Atrial Fibrillation Ablation in Congenital Heart Disease: Therapeutic Challenges and Future Perspectives.

The increasing prevalence of atrial fibrillation (AF) in adults with congenital heart disease raises significant questions regarding its management. The unique underlying anatomic and physiological background further adds to the difficulty in eliminating the AF burden in these patients. Herein, we provide an overview of the current knowledge on the pathophysiology and risk factors for AF in adult congenital heart disease, with a special focus on the existing challenges in AF ablation. Emerging imaging modalities and ablation techniques might have a role to play. Evidence regarding the safety and efficacy of AF ablation in adult congenital heart disease is summarized, especially for patients with an atrial septal defect, Ebstein anomaly of the tricuspid valve, tetralogy of Fallot, and Fontan circulation. Finally, any remaining gaps in knowledge and potential areas of future research are highlighted.

Association of Health Status Metrics with Clinical Outcomes in Patients with Adult Congenital Heart Disease and Atrial Arrhythmias.

The prognostic value of health status metrics in patients with adult congenital heart disease (ACHD) and atrial arrhythmias is unclear. In this retrospective cohort study of an ongoing national, multicenter registry (PROTECT-AR, NCT03854149), ACHD patients with atrial arrhythmias on apixaban are included. At baseline, health metrics were assessed using the physical component summary (PCS), the mental component summary (MCS) of the Short-Form-36 (SF-36) Health Survey, and the modified European Heart Rhythm Association (mEHRA) score. Patients were divided into groups according to their SF-36 PCS and MCS scores, using the normalized population mean of 50 on the PCS and MCS as a threshold. The primary outcome was the composite of mortality from any cause, major thromboembolic events, major/clinically relevant non-major bleedings, or hospitalizations. Multivariable Cox-regression analyses using clinically relevant parameters (age greater than 60 years, anatomic complexity, ejection fraction of the systemic ventricle, and CHA2DS2-VASc and HAS-BLED scores) were performed to examine the association of health metrics with the composite outcome. Over a median follow-up period of 20 months, the composite outcome occurred in 50 of 158 (32%) patients. The risk of the outcome was significantly higher in patients with SF-36 PCS ≤ 50 compared with those with PCS > 50 (adjusted hazard ratio (aHR), 1.98; 95% confidence interval [CI], 1.02−3.84; p = 0.04) after adjusting for possible confounders. The SF-36 MCS ≤ 50 was not associated with the outcome. The mEHRA score was incrementally associated with a higher risk of the composite outcome (aHR = 1.44 per 1 unit increase in score; 95% CI, 1.03−2.00; p = 0.03) in multivariable analysis. In ACHD patients with atrial arrhythmias, the SF-36 PCS ≤ 50 and mEHRA scores predicted an increased risk of adverse events.

CERT2 ceramide- and phospholipid-based risk score and major adverse cardiovascular events: A systematic review and meta-analysis.

Accumulating evidence over the last decade suggests the promising role of ceramides as potential mediators of coronary artery disease (CAD) or prognostic biomarkers of its clinical course. This meta-analysis (CRD42021241058) aimed to assess the prognostic value of a ceramide- and phosphatidylcholine-based risk score, Coronary Event Risk Test 2 (CERT2) score, for the prediction of major adverse cardiovascular events (MACE: cardiovascular death, myocardial infarction or stroke) in 26,896 individuals with established CAD. Patients with CERT2=0-3 were used as a reference group. Pooled risk ratio (RR) of MACE among patients with CERT2=4-6 was equal to 1.35 (95% confidence intervals, CI: 1.11-1.64). Patients with CERT2=7-8 had an 81% increased risk of MACE (RR=1.81, CI: 1.40-2.34), while those with CERT2=9-12 had a 165% increased risk of MACE (RR=2.65, CI: 1.85-3.80). Subgroup analysis in patients with chronic coronary syndrome yielded an adjusted hazard ratio for MACE equal to 1.20 (CI: 1.09-1.32) per one standard deviation increase of CERT2 score. A summary c-statistic of the score combined with classical risk assessment model was found equal to 0.68 (95% CI: 0.58 to 0.77; approximate 95% prediction interval 0.38 to 0.88). Therefore, CERT2 score seems to emerge as a robust predictor of MACE. However, additional research is warranted to establish the cost-effectiveness of CERT2 score calculation for the determination of residual risk in patients with CAD.

Impact of religious fasting on metabolic and hematological profile in both dyslipidemic and non-dyslipidemic fasters.

