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Background: Human umbilical cord matrix-mesenchymal stromal cells (hUCM-MSC) have demonstrated beneficial effects in experimental acute myocardial infarction (AMI). Reperfusion injury hampers myocardial recovery in a clinical setting and its management is an unmet need. We investigated the efficacy of intracoronary (IC) delivery of xenogeneic hUCM-MSC as reperfusion-adjuvant therapy in a translational model of AMI in swine., Methods: In a placebo-controlled trial, pot-belied pigs were randomly assigned to a sham-control group (vehicle-injection; n  = 8), AMI + vehicle ( n  = 12) or AMI + IC-injection ( n  = 11) of 5 × 10 5 hUCM-MSC/Kg, within 30 min of reperfusion. AMI was created percutaneously by balloon occlusion of the mid-LAD. Left-ventricular function was blindly evaluated at 8-weeks by invasive pressure-volume loop analysis (primary endpoint). Mechanistic readouts included histology, strength-length relationship in skinned cardiomyocytes and gene expression analysis by RNA-sequencing., Results: As compared to vehicle, hUCM-MSC enhanced systolic function as shown by higher ejection fraction (65 ± 6% vs. 43 ± 4%; p  = 0.0048), cardiac index (4.1 ± 0.4 vs. 3.1 ± 0.2 L/min/m 2 ; p  = 0.0378), preload recruitable stroke work (75 ± 13 vs. 36 ± 4 mmHg; p  = 0.0256) and end-systolic elastance (2.8 ± 0.7 vs. 2.1 ± 0.4 mmHg*m 2 /ml; p  = 0.0663). Infarct size was non-significantly lower in cell-treated animals (13.7 ± 2.2% vs. 15.9 ± 2.7%; Δ = -2.2%; p  = 0.23), as was interstitial fibrosis and cardiomyocyte hypertrophy in the remote myocardium. Sarcomere active tension improved, and genes related to extracellular matrix remodelling (including MMP9, TIMP1 and PAI1), collagen fibril organization and glycosaminoglycan biosynthesis were downregulated in animals treated with hUCM-MSC., Conclusion: Intracoronary transfer of xenogeneic hUCM-MSC shortly after reperfusion improved left-ventricular systolic function, which could not be explained by the observed extent of infarct size reduction alone. Combined contributions of favourable modification of myocardial interstitial fibrosis, matrix remodelling and enhanced cardiomyocyte contractility in the remote myocardium may provide mechanistic insight for the biological effect., Competing Interests: LR has received honoraria fees from EcBIO™—R&D in Biotechnology, SA (Lisbon, Portugal), and has served as a member of advisory boards for the company. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2023 Raposo, Cerqueira, Leite, Moreira-Costa, Laundos, Miranda, Mendes-Ferreira, Coelho, Gomes, Pinto-do-Ó, Nascimento, Lourenço, Cardim and Leite-Moreira.)

Introduction: The benefit of adding a second arterial conduit is still controversial, mainly in specific subgroups. We conducted a meta-analysis of randomized controlled trials (RCTs) and propensity score (PS) studies comparing survival and early results in elderly patients who underwent coronary artery bypass grafting (CABG) with multiple (MAG) versus single arterial grafting (SAG)., Evidence Acquisition: MEDLINE, Web of Science and Cochrane Library were used to find relevant literature (1960-April 2020). Survival at a ≥1-year follow-up and early outcomes were evaluated. Outcomes were collected from matched samples or PS adjusted analysis: hazard ratio (HR) along with their variance, frequencies or odds ratios. Random effect models were used to compute combined statistical measures and 95% confidence intervals (CI) through generic inverse variance method (time-to-event) or Mantel-Haenszel method (binary events)., Evidence Synthesis: Eleven PS cohorts and 1 RCT comprising >18,800 patients older than 70 (>6200 MAG and >12,500 SAG) were included in this meta-analysis. MAG was associated with lower long-term mortality (pooled HR: 0.81, 95% CI: 0.72-0.91, P<0.01, I 2 =64%) in the absence of higher risk of early mortality (pooled OR: 0.74, 95% CI: 0.44 to 1.25, P=0.27, I 2 =0%). In a meta-regression, MAG survival advantage was more pronounced in studies with a higher MAG usage rate (β=-0.0052, P=0.021)., Conclusions: Current evidence suggests that advanced age should not limit MAG's use considering its benefits in long-term survival. Of note, an individualized patient selection for this approach is warranted.

