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Purpose: The relationship between personality traits and cardiovascular disease has gathered sustained interest over the last years, type –D personality (TDP) being significantly associated with coronary artery disease (CAD). However, data regarding the connection between the TDP and the severity of CAD disease is scarce. The aim of our study was to assess the relationship between TDP and the complexity of CAD, and to compare it with other sociodemographic and clinical features. Patients and Methods: We conducted a cross-sectional case-control clinical-based study on 221 consecutive hospitalized patients with chest pain (60 ± 10.2 years; 131 men), referred for coronary angiography. Results: TDP was identified in 42 (19%) patients, using the DS 14 scale. Symptomatology profile was evaluated using the SCL-90 scale. Syntax score was greater in the subgroup of patients with TDP in comparison to non-TDP subgroup (26.21± 12.03 vs 15.49± 8.89, respectively, p< 0.001), and most of SCL-90 symptom dimensions have significantly higher levels in the subgroup of TDP with CAD patients (all p < 0.05). Smoking (β=0.132, p=0.037), dyslipidemia (β=0.149, p=0.013), Diabetes Mellitus (β=232, p< 0.001), NA dimension of TDP (β=0.255, p< 0.001) and SI (β=0.279, p< 0.001) dimension of TDP have a significant contribution to the complexity of CAD assessed by Syntax score. Conclusion: TDP was associated with a more complex CAD assessed by Syntax score, and may represent a dynamic interface between the biological and psychological vulnerabilities and the symptoms of CAD. [ABSTRACT FROM AUTHOR]

Right ventricular pacing is has deletorius effects due to left ventricular dysynchrony and remodelling and may result in heart failure. Over the last decade, His bundle pacing has emerged as the most physiologic form pacing. However, it has limitations, such as higher capture thresholds, lower R wave amplitudes, atrial oversensing, and increased risk for lead revisions from late threshold increase with subsequent premature battery depletion, which has prevented a wider adoption of this technique in routine clinical practice. Left bundle branch pacing has been developed as an alternative physiologic pacing strategy that overcomes most of His bundle pacing limitations. This article summarizes the current status of left bundle branch pacing. [ABSTRACT FROM AUTHOR]

Abstract: Background: Early diastolic transmitral velocity (E)/early mitral annular diastolic velocity (Ea) ratio has been proposed as the best Doppler predictor for evaluating left ventricular (LV) filling pressure. Purpose: To evaluate the relationship between a novel echocardiographic index, E/(Ea× Sa), and left ventricular end-diastolic pressure (LVEDP); Sa is the peak systolic mitral annular velocity. We measured this index at different sites of the mitral annulus and compared it with other Tissue Doppler parameters. Methods: Echocardiography was performed simultaneously with left heart catheterization in 110 consecutive patients in sinus rhythm. E, Sa, Ea and Aa (late mitral annular diastolic velocity) were determined at medial and lateral site, and average values obtained. E/Ea and E/(Ea× Sa) were calculated (medial, lateral, average). LVEDP was measured with invasively fluid-filled catheter. Results: We demonstrated significant correlations between LVEDP and E/(Ea× Sa)lateral (r =0.78, p <0.0001), E/Eaaverage (r =0.70, p <0.0001), E/Ealateral (r =0.66, p <0.0001), E/Eamedial (r =0.60, p <0.0001) and E/(Ea× Sa)medial (r =0.60, p <0.0001). E/(Ea× Sa)average had the strongest correlation with LVEDP (r =0.80, p <0.0001). An E/(Ea× Sa)average cut-off of 1.6 had 86% sensitivity and 85% specificity for detecting LVEDP>15 mmHg. Weaker correlations were found for Sa, Ea and Aa. E/(Ea× Sa)average was the best parameter to assess LVEDP in patients with normal LV ejection fraction (LVEF≥50%) (r =0.83, p <0.0001), depressed LVEF (r =0.76, p <0.0001), regional dysfunction (r =0.81, p <0.0001), or E/Eaaverage between 8 and 15 (r =0.67, p <0.0001). Conclusions: E/(Ea× Sa)average was the best predictor of LVEDP in sinus rhythm patients, regardless of LVEF, particularly in those with E/Eaaverage between 8 and 15 and in those with regional dysfunction. [Copyright &y& Elsevier]

COZMA, D.,et al.: Mechanism of Atrial Fibrillation: Decremental Conduction, Fragmentation, and Ectopic Activity in Patients with Drug Resistant Paroxysmal Atrial Fibrillation and Structurally Normal Heart. Atrial fibrillation (AF) has been associated with premature beats and decreased atrial conduction velocity. This study examined a new index of dynamic inter-atrial conduction time (iaCT) in patients with paroxysmal AF (PAF). We compared 42 consecutive patients with paroxysmal AF (mean age= 52± 16 years) without structural heart disease with 39 age-matched patients (mean age= 49± 15 years) who underwent ablation of junctional tachycardias. Prior to investigation, all antiarrhythmic drugs were discontinued for an appropriate period of time. The following measurements were made: baseline iaCT (iaCTb) between high right atrium (HRA) and distal coronary sinus, iaCT during HRA pacing S1S1 600 ms (iaCTS1), maximum prolongation of iaCT during S2 and S3 delivery (iaCTS2, iaCTS3). We then derived the decremental index (DI), the maximum percent prolongation of iaCT= iaCT S3-iaCTS1/iaCTS1%. In patients with PAF, iaCTb was 81.3± 24 ms versus 59.5± 14 ms in controls (P= 0.0001). Atrial fibrillation was reproducibly and easily induced with a prominent increase in iaCT in 11 patients with AF. In this subgroup DI was 92± 17%, compared to 45± 21% in the other patients with AF (P= 0.0001) and 21± 15% in the control group (P= 0.0001). Spontaneous isolated or repetitive ectopic activity was observed in 11 patients with AF (26%), and decremental atrial conduction was observed in 76% of patients with AF. This study supports the role of dynamic inter-atrial conduction disturbances in patients with lone PAF. The DI may be a new index of vulnerability to paroxysmal AF.(PACE 2005; 28:S115–S119) [ABSTRACT FROM AUTHOR]

