Unilateral renal artery stenosis causing hypertensive flash pulmonary oedema.

Flash pulmonary oedema can occur as a result of multiple triggers that may act independently or in concert. One such precipitating factor is bilateral renal artery stenosis which can be treated either with revascularisation or with medical therapy. Unilateral renal artery stenosis, however, is a rare cause of flash pulmonary oedema, especially when the contralateral kidney is still functional. We describe a case of an elderly woman with a history of heart failure with preserved ejection fraction and multiple hospitalisations for hypertensive crisis and flash pulmonary oedema who was found to have right, ostial renal artery stenosis that was treated with stent placement.

Anesthesia during delivery in pregnant women with dilated cardiomyopathy.

Emergency cesarean delivery in patients with heart failure increases maternal and fetal mortality. The present study aimed to identify the relationship between the use of anesthesia for delivery and progressive cardiac deterioration in women with dilated cardiomyopathy (DCM) and to examine its implications on maternal and fetal outcomes. Twenty-nine pregnancies in 25 women with DCM from the National Cerebral and Cardiovascular Center Hospital (Suita, Japan) were included in this retrospective longitudinal study. Fourteen of the patients (48.3%) delivered via cesarean section. Among these, 4 patients (13.8%) experienced heart failure within 42 days of delivery. The indication for cesarean delivery was heart failure in 3 patients and induction failure in 1 patient. The types of anesthesia used for these patients included general (n = 1), combined spinal-epidural (n = 2), and epidural (n = 1). Two of these cesarean deliveries were performed preterm. The left ventricular ejection fraction of patients with heart failure was ≤ 35% before 34 weeks gestation. Among the 25 patients without heart failure, 2 exhibited a left ventricular ejection fraction of ≤ 35% before 34 weeks gestation. Meanwhile, the types of anesthesia used for remaining 10 patients who did not experience heart failure included general (n = 1), combined spinal-epidural (n = 8), and epidural (n = 1). The rate of general anesthesia was 25% in patients who experienced heart failure and 4% in others. There was no incidence of maternal or fetal death. A preterm anesthetic evaluation may be warranted to optimize anesthetic management when the ejection fraction decreases to ≤ 35% before 34 weeks gestation in patients with DCM.

[Dyspnea and Right Heart Failure]. / Atemnot und Rechtsherzversagen.

Dyspnea and Right Heart Failure Abstract. Acute right ventricular failure is a critical condition diagnosed by clinical presentation combined with echocardiography. Additional diagnostic tools including laboratory, ECG, right heart catheterization, and other imaging modalities are needed to confirm the diagnosis and determine the cause. The identification and treatment of the underlying pathology, the reduction of right ventricular afterload (if possible), optimization of preload (often diuretics, rarely volume), and hemodynamic support using vasopressors and/or inodilators are mainstays of treatment. In severe cases, special therapies and mechanical circulatory support come into play.

Sudden Onset Iron Overload Cardiomyopathy After Liver Transplantation.

Iron overload cardiomyopathy has been described in patients who develop acute heart failure after liver transplantation but few reports of this are available. We present a case of a patient with end-stage liver disease who underwent a deceased donor liver transplantation and developed acute onset systolic heart failure with reduced left ventricular ejection fraction. A cardiac magnetic resonance image demonstrated late gadolinium enhancement with diffuse enhancement globally and T1 mapping with severely decreased pre-contrast T1 values suggesting iron overload cardiomyopathy. The patient was treated with iron chelating therapy as well as heart failure guideline-directed medical therapy with subsequent improvement in cardiac function on follow-up magnetic resonance images. Despite our patient's diagnosis of iron overload cardiomyopathy, her iron studies showed normal serum iron and ferritin levels and no evidence of hepatic iron deposition in the transplanted liver.

Heart Failure With Preserved Ejection Fraction: A Review.