Myocardial fluid homeostasis relies on a complex interplay between microvascular filtration, interstitial hydration, cardiomyocyte water uptake and lymphatic removal. Dysregulation of one or more of these mechanisms may result in myocardial oedema. Interstitial and intracellular fluid accumulation disrupts myocardial architecture, intercellular communication, and metabolic pathways, decreasing contractility and increasing myocardial stiffness. The widespread use of cardiac magnetic resonance enabled the identification of myocardial oedema as a clinically relevant imaging finding with prognostic implications in several types of heart failure. Furthermore, growing experimental evidence has contributed to a better understanding of the physical and molecular interactions in the microvascular barrier, myocardial interstitium and lymphatics and how they might be disrupted in heart failure. In this review, we summarize current knowledge on the factors controlling myocardial water balance in the healthy and failing heart and pinpoint the new potential therapeutic avenues., (© 2022 The Authors. ESC Heart Failure published by John Wiley & Sons Ltd on behalf of European Society of Cardiology.)

Competing Interests: The authors have no financial conflicts of interest.

Introduction: Comparison of short and mid-term outcomes between off-pump CABG (OPCAB) and on-pump CABG (ONCAB) in patients older than 65 throughout a meta-analysis of randomized clinical trials (RCTs)., Evidence Acquisition: A literature search was conducted using 3 databases. RCTs reporting mortality outcomes of OPCAB versus ONCAB among the elderly were included. Data on myocardial infarction, stroke, re-revascularization, renal failure and composite endpoints after CABG were also collected. Random effects models were used to compute statistical combined measures and 95% confidence intervals (CI)., Evidence Synthesis: Five RCTs encompassing 6221 patients were included (3105 OPCAB and 3116 ONCAB). There were no significant differences on mid-term mortality (pooled HR: 1.02, 95%CI: 0.89-1.17, P=0.80) and composite endpoint incidence (pooled HR: 0.98, 95%CI: 0.88-1.09, P=0.72) between OPCAB and ONCAB. At 30-day, there were no differences in mortality, myocardial infarction, stroke and renal complications. The need for early re-revascularization was significantly higher in OPCAB (pooled OR: 3.22, 95%CI: 1.28-8.09, P=0.01), with a higher percentage of incomplete revascularization being reported for OPCAB in trials included in this pooled result (34% in OPCAB vs. 29% in ONCAB, P<0.01)., Conclusions: Data from RCTs in elderly patients showed that OPCAB and ONCAB provide similar mid-term results. OPCAB was associated with a higher risk of early re-revascularization. As CABG on the elderly is still insufficiently explored, further RCTs, specifically designed targeting this population, are needed to establish a better CABG strategy for these patients.