Presents a study which compared echocardiographic with electrophysiologic measurements to determine if they are correlated. Methods; Results and discussion; Conclusion.

Since the prevalence of heart failure (HF) increases with age, HF is now one of the most common reasons for the hospitalization of elderly people. Although the treatment strategies and overall outcomes of HF patients have improved over time, hospitalization and mortality rates remain elevated, especially in developed countries where populations are aging. Therefore, this paper is intended to be a valuable multidisciplinary source of information for both doctors (cardiologists and general physicians) and pharmacists in order to decrease the morbidity and mortality of heart failure patients. We address several aspects regarding pharmacological treatment (including new approaches in HF treatment strategies [sacubitril/valsartan combination and sodium glucose co-transporter-2 inhibitors]), as well as the particularities of patients (age-induced changes and sex differences) and treatment (pharmacokinetic and pharmacodynamic changes in drugs; cardiorenal syndrome). The article also highlights several drugs and food supplements that may worsen the prognosis of HF patients and discusses some potential drug–drug interactions, their consequences and recommendations for health care providers, as well as the risks of adverse drug reactions and treatment discontinuation, as an interdisciplinary approach to treatment is essential for HF patients. [ABSTRACT FROM AUTHOR]

Dilated cardiomyopathy (DCM) represents a group of disorders affecting the structure and function of the heart muscle, leading to a high risk of heart failure and sudden cardiac death (SCD). DCM frequently involves an underlying genetic etiology. Genetic testing is valuable for risk stratification, treatment decisions, and family screening. Romanian population data on the genetic etiology of DCM are lacking. We aimed to investigate the genetic causes for DCM among Romanian adult patients at tertiary referral centers across the country. Clinical and genetic investigations were performed on adult patients presenting to tertiary hospitals in Romania. The genetic investigations used next-generation sequencing panels of disease-associated DCM genes. A total of 122 patients with DCM underwent genetic testing. The mean age at DCM diagnosis was 41.6 ± 12.4 years. The genetic investigations identified pathogenic or likely pathogenic variants in 50.8% of participants, while 25.4% had variants of unknown significance. Disease-causing variants in 15 genes were identified in people with DCM, with 31 previously unreported variants. Variants in TTN, LMNA, and DSP explained 75% of genetic causes for DCM. In total, 52.4% of patients had a family history of DCM/SCD. Left ventricular ejection fraction of <35% was observed in 41.9% of patients with disease-causing variants and 55% with negative or uncertain findings. Further genotype-phenotype correlations were explored in this study population. The substantial percentage (50.8%) of disease-causing variants identified in patients with DCM acknowledges the importance of genetic investigations. This study highlights the genetic landscape in genes associated with DCM in the Romanian population. [ABSTRACT FROM AUTHOR]

A case study of a 65-year-old woman who presented with heart failure is presented; she was diagnosed with giant left atrium (GLA).

(1) Background: Malperfusion is a central limiting factor in the setting of acute Type A aortic dissections (AAAD). We sought to find preoperative metabolic acidosis thresholds that might influence decision-making in this setting. (2) Methods: We retrospectively reviewed consecutive patients operated on with AAAD between January 2002 and December 2017. We analyzed preoperative variables that might influence early and long-term outcomes, with particular emphasis on malperfusion markers. (3) Results: Our sample consisted of 153 patients, most of them male (69.2%), with a mean age of 55.89 ± 12.8 years. Malperfusion was present in 20.9% of cases: peripheric 25, renal 7, cerebral 4, and mesenteric 3. Cardiogenic shock was present in 18.9% of patients. Logistic regression revealed entry site (odds ratio (OR) = 2.83, p = 0.03), cardiogenic shock (OR = 3.30, p = 0.03), prebypass pH (OR = 0.93, p = 0.02) as independent risk factors for early death (<30 days). Receiver operating characteristic (ROC) analysis identified a prebypass pH of 7.25 as a cutpoint for an unfavourable early outcome. Patients whose prebypass pH was ≤7.25 had a 2.98 higher relative risk (65.7% vs. 22%, p < 0.001). Prebypass pH 7.25 (hazard ratio (HR) = 4.00, p < 0.01) and entry site (HR = 2.10, p = 0.04) were independent predictors of early phase survival (<30 days), while long-term survival (>30 days) was determined by age >65 years (HR = 3.12, p = 0.02). (4) Conclusions: Patients with a prebypass pH ≤ 7.25 have an unacceptably high early mortality after AAAD repair. Those patients might benefit from a two-stage approach. [ABSTRACT FROM AUTHOR]