Importance: Heart failure with preserved ejection fraction (HFpEF), defined as HF with an EF of 50% or higher at diagnosis, affects approximately 3 million people in the US and up to 32 million people worldwide. Patients with HFpEF are hospitalized approximately 1.4 times per year and have an annual mortality rate of approximately 15%. Observations: Risk factors for HFpEF include older age, hypertension, diabetes, dyslipidemia, and obesity. Approximately 65% of patients with HFpEF present with dyspnea and physical examination, chest radiographic, echocardiographic, or invasive hemodynamic evidence of HF with overt congestion (volume overload) at rest. Approximately 35% of patients with HFpEF present with "unexplained" dyspnea on exertion, meaning they do not have clear physical, radiographic, or echocardiographic signs of HF. These patients have elevated atrial pressures with exercise as measured with invasive hemodynamic stress testing or estimated with Doppler echocardiography stress testing. In unselected patients presenting with unexplained dyspnea, the H2FPEF score incorporating clinical (age, hypertension, obesity, atrial fibrillation status) and resting Doppler echocardiographic (estimated pulmonary artery systolic pressure or left atrial pressure) variables can assist with diagnosis (H2FPEF score range, 0-9; score >5 indicates more than 95% probability of HFpEF). Specific causes of the clinical syndrome of HF with normal EF other than HFpEF should be identified and treated, such as valvular, infiltrative, or pericardial disease. First-line pharmacologic therapy consists of sodium-glucose cotransporter type 2 inhibitors, such as dapagliflozin or empagliflozin, which reduced HF hospitalization or cardiovascular death by approximately 20% compared with placebo in randomized clinical trials. Compared with usual care, exercise training and diet-induced weight loss produced clinically meaningful increases in functional capacity and quality of life in randomized clinical trials. Diuretics (typically loop diuretics, such as furosemide or torsemide) should be prescribed to patients with overt congestion to improve symptoms. Education in HF self-care (eg, adherence to medications and dietary restrictions, monitoring of symptoms and vital signs) can help avoid HF decompensation. Conclusions and Relevance: Approximately 3 million people in the US have HFpEF. First-line therapy consists of sodium-glucose cotransporter type 2 inhibitors, exercise, HF self-care, loop diuretics as needed to maintain euvolemia, and weight loss for patients with obesity and HFpEF.

Efficacy of catheter ablation for atrial fibrillation in patients with significant functional mitral regurgitation.

BACKGROUND: Catheter ablation has been established to be an effective therapy for paroxysmal atrial fibrillation (AF) and is recommended as the treatment of choice for many patients, including those with clinically significant functional mitral regurgitation (MR). However, there is little information available about the clinical efficacy of catheter ablation for paroxysmal AF in patients with significant functional MR. METHODS: We performed a retrospective study of 247 patients with paroxysmal AF who underwent AF ablation. The study included 28 (11.3%) patients with significant functional MR and 219 (88.7%) without significant functional MR. AF recurrence was defined as the occurrence of confirmed atrial tachyarrhythmia lasting >30 seconds beyond 3 months after catheter ablation. RESULTS: During a mean follow-up of 20.1 ± 7.4 months (range, 3-36 months), 45 (18.2%) patients developed recurrence of AF. The recurrence rate of AF was higher in patients with significant functional MR than in those without significant functional MR (42.9% vs 15.1%; P < .001). Univariable Cox proportional hazards regression analysis showed that significant functional MR (hazard ratio [HR], 3.46; 95% confidence interval [CI], 1.78-6.72; P < .001), age (HR, 1.04; 95% CI, 1.01-1.08; P = .009), the CHA2DS2-VASc score (HR, 1.28; 95% CI, 1.05-1.56; P = .017), and heart failure (HR, 4.71; 95% CI, 1.85-11.96; P = .001) were associated with the risk of recurrence. Multivariable analysis showed that significant functional MR (HR, 2.48; 95% CI, 1.21-5.05; P = .013), age (HR, 1.04; 95% CI, 1.00-1.07; P = .031), and heart failure (HR, 3.39; 95% CI, 1.27-9.03; P = .015) were independent predictors of AF recurrence. CONCLUSION: Patients with significant functional MR have an increased risk of AF recurrence after catheter ablation.

QRS Fragmentation in Preserved Ejection Fraction Heart Failure: Functional Insights, Pathological Correlates, and Prognosis.