Background: Little is known about the impact of severe aortic stenosis (AS) in aortic stiffness and if there is any change after removing AS barrier with aortic valve replacement (AVR) surgery., Objective: To estimate carotid-femoral pulse wave velocity (PWV) changes after AVR surgery and to define PWV predictors in severe AS patients., Methods: Single-center retrospective cohort, including patients with severe AS who underwent AVR surgery with bioprostheses, between February 2017 and January 2019 and performed PWV measurements (Complior®) before and after the procedure (2±1 months). Before and after AVR, PWV values were compared through paired tests. The associations of PWV with clinical data were studied and linear regression models were applied to estimate pre and postoperative PWV independent predictors. The significance level was set at 5%., Results: We included 150 patients in the sample, with mean age of 72±8 years, and 51% being males. We found a statistically significant increase in PWV values after surgery (9.0±2.1 m/s vs. 9.9±2.2, p<0.001, before and after AVR, respectively) and an inverse association with AS severity variables. In the linear regression model, age and systolic blood pressure (SBP) were established as independent predictors of higher pre- and postoperative PWV, while higher mean valvular gradient emerged as a determinant of lower pre-AVR PWV., Conclusion: We documented an inverse correlation of arterial stiffness with the severity of AS in patients with AS, and a significant increase in PWV values after AVR surgery. Advanced age and higher SBP were associated with higher PWV values, although arterial function measurements were within the normal range. (Arq Bras Cardiol. 2021; 116(3):475-482).

Objectives: The increasing complexity of surgical patients and working time constraints represent challenges for training. In this study, the European Association for Cardio-Thoracic Surgery Residents' Committee aimed to evaluate satisfaction with current training programmes across Europe., Methods: We conducted an online survey between October 2018 and April 2019, completed by a total of 219 participants from 24 countries., Results: The average respondent was in the fourth or fifth year of training, mostly on a cardiac surgery pathway. Most trainees follow a 5-6-year programme, with a compulsory final certification exam, but no regular skills evaluation. Only a minority are expected to take the examination by the European Board of Cardiothoracic Surgery. Participants work on average 61.0 ± 13.1 h per week, including 27.1 ± 20.2 on-call. In total, only 19.7% confirmed the implementation of the European Working Time Directive, with 42.0% being unaware that European regulations existed. Having designated time for research was reported by 13.0%, despite 47.0% having a postgraduate degree. On average, respondents rated their satisfaction 7.9 out of 10, although 56.2% of participants were not satisfied with their training opportunities. We found an association between trainee satisfaction and regular skills evaluation, first operator experience and protected research time., Conclusions: On average, residents are satisfied with their training, despite significant disparities in the quality and structure of cardiothoracic surgery training across Europe. Areas for potential improvement include increasing structured feedback, research time integration and better working hours compliance. The development of European guidelines on training standards may support this., (© The Author(s) 2020. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: There is currently conflicting evidence regarding outcomes of dual antiplatelet therapy (DAPT) in patients following coronary artery bypass grafting (CABG). We aim to compare the survival and safety outcomes of DAPT versus aspirin (ASA) within a 24h window after CABG., Methods: Single-center retrospective cohort study on consecutive patients undergoing 1st isolated CABG surgery in 2010. Survival analysis (median follow-up 9 years) was performed using Kaplan-Meier curves and multivariable Cox regression using propensity score (PS) as a covariate along with DAPT. Bleeding was assessed through red blood cells' (RBC) transfusion, re-exploration of thorax and drainage., Results: We included 351 patients (251 were DAPT). Kaplan-Meier curves showed similar cumulative survival between groups (9y: 75% DAPT vs. 67% ASA, Log-rank P=0.103), as well as the PS adjusted analysis (HR DAPT: 0.93, 95% CI: 0.57-1.51). We found no differences in early mortality (2 DAPT and 1 ASA). Total median cell-saver transfusion (300 mL vs. 250 mL) and the re-exploration of thorax due to bleeding (1.6% vs. 4%) showed no statistical significance either. On the other hand, postoperative total median chest tube drainage was higher in the ASA group (1220 mL DAPT vs. 1320 mL ASA, P=0.034). There was also a lower frequency of DAPT patients requiring RBC transfusions (≥3 units 4.8% vs. 13%, P=0.009, respectively). Redo-CABG was performed in 3 patients (2 DAPT vs. 1 ASA) during follow-up., Conclusions: Compared with ASA, DAPT showed a non-significant impact on long-term survival and demonstrated to be a safe option. Further studies are needed to provide recommendations on the therapeutical strategy following CABG.