Background: The aim of our study was to assess the real life cardiac resynchronization therapy (CRT) fusion left ventricular (LV) only pacing in patients with normal AV conduction (NAVc) without right ventricular (RV) lead. Methods: Consecutive NAVc patients with CRT indication were implanted with a right atrium RA/LV DDD pacing system. Complete follow-up at 1, 3 and every 6 months thereafter included echocardiography and stress testing. Results: We analysed 55 patients (62 ± 11 years). All patients were responders with significant LV reverse remodelling (LV end-diastolic volume 193.7 ± 81 vs. 243.2 ± 82 mL at baseline, p < 0.002) and increased LV ejection fraction (38 ± 7.9% vs. 27 ± 5.2% at baseline, p < 0.001). Mitral regurgitation decreased in 38 patients (69%). During follow-up (35 ± 18 months), 20 patients (36%) needed reprogramming sensed/paced AV delay or maximum tracking rate (MTR) because of inadequate or lost LV capture at exercise test; personalized programming to achieve up to 100% fusion pacing was used in all patients. One patient developed Mobitz II second degree AV block and triple chamber CRT-P upgrade was performed; defibrillator upgrade was not necessary. Conclusions: LV only pacing CRT-P without RV lead showed a positive outcome in carefully selected patients. [ABSTRACT FROM AUTHOR]

The goal of this study was to assess whether subtle changes in myocardial work indices may predict left ventricular (LV) remodeling and major cardiac events (MACEs) in patients with a first ST-elevation acute myocardial infarction (STEMI) and preserved LVEF after successful myocardial revascularization with PCI. Methods. Consecutive STEMI patients in sinus rhythm and with an LV ejection fraction ≥ 50% following a successful PCI were recruited. Conventional and two-dimensional speckle tracking echocardiography (2D-STE) was conducted within 36 h of the PCI and 3 months later. Patients having an increase of more than 20% in LV diastolic volume were included in the LV remodeling group. MACEs were noted throughout a four-year period of follow-up. Results: The study comprised 246 STEMI patients with a mean age of 66; 72% of whom were men. In 24% (58) of the patients, LV remodeling developed. These patients were older, more frequently hypertensive, and had a smoking history. They also exhibited significantly lower baseline and 3-month values for the myocardial global index (GWI), global constructive work (GCW), and global myocardial efficiency (GWE). The cut-off values of 1670 mmHg% for GWI and 83% for GWE were predictive of LV remodeling (p < 0.0001). During the four-year follow-up period, 19% of STEMI patients experienced a MACE, involving 15% from non-LV remodelers and 34% from LV remodelers (p = 0.01). The cut-off values for baseline GWI of 1680 mmHg% and baseline GWE of 84% had the best accuracy in predicting MACEs. In conclusion, non-invasive myocardial work indices offered a reproducible and accurate method to predict post-MI LV remodeling and MACEs. [ABSTRACT FROM AUTHOR]

Background: The left ventricular (LV) remodelling process represents the main cause of heart failure after a ST-segment elevation myocardial infarction (STEMI). Speckle-tracking echocardiography (STE) can detect early deformation impairment, while also predicting LV remodelling during follow-up. The aim of this study was to investigate the STE parameters in predicting cardiac remodelling following a percutaneous coronary intervention (PCI) in STEMI patients. Methods: The study population consisted of 60 patients with acute STEMI and no history of prior myocardial infarction treated with PCI. The patients were assessed both by conventional transthoracic and ST echocardiography in the first 12 h after admission and 6 months after the acute phase. Adverse remodelling was defined as an increase in LVEDV and/or LVESV by 15%. Results: Adverse remodelling occurred in 26 patients (43.33%). By multivariate regression equation, the risk of adverse remodelling increases with age (by 1.1-fold), triglyceride level (by 1.009-fold), and midmyocardial radial strain (mid-RS) (1.06-fold). Increased initial twist decreases the chances of adverse remodelling (0.847-fold). The LV twist presented the largest area under the receiver operating characteristic (ROC) curve to predict adverse remodelling (AUROC = 0.648; 95% CI [0.506;0.789], p = 0.04). A twist value higher than 11° has a 76.9% specificity and a 72.7% positive predictive value for reverse remodelling at 6 months. [ABSTRACT FROM AUTHOR]

Background: Remote monitoring (RM) is becoming a standard of care for patients with cardiac resynchronization therapy (CRT). This technology combines the use of pacemakers or implantable cardioverterdefibrillators (ICD) and wireless communication to provide physicians with continuous, real-time information on the patient's cardiac activity. The purpose of the study was to evaluate if the remote monitoring technology in the follow-up CRT patients is feasible and safe. Methods: A total of nine patients were enrolled in the study, implanted with a CRT system with wireless transmission capabilities. Immediately after the procedure received the RM, were enrolled in the virtual clinic and instructed by the doctor how to use the device at home. Regular virtual transmissions were made automatically every 3 weeks, respecting optimal transmission conditions. The accumulation of fluid in the lungs, atrial or ventricular tachyarrhythmia together with system integrity automatically activate alerts. Results: One hundred and one transmissions were collected and analyzed from the virtual ward. Average follow-up was 7.7±4.8 months, longest follow-up was 18 months. None of the patients experienced complications during the study period, with three of them being follow-up solely through telemetric means by implanting physician. Treatment optimization was successfully conducted via phone consultations, when necessary, without any adverse events. Conclusions: The results of our study suggest that RM could be integrated into routine CRT management protocols, enhancing patients care and resource utilization. [ABSTRACT FROM AUTHOR]