Background Fragmented QRS (fQRS) morphology as a surrogate marker of the possible presence of myocardial scarring has been shown to confer a higher risk in patients with reduced ejection fraction heart failure. We aimed to investigate the pathophysiological correlates and prognostic implications of fQRS in patients with heart failure with preserved ejection fraction (HFpEF). Methods and Results We consecutively studied 960 patients with HFpEF (76.4±12.7 years, men: 37.2%). fQRS was assessed using a body surface ECG during hospitalization. QRS morphology was available and classified into 3 categories among 960 subjects with HFpEF as non-fQRS, inferior fQRS, and anterior/lateral fQRS groups. Despite comparable clinical features in most baseline demographics among the 3 fQRS categories, anterior/lateral fQRS showed significantly higher B-type natriuretic peptide/troponin levels (both P<0.001), with both the inferior and anterior/lateral fQRS HFpEF groups demonstrating a higher degree of unfavorable cardiac remodeling, greater extent of myocardial perfusion defect, and slower coronary flow phenomenon (all P<0.05). Patients with anterior/lateral fQRS HFpEF exhibited significantly altered cardiac structure/function and more impaired diastolic indices (all P<0.05). During a median of 657 days follow-up, the presence of anterior/lateral fQRS conferred a doubled HF re-admission risk (adjusted hazard ratio 1.90, P<0.001), with both inferior and anterior/lateral fQRS having a higher risk of cardiovascular and all-cause death (all P<0.05) by using Cox regression models. Conclusions The presence of fQRS in HFpEF was associated with more extensive myocardial perfusion defects and worsened mechanics, which possibly denotes a more severe involvement of cardiac damage. Early recognition in such patients with HFpEF likely benefits from targeted therapeutic interventions.

[Tricuspid regurgitation in 2023 : Where are we with the treatment of the forgotten valve?] / Insuffisance tricuspide en 2023 : modalités de traitement pour la valve oubliée.

The negative impact of tricuspid regurgitation on prognosis in now well established. It also appears clear that surgical and possibly percutaneous treatment should be performed before reaching a point of no return with advanced heart failure and deterioration of right ventricle function. Percutaneous treatment has been divided into coaptation restoration devices, annuloplasty devices, and ortho- or heterotopic valve replacement. The present article offers a brief review of diagnostic modalities beyond echocardiography, surgical treatment as well as of the multiple recent development in the percutaneous treatment of this frequent condition.

L'impact pronostique défavorable de l'insuffisance tricuspide (IT) est maintenant bien établi, ainsi que la nécessité d'intervenir chirurgicalement ou de manière percutanée lorsque le traitement médicamenteux est insuffisant. Des données récentes suggèrent par ailleurs qu'il est probablement judicieux d'intervenir avant qu'un stade trop avancé d'insuffisance cardiaque et d'atteinte du ventricule droit ne soit atteint. Le traitement percutané est divisé en dispositifs de restauration de la coaptation valvulaire, d'annuloplastie et de remplacement de valve ortho ou hétérotopique. Cet article propose une brève revue des modalités diagnostiques au-delà de l'échocardiographie, du traitement chirurgical ainsi que des multiples développements récents dans le traitement percutané de cette pathologie fréquente.

[High-flow fistula: a problem not easy to handle].

High-output cardiac failure is a well-known phenomenon of high-flow fistula in hemodialysis patients. The definition of "high flow" is varied and almost always connected to proximal arteriovenous fistulas (AVF). High flow access is a condition in which hemodynamics is affected by a greater rate of blood flow required for hemodialysis and this can compromise circulatory dynamics, particularly in the elderly in the context of pre-existing heart disease. High access flow is associated with complications like high output heart failure, pulmonary hypertension, massively dilated fistula, central vein stenosis, dialysis associated steal syndrome or distal hypoperfusion ischemic syndrome. Although there is no single agreement about the values of AVF flow volume, nor about the definition of high-flow AVF, there is no doubt that AVF flow should be considered too high if signs of cardiac failure develop. The exact threshold for defining high flow access has not been validated or universally accepted by the guidelines, although a vascular access flow rate of 1 to 1.5 l/min has been suggested. Moreover, even lower values may be indicative of relatively excessive blood flow, depending on the patient's condition. The pathophysiology contributing to this disease process is the shunting of blood from the high-resistance arterial system into the lower resistance venous system, increasing the venous return up to cardiac failure. Accurate and well-timed diagnosis of high flow arteriovenous hemodynamics by monitoring of blood flow of fistula and cardiac function is required in order to stop this process prior to cardiac failure. We present two cases of patients with high flow arteriovenous fistula with a review of the literature.