We present a rare case of a levoatrial cardinal vein identified during the work-up of a patient with coarctation of the aorta. Early diagnosis and repair in the neonatal period prevented future manifestations of left-to-right shunt and the need for reoperations, in contrast with the later-age presentation of this congenital anomaly. An integrative approach was crucial for prompt detection, intraoperative confirmation and complete one-stage repair., (Copyright © 2020 Sociedade Portuguesa de Cardiologia. Publicado por Elsevier España, S.L.U. All rights reserved.)

Background: The interplay between the stiffened heart and vessels has long been viewed as a core mechanism in heart failure with preserved ejection fraction, but the incremental vascular molecular remodeling mechanisms from systemic arterial hypertension to heart failure with preserved ejection fraction remain poorly investigated. Our aim was to characterize central arterial remodeling and dysfunction in ZSF1 obese rats and to compare it with hypertensive ZSF1 lean and healthy Wistar-Kyoto controls., Methods and Results: Twenty-week-old male ZSF1 obese (n=9), lean (n=9), and Wistar-Kyoto rats (n=9) underwent left ventricular pressure-volume loop evaluation and synchronous acquisition of ascending aortic flow and pressure. Aortic rings underwent functional evaluation, histology, and molecular biology studies. Although mean arterial pressure, characteristic aortic impedance, and reactivity to phenylephrine were similarly increased in hypertensive ZSF1 lean and obese, only ZSF1 obese showed impaired relaxation and upward-shifted end-diastolic pressure-volume relationships despite preserved systolic function indexes, denoting heart failure with preserved ejection fraction. ZSF1 obese phenotype further showed decreased aortic compliance, increased wave reflection, and impaired direct NO donor and endothelial-mediated vasodilation which were accompanied on structural and molecular grounds by aortic media thickening, higher collagen content and collagen/elastin ratio, increased fibronectin and α-5 integrin protein expression and upregulated TGF (transforming growth factor)-β and CTGF (connective tissue growth factor) levels., Conclusions: Functional, molecular, and structural disturbances of central vessels and their potentially underlying pathways were newly characterized in experimental heart failure with preserved ejection fraction rendering the ZSF1 obese rat model suitable for preclinical testing.

Intrauterine fetal conditions can have lifelong cardiovascular effects. The impact of maternal diabetes mellitus on children's cardiovascular profile is not well established. The goal of this study was to explore the association between maternal diabetes mellitus and offspring's blood pressure (BP) ≤10 years of age. Generation XXI is a prospective birth cohort, which enrolled 8301 mother-offspring pairs, including 586 (7.1%) children of diabetic mothers. The associations between maternal diabetes mellitus and BP at 4, 7, and 10 years of age was modeled using linear regression. A mixed-effects model was built to assess differences in BP variation over time. Path analysis was used to quantify effects of potential mediators. Maternal diabetes mellitus was associated with higher BP in offspring at the age of 10 (systolic: β, 1.48; 95% CI, 0.36-2.59; and diastolic: β, 0.86; 95% CI, 0.05-1.71). This association was independent of maternal perinatal characteristics, and it was mediated by child's body mass index and, to a lesser extent, by gestational age, type of birth, and birth weight (indirect effect proportion, 73%). No significant differences in BP were found at 4 and 7 years of age. Longitudinal analysis showed an accelerated systolic BP increase on maternal diabetes mellitus group (β, 1.16; 95% CI, 0.03-2.28). These finding were especially relevant in males, suggesting sex differences in the mechanisms of BP prenatal programing. Our results provide further evidence that maternal diabetes mellitus is associated with high BP late in childhood, demonstrating a significant role of child's body mass in the pathway of this association.