Background: CRT improves systolic and diastolic function, increasing cardiac output. Aim of the study: to assess the outcome of LV diastolic dyssynchrony in a population of fusion pacing CRT. Methods: Diastolic dyssynchrony was measured by offline speckle-tracking-derived TDI timing assessment of the simultaneity of E″ and A″ basal septal and lateral walls. New parameters introduced: E″ and, respectively, A″ time (E″T/A″T) as the time difference between E″ (respectively, A″) peak septal and lateral wall. Patients were divided into super-responders (SR), responders (R), and non-responders (NR). Results: Baseline characteristics: 62 pts (62 ± 11 y.o.) with idiopathic DCM, EF 27 ± 5.2%; 29% type III diastolic dysfunction (DD), 63% type II, 8% type I. Average follow-up 45 ± 19 months: LVEF 37 ± 7.9%, 34%SR, 61%R, 5%NR. The E″T decreased from 90 ± 20 ms to 25 ± 10 ms in SR with significant LV reverse remodeling (LV end-diastolic volume 193.7 ± 81 vs. 243.2 ± 82 mL at baseline, p < 0.0028) and lower LV filling pressures (E/E′ 13.2 ± 4.6 vs. 11.4 ± 4.5, p = 0.0295). DD profile improved in 65% of R with a reduction in E/E′ ratio (21 ± 9 vs. 14 ± 4 ms, p < 0.0001). Significant cut-off value calculated by ROC curve for LV diastolic dyssynchrony is E″T > 80 ms and A″T > 30 msec. Conclusions: The study identifies the cut-off values of diastolic dyssynchrony parameters as predictors of favorable outcomes in responders and super-responder patients with fusion CRT pacing. These findings may have important implications in patient selection and follow-up. [ABSTRACT FROM AUTHOR]

Objective of the Study: to evaluate the relation between global myocardial index (GMI) and the pattern of left ventricular (LV) volume curves variation, using automatic border detection (ABD), and their role in assessing LV asynchrony. Methods: We studied 52 patients (mean age = 55 ± 17 years) with dilated cardiomyopathy. QRS duration (QRSd) and GMI were measured. Currently accepted TDI and M-mode parameters were used to indicate LV dyssynchrony. On-line continuous LV volume changes were recorded using ABD. Ejection time (ET ABD) was measured from the ABD wave-forms as time interval between maximal and minimal volume variation during LV electromechanical systole. We derived the ejection time index (ETiABD) as the ratio between ET ABD and RR interval (ETiABD = ET/RR). Results: 31 patients had a QRSd >120 ms and 21 patients had a QRSd <120 ms. Ventricular dyssynchrony was observed in 39 patients (29 patients had a QRSd > 120 ms). GMI was significantly higher in patients with, than in patients without ventricular dyssynchrony (1.06 ± 0.18 vs 0.73 ± 0.13, P = 0.0001), while ETABD was significantly smaller (233 ± 39 ms vs 321 ± 28 ms, P = 0.0001). The corresponding difference for ETiABD was 26.9 ± 6.8% vs 6.3 ± 4%, P < 0.0001. By simple regression analysis an inverse linear correlation was observed between GMI and ETiABD (r2=–0.51, P < 0.0001). The pattern of ABD waveforms showed increased isovolumic contraction and relaxation times in patients with LV asynchrony, similar to the GMI pattern. Conclusions: Regional delays in ventricular activation cause uncoordinated and prolonged ventricular contractions, with lengthening of the isovolumic contraction and relaxation times and shortening of the time available for filling and ejection. GMI explores these parameters and together with ABD might be useful to identify patients with ventricular asynchrony. [ABSTRACT FROM AUTHOR]

Background: The ellipse formula often underestimates left atrial (LA) dilation. Complete echocardiographic analysis of LA shape in relation to electrical remodeling has not been performed. Aim of the Study: To analyze the relation between LA shape/surface and vulnerability to atrial fibrillation (AF). Methods: We studied 112 patients aged 43 ± 16 years, and referred for electrophysiological study. LA surface (LAS) was measured at end-systole (maximal). Trapezoidal LA shape was defined if the transverse dimension was less than the basal dimension. Decremental index (DI) was calculated as the maximal percentage prolongation of interatrial conduction time during atrial extrastimulation. The LA was considered vulnerable if AF was inducible. DI >50%, repetitive atrial activity, and fragmented electrograms defined susceptibility to vulnerability. Results: LAS ranged between 10.5 and 36.6 cm2; 77 patients had a trapezoidal LA. By simple regression analysis LAS correlated with DI (r2= 0.38, P = 0.0001). LAS predicted susceptibility to vulnerability better than vulnerability to AF (area under the ROC curve: 0.93 vs 0.81). The best cut-off value for LAS as predictor of susceptibility to vulnerability was 19.5 cm2 (sensitivity: 89%; specificity: 90.5%; positive predictive value: 93.4%; negative predictive value: 84.4%). Using LAS >25 cm2 as a cut-off value, LA vulnerability to AF was detected with a sensitivity of 56.2% and a specificity of 95% (positive predictive value: 81.8%; negative predictive value: 83.3%). LA shape was trapezoidal in 72% patients with LAS >25 cm2 and in 30% patients with LAS <19.5 cm2 (P < 0.0001). Conclusions: LA dilation and electrical remodeling are related. Progressive LA dilation is accompanied by shape remodeling. Appropriate characterization of LA remodeling should therefore include LAS measurement and LA shape assessment. [ABSTRACT FROM AUTHOR]