[Left bundle branch block - dilated cardiomyopathy - heart failure: common links in the closed pathogenetic chain].

This review summarizes the available information on the epidemiology and prognosis of patients with left bundle branch block (LBBB), morphological alterations of the myocardium both resulting in and ensuing LBBB, cardiac biomechanics in LBBB, and possibilities of its correction.

IL-12α deficiency attenuates pressure overload-induced cardiac inflammation, hypertrophy, dysfunction, and heart failure progression.

IL-12α plays an important role in modulating inflammatory response, fibroblast proliferation and angiogenesis through modulating macrophage polarization or T cell function, but its effect on cardiorespiratory fitness is not clear. Here, we studied the effect of IL-12α on cardiac inflammation, hypertrophy, dysfunction, and lung remodeling in IL-12α gene knockout (KO) mice in response to chronic systolic pressure overload produced by transverse aortic constriction (TAC). Our results showed that IL-12α KO significantly ameliorated TAC-induced left ventricular (LV) failure, as evidenced by a smaller decrease of LV ejection fraction. IL-12α KO also exhibited significantly attenuated TAC-induced increase of LV weight, left atrial weight, lung weight, right ventricular weight, and the ratios of them in comparison to body weight or tibial length. In addition, IL-12α KO showed significantly attenuated TAC-induced LV leukocyte infiltration, fibrosis, cardiomyocyte hypertrophy, and lung inflammation and remodeling (such as lung fibrosis and vessel muscularization). Moreover, IL-12α KO displayed significantly attenuated TAC-induced activation of CD4+ T cells and CD8+ T cells in the lung. Furthermore, IL-12α KO showed significantly suppressed accumulation and activation of pulmonary macrophages and dendritic cells. Taken together, these findings indicate that inhibition of IL-12α is effective in attenuating systolic overload-induced cardiac inflammation, heart failure development, promoting transition from LV failure to lung remodeling and right ventricular hypertrophy.

[Two-chambered Right Ventricle Diagnosed in Adulthood:Report of a Case].

A 64-year-old female without symptoms of heart failure was diagnosed with a two-chambered right ventricle (TCRV) during examination of a heart murmur and cardiac enlargement, for which surgery was performed. Under cardiopulmonary bypass and cardiac arrest, we first performed a right atrium and pulmonary artery incision and observed the right ventricle through the tricuspid and pulmonary valves, although we could not obtain a sufficient view of the right ventricular outflow tract. After subsequently incising the right ventricular outflow tract and the anomalous muscle bundle, the right ventricular outflow tract was patch-enlarged using a bovine cardiovascular membrane. After weaning from cardiopulmonary bypass, disappearance of the pressure gradient in the right ventricular outflow tract was confirmed. The patient's postoperative course was uneventful without any complications including arrhythmia.

The Cardiovascular Manifestations of COVID-19.

The Coronavirus 2019 (COVID-19) pandemic, caused by the Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) virus, has resulted in unprecedented morbidity and mortality worldwide. While COVID-19 typically presents as viral pneumonia, cardiovascular manifestations such as acute coronary syndromes, arterial and venous thrombosis, acutely decompensated heart failure (HF), and arrhythmia are frequently observed. Many of these complications are associated with poorer outcomes, including death. Herein we review the relationship between cardiovascular risk factors and outcomes among patients with COVID-19, cardiovascular manifestations of COVID-19, and cardiovascular complications associated with COVID-19 vaccination.

Pulmonary hypertension among patients hospitalized with acute heart failure in Buea, South West Region of Cameroon.