Background: Most observational studies support long-term survival benefit after bilateral internal mammary artery (BIMA) compared with single internal mammary artery (SIMA) coronary artery bypass grafting (CABG) but data on females is scarce. We compared survival and safety of BIMA versus SIMA CABG between males and females at our tertiary care center., Methods: Single-center retrospective cohort including consecutive patients with at least 2 left-coronary system (LCS) vessel disease who underwent isolated CABG with at least 1 IMA conduit and a minimum of 2 conduits targeting the LCS in 2004-2013. All-cause mortality was the primary outcome, secondary outcomes were early mortality and reoperation due to sternal wound complications (SWC). Kaplan-Meier analysis after inverse probability weighting using propensity score (IPW) was used to compare BIMA and SIMA CABG amongst genders. Results were confirmed in subgroup analysis., Results: BIMA CABG was performed in 39% out of 2424 eligible procedures and in 27% of 460 females. No differences were found in survival after BIMA and SIMA CABG (median and maximum follow-up of 5.5 and 12 years, respectively) but a statistical interaction was observed with gender (P < 0.001). Females who underwent BIMA CABG showed higher mortality (weighted HR in females subset: 3.16; 95% CI: 1.56-6.29, P = 0.001). BIMA CABG showed a higher incidence of reoperation due to SWC (IPW adjusted model OR: 1.74; 95% CI: 1.16-2.60) that was mostly ascribable to males (weighted OR in males: 3.10; 95% CI: 1.74-5.51, P < 0.001)., Conclusions: Females may experience higher mortality after BIMA CABG which should be further explored., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Objective: To report the hemodynamic profile and short- and medium-term outcomes of Freedom Solo and Solo Smart stentless aortic valves implanted at our center., Methods: Between 2009 and 2015, all patients undergoing aortic valve replacement using Solo stentless valves at our center were enrolled. Clinical and echocardiographic follow-up was carried out six months postoperatively. Survival and major events, including structural valve deterioration and non-structural valve dysfunction, endocarditis, reoperation and stroke, were assessed through medical records or telephone interview with the referring cardiologist up to November 2015 (mean and maximum follow-up 39±22 and 78 months, respectively)., Results: Patients' (n=345) mean age was 72±8 years, 52% were female and median euroSCORE II was 2.7 (1.5-4.7). There was no intraoperative mortality and in-hospital mortality was 2.6%. Postoperatively, mean transvalvular gradient was 11.9±4.5 mmHg and effective orifice area was 1.9±0.5 cm 2 . Patient-prosthesis mismatch occurred in 14% but was severe in only one patient. Cumulative survival at six years was 72%. Six patients were reoperated: three due to endocarditis, two for structural prosthesis deterioration and one because of periprosthetic fistula. Five patients suffered stroke, three had medically-treated endocarditis and one had structural valve deterioration but was not considered suitable for reoperation. None of the remainder had structural valve deterioration or non-structural valve dysfunction., Conclusions: Solo stentless aortic valves are safe to implant, with promising clinical outcomes in short- and medium-term assessment. Moreover, they show an excellent hemodynamic performance: low transvalvular gradients, large effective orifice areas and low incidence of patient-prosthesis mismatch., (Copyright © 2018 Sociedade Portuguesa de Cardiologia. Publicado por Elsevier España, S.L.U. All rights reserved.)