Simple Summary: Acute myocardial infarction patients are at high risk for heart failure, even after successful revascularization therapy. We performed a study that aimed to identify early predictors of heart failure after myocardial infarction. The study included 244 patients discharged with a normal heart function after their first myocardial infarction. At the 2- year follow-up, we found that 186 (76%) showed an improvement in left ventricular function and 61 (24%) had a deterioration of the latter. Comparing the two groups, we found patients in the latter group were older, more often hypertensive, smokers, and had more severe clinical presentations of the acute myocardial infarction and more extensive coronary disease. A total of 19 patients (8%) had experienced hospitalizations for heart failure, 6% being from group I and 12 % from group II, and this difference was notable. We observed that the presence of heart failure at the admission for acute myocardial infarction and abnormal deformation patterns of the infarct-related myocardial segments detected by echocardiography accurately predicted the occurrence of heart failure during the next two years. The presence of these parameters might enable a better risk-stratification and initiation of an effective preventive therapy in acute myocardial infarction patients. (1) Acute myocardial infarction (AMI) patients are at risk of left ventricular (LV) remodeling and heart failure (HF), even after successful revascularization by percutaneous coronary intervention (PCI). We wanted to assess the independent predictors of these outcomes in AMI patients. (2) Methods: The study enrolled patients with a LVEF ≥50% after a successful PCI for their first AMI. After 24 months, patients were separated into two groups based on whether their LVEF remained ≥50% (group I), or decreased to <50% (group II). (3) Outcomes: 26% of the patients experienced a decrease in LVEF below 50%, 41% showed LV remodeling, and 8% had experienced HF hospitalizations. HF hospitalizations were significantly more frequent in group II patients (p < 0.0001). The Killip class at admission >2, infarct-related longitudinal strain ≤−12.5%, and the presence of LV remodeling were identified as independent predictors of HF hospitalizations. (4) Conclusions: About 26% of AMI patients with normal LV function after a successful PCI developed HF. More sensitive techniques are required that allow for a more efficient risk-stratification and preventive therapy to reduce LV remodeling and HF in AMI patients with LVEF ≥50% after a successful PCI. The detection of abnormal ventricular deformation patterns after PCI by speckle-tracking echocardiography might be a valuable method in this approach. [ABSTRACT FROM AUTHOR]

Cardio-renal and metabolic modifications during gestation are crucial determinants of foetal and maternal health in the short and long term. The cardio-renal metabolic syndrome is a vicious circle that starts in the presence of risk factors such as obesity, hypertension, diabetes, kidney disease and ageing, all predisposing to a status dominated by increased arterial stiffness and alteration of the vascular wall, which eventually damages the target organs, such as the heart and kidneys. The literature is scarce regarding cardio-renal metabolic syndrome in pregnancy cohorts. The present paper exposes the current state of the art and emphasises the most important findings of this entity, particularly in pregnant women. The early assessment of arterial function can lead to proper and individualised measures for women predisposed to hypertension, pre-eclampsia, eclampsia, and diabetes mellitus. This review focuses on available information regarding the assessment of arterial function during gestation, possible cut-off values, the possible predictive role for future events and modalities to reverse or control its dysfunction, a fact of crucial importance with excellent outcomes at meagre costs. [ABSTRACT FROM AUTHOR]

Background: Fusion CRT pacing (FCRT) is noninferior to biventricular pacing, according to the current data. The aim of this study is to assess the response to FCRT and to identify predictors of super-responders (SRs) in a nonischemic population with normal AV conduction. Methods: LV-only CRT patients (pts) with a right atrium/left ventricle pacing system implanted in two CRT centers in Romania were included. Device interrogation, exercise tests, echocardiography, and individualized drug optimization were performed every 6 months during close follow-up. SRs pts were defined as those with left ventricular end-systolic volume (LVESV) improvement ≥30% and stable ejection fraction (LVEF) ≥45%. Results: A total of 25 out of 83 pts (31%) were SRs, with nonischemic LBBB low EF cardiomyopathy (50 male, 62 ± 9 y.o.) initially included. Mean follow-up was 5 years ± 27 months. Patients were divided in two groups: SRs and non-SRs (52 responders/6 hypo-responders). Two predictors were found in the SRs group: a higher baseline LVEF (SRs 29 ± 5% vs. non-SRs 26 ± 5%, p = 0.02) and a lower pulmonary arterial systolic pressure (SRs 38 ± 11 mm Hg vs. non-SRs 50 ± 15 mmHg, p = 0.003). Baseline severe mitral regurgitation was found in 11% of SRs vs. 64% in the non-SRs group. Conclusions: SRs in the selected NICM-FCRT group are significative high. Higher baseline LVEF and mild pulmonary arterial hypertension were independently associated with super-response. [ABSTRACT FROM AUTHOR]

