, acute coronary syndrome was most common cardiovascular diagnosis in 23 (25.6% cases) followed by rheumatic heart disease in 21 (23.4%) cases, dilated cardiomyopathy in 7 (7.8% cases), ischemic cardiomyopathy with reduced ejection fraction (EF) in 7 (7.8%) cases, post coronary artery bypass graft (CABG) in 8 (8.9%), post valve replacement in 5 (5.5%), congenital heart disease in 3.3% cases and complete heart block in 3.3% cases. Most of the cases were symptomatic with moderate illness in 46.7% cases, mild illness in 41.4% cases and severe/critical illness in 11.1% cases. Among COVID patients with cardiovascular disease, the mortality was 11.1%. Conclusion: Patients with cardiovascular disease with COVID 19 have more severe COVID 19 symptoms and has higher COVID 19 related death, so strict vigilance and early intervention is needed to improve its outcome.

Aims Direct remuscularization with pluripotent stem cell-derived cardiomyocytes (PSC-CMs) seeks to address the onset of heart failure post-myocardial infarction (MI) by treating the persistent muscle deficiency that underlies it. However, direct remuscularization with PSC-CMs could potentially be arrhythmogenic. We investigated two possible mechanisms of arrhythmogenesis-focal vs reentrant-arising from direct remuscularization with PSC-CM patches in two personalized, human ventricular computer models of post-MI. Moreover, we developed a principled approach for evaluating arrhythmogenicity of direct remuscularization that factors in the VT propensity of the patient-specific post-MI fibrotic substrate and use it to investigate different conditions of patch remuscularization. Methods & results Two personalized, human ventricular models of post-MI (P1 & P2) were constructed from late gadolinium enhanced (LGE)-magnetic resonance images (MRI). In each model, remuscularization with PSC-CM patches were simulated under different treatment conditions that included patch engraftment, patch myofibril orientation, remuscularization site, patch size (thickness and diameter), and patch maturation. To determine arrhythmogenicity of treatment conditions, VT burden of heart models was quantified prior to and after simulated remuscularization and compared. VT burden was quantified based on inducibility (i.e., weighted sum of pacing sites that induced) and severity (i.e., the number of distinct VT morphologies induced). Prior to remuscularization, VT burden was significant in P1 (0.275) and not in P2 (0.0, not VT inducible). We highlight that reentrant VT mechanisms would dominate over focal mechanisms; spontaneous beats emerging from PSC-CM grafts were always a fraction of resting sinus rate. Moreover, incomplete patch engraftment can be particularly arrhythmogenic, giving rise to particularly aberrant electrical activation and conduction slowing across the PSC-CM patches along with elevated VT burden when compared to complete engraftment. Under conditions of complete patch engraftment, remuscularization was almost always arrhythmogenic in P2 but certain treatment conditions could be anti-arrhythmogenic in P1. Moreover, the remuscularization site was the most important factor affecting VT burden in both P1 and P2. Complete maturation of PSC-CM patches, both ionically and electrotonically, at the appropriate site could completely alleviate VT burden. Conclusion We identified that reentrant VT would be the primary VT mechanism in patch remuscularization. To evaluate the arrhythmogenicity of remuscularization, we developed a principled approach that factors in the propensity of the patient-specific fibrotic substrate for VT. We showed that arrhythmogenicity is sensitive to the patient-specific fibrotic substrate and remuscularization site. We demonstrate that targeted remuscularization can be safe in the appropriate individual and holds the potential to nondestructively eliminate VT post-MI in addition to addressing muscle deficiency underlying heart failure progression. Translational perspective If safety from ventricular arrhythmias can be addressed, direct remuscularization with PSC-CMs-achieved either through engineered myocardial patches or intramyocardial injections-holds the potential to halt heart failure progression post-MI. Using personalized 3 D models of the post-MI ventricles derived from LGE-MRI, we provide evidence that arrhythmogenesis following remuscularization with PSC-CM patches is driven by a reentrant as opposed to focal VT mechanism. Moreover, the existing patient-specific fibrotic substrate together with the remuscularization site were primary determinants of arrhythmogenesis. These results suggest that the clinical safety of remuscularization can be achieved through patient-specific optimization guided in-part by computational modeling.