Objectives: Septic shock is a life-threatening clinical situation associated with acute myocardial and vascular dysfunction, whose pathophysiology is still poorly understood. Herein, we investigated microRNA-155-dependent mechanisms of myocardial and vascular dysfunction in septic shock., Design: Prospective, randomized controlled experimental murine study and clinical cohort analysis., Setting: University research laboratory and ICU at a tertiary-care center., Patients: Septic patients, ICU controls, and healthy controls. Postmortem myocardial samples from septic and nonseptic patients. Ex vivo evaluation of arterial rings from patients undergoing coronary artery bypass grafting., Subjects: C57Bl/6J and genetic background-matched microRNA-155 knockout mice., Interventions: Two mouse models of septic shock were used. Genetic deletion and pharmacologic inhibition of microRNA-155 were performed. Ex vivo myographic studies were performed using mouse and human arterial rings., Measurements and Main Results: We identified microRNA-155 as a highly up-regulated multifunctional mediator of sepsis-associated cardiovascular dysfunction. In humans, plasma and myocardial microRNA-155 levels correlate with sepsis-related mortality and cardiac injury, respectively, whereas in murine models, microRNA-155 deletion and pharmacologic inhibition attenuate sepsis-associated cardiovascular dysfunction and mortality. MicroRNA-155 up-regulation in septic myocardium was found to be mostly supported by microvascular endothelial cells. This promoted myocardial microvascular permeability and edema, bioenergetic deterioration, contractile dysfunction, proinflammatory, and nitric oxide-cGMP-protein kinase G signaling overactivation. In isolate cardiac microvascular endothelial cells, microRNA-155 up-regulation significantly contributes to LPS-induced proinflammatory cytokine up-regulation, leukocyte adhesion, and nitric oxide overproduction. Furthermore, we identified direct targeting of CD47 by microRNA-155 as a novel mechanism of myocardial and vascular contractile depression in sepsis, promoting microvascular endothelial cell and vascular insensitivity to thrombospondin-1-mediated inhibition of nitric oxide production and nitric oxide-mediated vasorelaxation, respectively. Additionally, microRNA-155 directly targets angiotensin type 1 receptor, decreasing vascular angiotensin II reactivity. Deletion of microRNA-155 restored angiotensin II and thrombospondin-1 vascular reactivity in LPS-exposed arterial rings., Conclusions: Our study demonstrates multiple new microRNA-155-mediated mechanisms of sepsis-associated cardiovascular dysfunction, supporting the translational potential of microRNA-155 inhibition in human septic shock.

Objectives: The goal of this study was to compare the stentless Freedom Solo® (FS) and the stented Trifecta® (TF) aortic bioprostheses with regard to haemodynamic profile, left ventricular mass regression and early and late postoperative outcomes and survival., Methods: A longitudinal cohort study of consecutive patients undergoing aortic valve replacement (2009-16) with either the FS or TF at 1 centre was performed. Local databases and national records were queried. Prosthesis haemodynamics and left ventricular dimensions were obtained from postoperative echocardiograms. After propensity score matching (21 covariates), the Kaplan-Meier and competing risk analyses were performed for survival and the combined outcome of structural valve deterioration and endocarditis, respectively. Haemodynamics and mass regression were assessed by a mixed-effects model including propensity score as a covariate., Results: From a total sample of 397 patients with the FS and 525 TF bioprostheses with a median follow-up time of 4.0 (2.2-6.0) and 2.4 (1.4-3.7) years, respectively, a matched sample of 329 pairs was obtained. Matched groups showed no differences in survival (hazard ratio = 1.04, 95% confidence interval = 0.69-1.56) or cumulative hazards of combined outcome (subdistribution hazard ratio = 0.54, 95% confidence interval = 0.21-1.39). Although the TF showed an improved haemodynamic profile, no difference was found in mass regression. Patients with TF bioprostheses had higher rates of prolonged mechanical ventilation, whereas patients with the FS bioprosthesis showed higher rates of thrombocytopenia., Conclusions: The TF showed an improved haemodynamic profile compared to the FS, but this did not translate into further reverse remodelling. Postoperative outcomes and survival rates were comparable for both bioprostheses. Long-term follow-up is needed for comparisons with classical bioprosthesis models.