Introduction: pulmonary hypertension (PH) is a common and severe complication in patients with heart failure (HF). It is associated with increased morbidity and mortality. There is limited data in Cameroon on the prevalence of PH in hospitalized HF patients and its impact on outcome. Methods: we analyzed data from consecutive adult patients hospitalized with. Pulmonary hypertension (PH) was defined as pulmonary artery systolic pressure (PASP) ≥ 35mmHg. Results: eighty-six (86) consecutive patients were hospitalized and 66(76.7%) had measurable PASP on echocardiography. Of those with echocardiographically measurable PASP (66), there were 39 (59.1%) females. The median (IQR) age was 60 (42-76) years. The prevalence of PH was 93.9%. PH was present in all (100%) patients with right heart failure (RHF) and in 62 (93.9%) patients with left heart failure (LHF). Severe PH (PASP ≥55 mmHg) was seen in 45 (68.2%, [95% CI: 55.6-75.1]) patients. The mean PASP was significantly higher in those with isolated RHF compared with those who had isolated left or bi-ventricular failure. Factors likely associated with moderate-to-severe PH (PASP ≥ 45 mmHg) were female sex, RHF, and right atrial dilatation. After adjusting for sex, right atrial dilation was independently associated with moderate-to-severe PH. In-hospital death occurred in 7 (10.6%, [95% CI: 4.4-20.6]) patients. The median (IQR) time to death was 6 (3-7) days and ranged from 2 to 8 days. All deaths (100%) occurred in those with moderate-to-severe PH. Conclusion: the prevalence of pulmonary hypertension in hospitalized heart failure patients was high with two third of the patients having severe PH, and most commonly occurred in females. All deaths occurred in patients with moderate-to-severe PH.

Gut Molecules in Cardiometabolic Diseases: The Mechanisms behind the Story.

Atherosclerotic cardiovascular disease is the most common cause of morbidity and mortality worldwide. Diabetes mellitus increases cardiovascular risk. Heart failure and atrial fibrillation are associated comorbidities that share the main cardiovascular risk factors. The use of incretin-based therapies promoted the idea that activation of alternative signaling pathways is effective in reducing the risk of atherosclerosis and heart failure. Gut-derived molecules, gut hormones, and gut microbiota metabolites showed both positive and detrimental effects in cardiometabolic disorders. Although inflammation plays a key role in cardiometabolic disorders, additional intracellular signaling pathways are involved and could explain the observed effects. Revealing the involved molecular mechanisms could provide novel therapeutic strategies and a better understanding of the relationship between the gut, metabolic syndrome, and cardiovascular diseases.

Prognostic significance of the triglyceride-glucose index for patients with ischemic heart failure after percutaneous coronary intervention.

Background: In previous studies, the TyG index (triglyceride-glucose index) has been proven to be closely associated with the prognosis of cardiovascular disease. However, the impact of TyG index on the prognosis of patients with ischemic HF (heart failure) undergoing PCI (percutaneous coronary intervention) is still unclear. Method: In this study, 2055 patients with ischemic HF were retrospectively enrolled and classified into four groups based on quartiles of the TyG index. The primary endpoint was MACE (major adverse cardiovascular events) consisting of all-cause mortality, non-fatal MI (myocardial infarction), and any revascularization. The incidence of the endpoints among the four groups was assessed through Kaplan-Meier survival analysis. The independent correlation between TyG index and endpoints was analyzed with multivariate Cox regression models. Besides, the RCS (restricted cubic spline) analysis was performed to examine the nonlinear relationship between TyG index and MACE. Result: The incidence of MACE was significantly higher in participants with a higher TyG index. The positive association between the TyG index and MACE was also confirmed in the Kaplan-Meier survival analyses. Multivariate cox proportional hazards analysis indicated that the TyG index was independently associated with the increased risk of MACE, regardless of whether TyG was a continuous [TyG, per 1-unit increase, HR (hazard ratio) 1.41, 95% CI (confidence interval) 1.22-1.62, P < 0.001] or categorical variable [quartile of TyG, the HR (95% CI) values for quartile 4 was 1.92 (1.48-2.49), with quartile 1 as a reference]. In addition, the nonlinear association of TyG index with MACE was shown through RCS model and the risk of MACE increased as the TyG index increased in general (Nonlinear p=0.0215). Besides, no obvious interaction was found in the association of TyG with MACE between the DM (diabetes mellitus) group and the no-DM group. Conclusion: Among patients with ischemic HF undergoing PCI, the TyG index was correlated with MACE independently and positively.