Background: Betablockers (BB)/ivabradine titration in fusion CRT pacing (CRTP) is understudied. Aim: To assess drug optimization using systematic exercise tests (ET) in fusion CRTP with preserved atrioventricular conduction (AVc). Methods: Changes in drug management were assessed during systematic follow-ups in CRTP patients without right ventricle lead. Shorter AVc (PR interval) allowed BB up-titration, while longer AVc needed BB down-titration, favoring ivabradine. Constant fusion pacing was the goal to improve outcomes. Results: 64 patients, 62.5 ± 9.5 y.o divided into three groups: shorter PR (<160 ms), normal (160–200 ms), longer (200–240 ms); follow-up 59 ± 26 months. Drugs were titrated in case of: capture loss due to AVc shortening (14%), AVc lengthening (5%), chronotropic incompetence (11%), maximum tracking rate issues (9%), brady/tachyarrhythmias (8%). Interventions: BB up-titration (78% shorter PR, 19% normal PR, 5% longer PR), BB down-titration (22% shorter PR, 14% normal PR), BB exclusion (16% longer PR), adding/up-titration ivabradine (22% shorter PR, 19% normal PR, 5% longer PR), ivabradine down-titration (22% shorter PR, 3% normal PR), ivabradine exclusion (11% normal PR, 5% longer PR). Drug strategy was changed in 165 follow-ups from 371 recorded (42% patients). Conclusions: BBs/ivabradine titration and routine ET during follow-ups in patients with fusion CRTP should be a standard approach to maximize resynchronization response. Fusion CRTP showed a positive outcome with important LV reverse remodeling and significant LVEF improvement in carefully selected patients. [ABSTRACT FROM AUTHOR]

The aim of this paper is to provide an accurate overview regarding the current recommended approach for antihypertensive treatment. The importance of DNA sequencing in understanding the complex implication of genetics in hypertension could represent an important step in understanding antihypertensive treatment as well as in developing new medical strategies. Despite a pool of data from studies regarding cardiovascular risk factors emphasizing a worse prognosis for female patients rather than male patients, there are also results indicating that women are more likely to be predisposed to the use of antihypertensive medication and less likely to develop uncontrolled hypertension. Moreover, lower systolic blood pressure values are associated with increased cardiovascular risk in women compared to men. The prevalence, awareness and, most importantly, treatment of hypertension is variable in male and female patients, since the mechanisms responsible for this pathology may be different and closely related to gender factors such as the renin–angiotensin system, sympathetic nervous activity, endothelin-1, sex hormones, aldosterone, and the immune system. Thus, gender-related antihypertensive treatment individualization may be a valuable tool in improving female patients' prognosis. [ABSTRACT FROM AUTHOR]

This case report describes eight years of follow-up in a young adult with arrhythmogenic right ventricular dysplasia (ARVD). He presented with exertional palpitations, symmetric T wave inversions and possible epsilon waves in the right precordial leads on electrocardiogram (EKG), raising suspicion for ARVD. Transthoracic echocardiography revealed a dilated and excessively trabeculated right ventricle (RV), and cardiac magnetic resonance imaging showed fatty infiltration of the RV myocardium. These findings established the diagnosis of ARVD, and given his palpitations, a defibrillator was implanted. Over the next years, he had several episodes of ventricular tachycardia requiring therapy from his device, despite escalating medical therapy. He therefore underwent radiofrequency catheter ablation for the VT, which successfully controlled the VT. [ABSTRACT FROM AUTHOR]

Introduction - The current scientific literature suggests similar or even better catheter contact on caval regions of the cavo-tricuspid isthmus (CTI) compared to the more medial or annular part. Yet CTI ablation can be challenging owing to instability at the inferior vena cava (IVC) edge. No study specifically addressed the issue of catheter-tissue contact on caval/mid/annular regions of the CTI. Methods - Twenty-seven patients (22 men, 67±12 years) underwent typical atrial flutter ablation with a contact force (CF) sensing catheter (Tacticath 75, Abott) and were prospectively included. Operators aimed at optimizing CF for all RF pulses. The product of CF, time (force-time integral; FTI) and delivered power (FTPI) has been proposed as an estimate of lesion size. In a subset of 8 consecutive pts, electrograms (EGM) of all RF lesions were analyzed. Annular CTI was defined as sites showing both atrial and ventricular near-field bipolar EGM. Mid CTI sites had only atrial near field bipolar EGM on both distal and proximal dipoles (or distal only in case of superior-to-inferior approach). Caval sites had near-field bipolar EGM only in distal dipole, while the proximal one was inferiorly located. Results - Complete persistent (at 30 min) CTI block was obtained in all patients. A steerable sheath was used in 12 pts (44%). Procedure duration was 93±30 min, RF delivery time 10±6 min, fluoroscopy time 14±8 min. Mean CF was 15.8±5.9 g. CF was signifi- cantly lower (11.1±9.7 g) at the caval CTI than at mid CTI (19.9±11.8 g) and annular CTI (20±12.2 g; p=0.001). CF and FTI were higher during sinus rhythm than during Fl(23.2±15.3 vs 18.5±15.4 g, p=0.04 and 677±432 vs 532±357 gs, p=0.03). Use of a sheath improved mean CF (24.4±12.5 vs 18.4±14.9 g, p=0.01) but this was not significant at caval sites (17.5±11.4 vs 12.6±10.7 g, p=0.31). Conclusion - Applied forces are significantly lower at the IVC edge during CTI ablation. This supports the use of a steerable sheath in challenging cases. [ABSTRACT FROM AUTHOR]