So far, opposing outcomes have been reported following neonatal apex resection in mice, questioning the validity of this injury model to investigate regenerative mechanisms. We performed a systematic evaluation, up to 180 days after surgery, of the pathophysiological events activated upon apex resection. In response to cardiac injury, we observed increased cardiomyocyte proliferation in remote and apex regions, neovascularization, and local fibrosis. In adulthood, resected hearts remain consistently shorter and display permanent fibrotic tissue deposition in the center of the resection plane, indicating limited apex regrowth. However, thickening of the left ventricle wall, explained by an upsurge in cardiomyocyte proliferation during the initial response to injury, compensated cardiomyocyte loss and supported normal systolic function. Thus, apex resection triggers both regenerative and reparative mechanisms, endorsing this injury model for studies aimed at promoting cardiomyocyte proliferation and/or downplaying fibrosis., (Copyright © 2018 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: Intrauterine exposure to a diabetic environment is associated with adverse fetal myocardial remodeling. The aim of this study was to assess the biventricular systolic and diastolic function of fetuses exposed to maternal diabetes (MD) compared with control subjects, using a comprehensive cardiac functional assessment and exploring the role of speckle-tracking to assess myocardial deformation. The authors hypothesized that fetuses exposed to MD present signs of biventricular dysfunction, which can be detected by deformation analysis., Methods: A cross-sectional study was conducted in 129 fetuses with structurally normal hearts, including 76 fetuses of mothers with diabetes and 53 of mothers without diabetes. Maternal baseline characteristics, standard fetoplacental Doppler indices, and conventional echocardiographic and myocardial deformation parameters were prospectively collected at 30 to 33 weeks of gestation., Results: Fetuses of mothers with diabetes had a significantly thicker interventricular septum compared with control subjects (median, 4.25 mm [interquartile range (IQR), 3.87-4.50 mm] vs 3.67 mm [IQR, 3.40-3.93 mm), P < .001), but no effect modification was demonstrated on myocardial deformation analysis. No significant differences were found in conventional systolic and diastolic functional parameters for the left ventricle and right ventricle, except for lower left ventricular cardiac output in the MD group (median, 320 mL/min [IQR, 269-377 mL/min] vs 365 mL/min [IQR, 311-422 mL/min], P < .05]. Deformation analysis demonstrated a significantly lower early diastolic strain rate (SRe) and late diastolic strain rate (SRa) for both ventricles in the MD group (left ventricle: SRe 1.85 ± 0.72 vs 2.26 ± 0.68 sec -1 , SRa 1.50 ± 0.52 vs 1.78 ± 0.57 sec -1 ; right ventricle: SRe 1.57 ± 0.73 vs 1.97 ± 0.73 sec -1 , SRa 2 ± 0.77 vs 1.68 ± 0.79 sec -1 ; P < .05), suggesting biventricular diastolic impairment. Additionally, the right ventricle presented a lower global longitudinal strain in the study group (-13.67 ± 4.18% vs -15.52 ± 3.86%, P < .05). Multivariate analysis revealed that maternal age is an independent predictor of left and right ventricular global longitudinal strain (P < .05), with a significant effect only in MD after group stratification., Conclusions: Fetuses of mothers with diabetes present signs of biventricular diastolic dysfunction and right ventricular systolic dysfunction by deformation analysis in the third trimester of pregnancy. They may represent a special indication group for functional cardiac assessment, independently of septal hypertrophy. Two-dimensional speckle-tracking could offer an additional benefit over conventional echocardiography to detect subclinical unfavorable changes in myocardial function in this population., (Copyright © 2017 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.)