Clinical outcomes in end stage renal disease on dialysis and severe coronary artery disease: A real-world study.

BACKGROUND: The optimal management of patients with end-stage renal disease (ESRD) on dialysis with severe coronary artery disease (CAD) has not been determined. METHODS: Between 2013 and 2017, all patients with ESRD on dialysis who had left main (LM) disease, triple vessel disease (TVD) and/or severe CAD for consideration of coronary artery bypass graft (CABG) were included. Patients were divided into 3 groups based on final treatment modality: CABG, percutaneous coronary intervention (PCI), optimal medical therapy (OMT). Outcome measures include in-hospital, 180-day, 1-year and overall mortality and major adverse cardiac events (MACE). RESULTS: In total, 418 patients were included (CABG 11.0%, PCI 65.6%, OMT 23.4%). Overall, 1-year mortality and MACE rates were 27.5% and 55.0% respectively. Patients who underwent CABG were significantly younger, more likely to have LM disease and have no prior heart failure. In this non-randomized setting, treatment modality did not impact on 1-year mortality, although the CABG group had significantly lower 1-year MACE rates (CABG 32.6%, PCI 57.3%, OMT 59.2%; CABG vs. OMT p < 0.01, CABG vs. PCI p < 0.001). Independent predictors of overall mortality include STEMI presentation (HR 2.31, 95% CI 1.38-3.86), prior heart failure (HR 1.84, 95% CI 1.22-2.75), LM disease (HR 1.71, 95% CI 1.26-2.31), NSTE-ACS presentation (HR 1.40, 95% CI 1.03-1.91) and increased age (HR 1.02, 95% CI 1.01-1.04). CONCLUSION: Treatment decisions for patients with severe CAD with ESRD on dialysis are complex. Understanding independent predictors of mortality and MACE in specific treatment subgroups may provide valuable insights into the selection of optimal treatment options.

Platelet, Neutrophil and Lymphocyte Quantitative Abnormalities in Patients with Heart Failure: A Retrospective Study.

Background: Heart failure pathophysiology and its clinical symptoms are characterized by inflammation. Elevated levels of leukocyte subpopulations are a well-known indicator of inflammation and play a predictive role in determining the prognosis of patients with cardiovascular diseases. Besides, platelets are essential mediators of inflammation, especially when they interact with leukocytes. Platelet synthesis, activation, and function are all impacted by heart failure. Thus, the study was aimed at determining the magnitude of platelet, neutrophil, and lymphocyte abnormalities in patients with heart failure. Methods: A retrospective cross-sectional study was conducted from June to July 2022 at the University of Gondar comprehensive specialized hospital. A total of 245 medical records of heart failure patients were included. Data regarding socio-demographic, clinical, and some hematological and biochemical parameters were collected from medical records. Data was entered into Epi-Data 4.6.0.2 and then exported to Stata 11.0 statistical software for analysis. A binary logistic regression analysis with its odds ratio was calculated to identify factors associated with the outcome variables. P-value <0.05 was considered statistically significant. Results: The most frequent leukocyte abnormality among adults with heart failure was neutrophilia, which was detected in 17.55% (95% CI: 13.26-22.87). Besides, lymphocytosis was observed in 10.20% (95% CI: 6.97-14.70) of patients. The magnitude of thrombocytopenia and thrombocytosis among patients with heart failure was 12.24% (95% CI: 8.67-17.01%) and 2.86% (95% CI: 1.36-5.90%), respectively. Only being female was significantly associated with neutrophilia in patients with heart failure (AOR = 2.33; 95% CI: 1.05-5.16). However, none of the variables were significantly associated with platelet and lymphocyte abnormalities. Conclusion: Neutrophilia, lymphocytosis, and thrombocytopenia are the common leukocyte and platelet abnormalities in heart failure patients. Therefore, early detection and management of the underlying causes of those abnormalities may be important to improve patients' outcomes and prevent further complications.