Objectives - The European Cardiac Resynchronization Therapy Survey II is the second CRT survey of the Heart Failure Association and European Heart Rhythm Association designed to observe implantation and follow-up practices across European countries. These data allow, for the first time, a valuable insight on CRT implantation strategies for Romanian patients. Methods - A total of 214 patients undergoing CRT-P/CRT-D implantations in 7 Romanian implantation centers were included in the survey. A one-time online case report form including data on implantation indication and procedure was completed for each implantation attempt. Results - Romanian patients were younger than the other European patients (p<0.001), had more severe symptoms of heart failure, lower ejection fraction and wider QRS complexes. More than half of the patients had non-ischemic cardiomyopathy. Most of the patients were in sinus rhythm, with a median intrinsic QRS duration of 163±24 ms. Echocardiography was the imaging method most often used and the median left ventricular ejection fraction was 24.9±8%. In comparison with other European countries, CRT-D devices and multipolar ventricular leads were more rarely implanted (p<0.001). Conclusions - In Romania indications regarding CRT implantation follow the most recent ESC guidelines, but the ratio of CRT-D devices in Romania is lower than in the other European countries and patients with more severe heart failure receive CRT. CRT should be considered earlier in heart failure patients in order to improve outcome. [ABSTRACT FROM AUTHOR]

Aims - Baseline mechanical intraventricular dyssynchrony showed only a weak correlation with response to CRT in HF patients with wide QRS. We aimed to evaluate the effects of RV pacing on baseline intraventricular dyssynchrony in patients submitted to CRT. Methods - In 40 consecutive HF patients (LBBB, sinus rhythm, normal PR interval, 22 ischemic etiology, 65.5±10.7 years, 21 women, NYHA class 3.3 ± 0.5, LV ejection fraction 20.1±4.1%), speckle tracking radial strain was performed during sinus rhythm (ODO mode) and during RV pacing (DDD with optimum AV interval) one week after biventricular device implantation. RV lead was placed on interventricular septum (RVS, n=30) and RV apex (RVA, n=10). Patients had significant baseline intraventricular dyssynchrony, (i.e. =130 ms time difference in peak septal wall to infero-lateral wall strain). Maximum LV delay area (MDA) was defined as the segment with the latest systolic peak from the 6 regional color-coded time-strain curves. Midventricular global radial strain (mGRS) was determined averaging the segmental radial strain values. Results - Overall, RV pacing did not significantly increased intraventricular dyssynchrony (350±98 ms vs. 322±90 ms during SR, p=0.08). However, RVA pacing significantly increased LV dyssynchrony (367±58 ms vs. 312±60 ms during SR, p<0.001). mGRS was significantly reduced during RV pacing (13.3±8.5% vs. 18.3±7.4% during SR, p<0.001). The location of MDA shifted during RV pacing in 31 out of 40 patients (77%). Conclusions - In HF patients with wide QRS submitted to CRT, RV pacing alters the pattern of intraventricular dyssynchrony and impairs LV strain. [ABSTRACT FROM AUTHOR]

Objectives – to assess the outcome of direct current cardioversion (DCCV) in patients (pts) with symptomatic persistent atrial fi brillation (PAF) and LA dilatation. Methods – We analyzed 84 pts (49 male) aged 64.6±9.8 y.o, with PAF 2 and LAVI >40 ml/m2 . Echocardiographic parameters included: ejection fraction (EF), LA diameter (LAD), LA area (LAA) and LA volume (LAV - planimetry 4 chamber view). For each pt we calculated LAVI (left atrium volume index). All pts received proper anticoagulation and antiarrhythmic treatment. The management included a full control of blood pressure before cardioversion during the 3 weeks of prior anticoagulation. Pts with maximum of 3 conversion/year were admitted. Results – Arterial hypertension was diagnosed in 80% of pts, while 13% had coronary artery disease. All pts received proper anticoagulation (36 pts on dabigatran, 5 pts on apixaban, 43 pts on acenocumarol with INR values in therapeutic limits) and antiarrhythmic treatment: amiodarone (57 pts), propafenone (4 pts), fl ecainide (13 pts), sotalol (3 pt), amiodarone+fl ecainide (7 pts). All 84 pts underwent uncomplicated DCCV (1 to 3 external electrical shocks with energy between 150 and 200 J). Parameters: LAD 4.6±0.6 cm; LAA 30.1±4.8 cm2 (range 20-46 cm2 ); LAV was 114.5±29.5 ml (range 60-220 ml); EF 48.4±7.8 %. Calculated LAVI was 52.37±8.9 ml/m2 . The mean CHA2 DS2 -VASc score was 3.02±1.28. DCCV was successful in restoring sinus rhythm (SR) in 79 pts (94%). The mean total follow-up was 22±9 months, while 25 pts (30%) needed reconversion after 9±4 months. Another 13 pts (15%) were left in permanent AF at the end of the follow-up period. Conclusion – Electrocardioversion of symptomatic PAF in LA dilatation showed a positive outcome, even if multiple DCCV and adapted strategy in all pts is needed. [ABSTRACT FROM AUTHOR]

Recent data have demonstrated that a new tissue Doppler index, E/(E'×S'), index that includes the ratio between early diastolic transmitral and mitral annulus velocity (E/E'), as well as the systolic mitral annulus velocity (S'), has a good accuracy to predict cardiac death in patients with heart failure (HF). We analyzed the prognostic value of the E/(E'×S') ratio in patients with heart failure with reduced ejection fraction (HFrEF). Methods - Echocardiographic examination was performed in 166 patients hospitalized with the diagnosis of heart failure with reduced ejection fraction, before discharge as well as one month later. Worsening of E/(E'×S') was defined as a value greater than the previous value determined at discharge. The primary event consisted of cardiac death or hospital admission due to HF worsening. Results - During follow-up (34±8.8 months) cardiac events were recorded for 113 patients (68%). The optimal cut-off value for E/(E'×S') ratio was 1.96 with 84% sensitivity and 80% specificity. At discharge, 60 patients (36,2%) presented a value of the E/(E'×S') index =1.96 (group I) and 106 patients (63.8%) encountered a value of the E/(E'×S') index >1.96 (group II). The composite end point was significantly higher in group II than in group I (95 events, 89.6% versus 18 events, 30%, p<0.001). Patients with an E/(E'×S') ratio >1.96 at discharge and its worsening after one month presented the worst prognosis (p<0.05). Conclusions - In patients with with heart failure with reduced ejection fraction, a value of the E/(E'×S') index >1.96 at hospital discharge associated with its worsening after one month is an important predictor for future cardiac events. [ABSTRACT FROM AUTHOR]