Background: New models of aortic bioprostheses have proven excellent early haemodynamic profile, but their mid and long-term performance warrants further systematic assessment. The aim of this study is to report clinical and haemodynamic performance of St. Jude Medical Trifecta bioprosthesis during 5 years of implantation., Methods: We performed a single centre, retrospective, observational and descriptive study including all 556 individuals who underwent aortic valve replacement (AVR) with the Trifecta bioprosthesis (between July of 2011 and June of 2016). Survival and re-intervention were censored in February 2017. Postoperative ambulatory echocardiographic data was available for 490 patients. A complete clinical follow-up was available in 463 individuals (mean follow-up time, 27±17 months)., Results: In our sample the mean age was 73±9 years, 57.6% were male and median European System for Cardiac Operative Risk Evaluation (EuroSCORE) II was 2.9 (interquartile range, 1.6-5.8). There were 301 (54.1%) combined procedures, mostly coronary artery bypass grafting in 170 (30.6%). Overall 30-days mortality was 5.4% (n=30) and cumulative survival at 5-years was 72.3%. There were 23 (4.3%) permanent pacemaker implantations. During follow-up, 5 (0.9%) patients presented non-structural valve dysfunction (NSVD) and 4 (0.8%) underwent reoperation due to prosthesis endocarditis. At the first ambulatory evaluation transvalvular mean gradient and effective orifice area (EOA) were 10.9±4.1 mmHg and 2.0±0.5 cm 2 , respectively. Severe patient-prosthesis mismatch (PPM) was observed in 5 (1.1%) individuals and moderate in 52 (11.3%)., Conclusions: In a "real-world" clinical setting, our findings support the good overall mid-term haemodynamic and safety profile of the Trifecta bioprosthesis., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.

Aims: Pulmonary arterial hypertension (PAH) is a serious disease that affects both the pulmonary vasculature and the right ventricle (RV). Current treatment options are insufficient. The cardiac neuregulin (NRG)-1/ErbB system is deregulated during heart failure, and treatment with recombinant human NRG-1 (rhNRG-1) has been shown to be beneficial in animal models and in patients with left ventricular (LV) dysfunction. This study aimed to evaluate the effects of rhNRG-1 in RV function and pulmonary vasculature in monocrotaline (MCT)-induced PAH and RV hypertrophy (RVH)., Methods and Results: Male wistar rats (7- to 8-weeks old, n = 78) were injected with MCT (60 mg/kg, s.c.) or saline and treated with rhNRG-1 (40 µg/kg/day) or vehicle for 1 week, starting 2 weeks after MCT administration. Another set of animals was submitted to pulmonary artery banding (PAB) or sham surgery, and followed the same protocol. MCT administration resulted in the development of PAH, pulmonary arterial and RV remodelling, and dysfunction, and increased RV markers of cardiac damage. Treatment with rhNRG-1 attenuated RVH, improved RV function, and decreased RV expression of disease markers. Moreover, rhNRG-1 decreased pulmonary vascular remodelling and attenuated MCT-induced endothelial dysfunction. The anti-remodelling effects of rhNRG-1 were confirmed in the PAB model, where rhNRG-1 treatment was able to attenuate PAB-induced RVH., Conclusion: rhNRG-1 treatment attenuates pulmonary arterial and RV remodelling, and dysfunction in a rat model of MCT-induced PAH and has direct anti-remodelling effects on the pressure-overloaded RV., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2015. For permissions please email: journals.permissions@oup.com.)

Introduction: The satisfaction with the medical profession has been identified as an essential factor for the quality of care, the wellbeing of patients and the healthcare systems' stability. Recent studies have emphasized a growing discontent of physicians, mainly as a result of changes in labor relations., Objectives: To assess the perception of Portuguese medical residents about: correspondence of residency with previous expectations; degree of satisfaction with the specialty, profession and place of training; reasons for dissatisfaction; opinion regarding clinical practice in Portugal and emigration intents., Material and Methods: Cross-sectional study. Data collection was conducted through the "Satisfaction with Specialization Survey", created in an online platform, designed for this purpose, between May and August 2014., Results: From a total population of 5788 medical residents, 804 (12.25 %) responses were obtained. From this sample, 77% of the responses were from residents in the first three years. Results showed that 90% of the residents are satisfied with their specialty, 85% with the medical profession and 86% with their place of training. Nevertheless, results showed a decrease in satisfaction over the final years of residency. The overall assessment of the clinical practice scenario in Portugal was negative and 65% of residents have plans to emigrate after completing their residency., Conclusion: Portuguese residents revealed high satisfaction levels regarding their profession. However, their views on Portuguese clinical practice and the results concerning the intent to emigrate highlight the need to take steps to reverse this scenario.