Improving the outcomes of patients with acute coronary syndromes has become a matter of great importance, since worldwide coronary artery disease is still the leading cause of morbidity and mortality. Beginning with the reperfusion era, the goal of STEMI treatment is to restore blood flow to ischemic myocardium in order to reduce infarct size, but beyond the benefit of reperfusion, an important number of patients develop reperfusion injury and the "no-reflow" phenomenon. Taking these data into account and also the fact that coronary microvascular dysfunction increases the risk of cardiovascular events, we consider that an additional strategy in order to improve the outcomes of STEMI patients could be represented by the assessment of coronary microvascular functional and structural obstruction. Along with some issues related to the pathogenesis of coronary microvascular obstruction, some diagnostic methods as well as a few therapeutic options are been presented. [ABSTRACT FROM AUTHOR]

The management of antithrombotic treatment in elderly patients represents a great challenge in every day medical practice, taking into account both increased ischemic events risk as well as high bleeding risk as characteristics of this particular subset of patients. The great number of physiopathological changes that are found in elderly people in multiple organs and systems, mostly liver and kidneys, lead to an increase in the individual variability of therapeutic response, as well as to an augmented drug toxicity and potential decreased therapeutic benefit. [ABSTRACT FROM AUTHOR]

Introduction - Situs inversus totalis is a rare congenital malformation, diagnosed at about 1 from 10.000 of patients. It's diagnosis is usually made incidentally. Case report - Female patient, 46 years old, diagnosed with dextrocardia at the age of 16 based on chest X ray, is referred to our clinic for assessement of one sincopal episode. The ECG trace at admission revealed sinus bradycardia, a heart rate of 35 beats per minute, negative T waves in precordial leads V1,V2. Transthoracic echocardiography revealed concordant atrioventricular and ventriculo-arterial connections, normal size for both ventricles, normal biventricular function and mild tricuspid regurgitation. A dual pacemaker was performed, with favorable evolution. Disscusions - Limited data about patients with situs inversus totalis and rhythm/conduction disorders, makes more difficult their management, being fundamental to make a correct diagnosis. The implantation technique of a patient with dextrocardia can be a very challenging one. [ABSTRACT FROM AUTHOR]

Introduction -- Several studies evaluated left ventricular only pacing in patients with classical CRT with similar outcomes compared to biventricular pacing, but few data exist about CRT using bicameral devices with only 2 leads right atrium/left ventricle (RA/LV). Case report -- We present the case of a 42 y.o. male with idiopathic dilated cardiomyopathy, left bundle brunch block and symptoms of NYHA III class heart failure. Echocardiography showed severe global hypokinesia, EF 28 %, and mechanical dyssynchrony. With no evidence of ventricular arrhythmias and normal AV conduction, the patient had class I indication for CRT and was implanted with a bicameral pacemaker with only 2 leads RA/LV. At 3 months follow-up: echo examination showed important LV remodeling (EF 46%) and clinical improvement of NYHA class; same results were seen during the 5 years follow-up. This case report shows that bicameral pacemaker with only RA/LV leads may be considered an alternative to classic CRT in selected patients, as we showed in a recent small study. We hoped that future large multicenter studies can better assess indications, efficiency and advantages for CRT using dual chamber RA/LV pacing. [ABSTRACT FROM AUTHOR]

This study assessed the value of heart rate recovery index (HRRI), a new parameter of an exercise test, as the predictor of response to cardiac resynchronization therapy (CRT). Methods: Consecutive patients receiving a CRT device were followed up after implantation and every 6 months. An effort test (ET) was quantified by minimum heart rate/maximum heart rate, as well as acceleration and deceleration times. HRRI was calculated as the ratio between acceleration and deceleration time (AT/DT) and compared to outcome. We used logistic regression to assess the predictive value of HRRI for responders and non-responders to CRT. The area under the curve (AUC) was computed to distinguish between positive and negative outcomes. Results: A total of 109 patients (74 men, mean age 63.3 ± 9.8 years) were analyzed; permanent long-term fusion CRT pacing was possible in 65 patients. Patients were assigned to two groups: responders and non-responders (98/11 patients). During a mean follow-up of 36 months, 545 ETs were performed. HRRI was significantly higher in responders versus non-responders (3.16 ± 2 vs. 1.4 ± 0.5, p < 0.001). The optimal cutoff value for HRRI as a predictor of CRT response was 1.51 (area under the receiver operating characteristic (ROC) curve = 0.844). Responders had significant left-ventricular (LV) reverse remodeling (LV end-diastolic volume = 240 ± 90 mL vs. 217 ± 89 mL, p < 0.001) and higher LV ejection fraction (26 ± 5.8% vs. 35 ± 8.7%, p < 0.001). Conclusions: HRRI computation during routine ET is useful for the evaluation of responsiveness to CRT. [ABSTRACT FROM AUTHOR]