BACKGROUND/OBJECTIVES: Religious fasting (RF) is practiced annually by millions of Christian and Muslim followers worldwide. Scarce data exist on the impact of RF on the metabolic and hematological profile of individuals with or without dyslipidemia. SUBJECTS/METHODS: The present study included: (i) 60 Greek Orthodox participants, 30 with dyslipidemia and 30 without dyslipidemia, who abstained from meat, fish and dairy products for seven consecutive weeks, and (ii) 15 young, non-dyslipidemic Muslim participants abstaining totally from food and liquid from dawn till sunset during 30 days. Biochemical (iron, ferritin, vitamin B12, calcium, low-density lipoprotein (LDL), high-density lipoprotein (HDL), total cholesterol (TC), triglyceride and fasting glucose) and hematological (hemoglobin, hematocrit) serum blood test results of study participants were measured pre- and post- RF (at weeks 0 and 7 for Orthodox participants and at weeks 0 and 4 for Muslim participants). RESULTS: In dyslipidemic and non-dyslipidemic Orthodox participants, a significant reduction of fasting glucose, HDL, LDL and TC levels was found post-RF. Hemoglobin, hematocrit, iron and ferritin levels were significantly increased, while post-RF vitamin B12 and calcium levels were substantially decreased. Subanalysis between dyslipidemic and non-dyslipidemic Orthodox participants revealed a greater decrease of cholesterol levels in the former. In Muslim participants, triglyceride, LDL and total cholesterol levels were increased post-RF (all p values < 0.05). CONCLUSIONS: Our study adds to the existing literature evidence about the significant impact of RF on metabolic and hematological profiles of Orthodox and Muslim followers. The prevention of calcium and B12 deficiency during Orthodox RF by supplement consumption as well as the protection from dehydration and dysregulation of lipid metabolism during Ramadan RF should concern both clinicians and dietician nutritionists. Nevertheless, studies with larger sample size and/or long-term follow-up are warranted before reaching definite conclusions about the effects of RF on human health.

Volumetric Imaging of Lung Tissue at Micrometer Resolution: Clinical Applications of Micro-CT for the Diagnosis of Pulmonary Diseases.

Micro-computed tomography (micro-CT) is a promising novel medical imaging modality that allows for non-destructive volumetric imaging of surgical tissue specimens at high spatial resolution. The aim of this study is to provide a comprehensive assessment of the clinical applications of micro-CT for the tissue-based diagnosis of lung diseases. This scoping review was conducted in accordance with the PRISMA Extension for Scoping Reviews, aiming to include every clinical study reporting on micro-CT imaging of human lung tissues. A literature search yielded 570 candidate articles, out of which 37 were finally included in the review. Of the selected studies, 9 studies explored via micro-CT imaging the morphology and anatomy of normal human lung tissue; 21 studies investigated microanatomic pulmonary alterations due to obstructive or restrictive lung diseases, such as chronic obstructive pulmonary disease, idiopathic pulmonary fibrosis, and cystic fibrosis; and 7 studies examined the utility of micro-CT imaging in assessing lung cancer lesions (n = 4) or in transplantation-related pulmonary alterations (n = 3). The selected studies reported that micro-CT could successfully detect several lung diseases providing three-dimensional images of greater detail and resolution than routine optical slide microscopy, and could additionally provide valuable volumetric insight in both restrictive and obstructive lung diseases. In conclusion, micro-CT-based volumetric measurements and qualitative evaluations of pulmonary tissue structures can be utilized for the clinical management of a variety of lung diseases. With micro-CT devices becoming more accessible, the technology has the potential to establish itself as a core diagnostic imaging modality in pathology and to enable integrated histopathologic and radiologic assessment of lung cancer and other lung diseases.

Association of GRACE Risk Score with Coronary Artery Disease Complexity in Patients with Acute Coronary Syndrome.

The GRACE score constitutes a useful tool for risk stratification in patients with acute coronary syndrome (ACS), while the SYNTAX score determines the complexity of coronary artery disease (CAD). This study sought to correlate these scores and assess the accuracy of the GRACE score in predicting the extent of CAD. A total of 539 patients with ACS undergoing coronary angiography were included in this analysis. The patients were classified into those with a SYNTAX score < 33 and a SYNTAX score ≥ 33. Spearman's correlation and receiver operator characteristic analysis were conducted to investigate the role of the GRACE score as a predictor of the SYNTAX score. There was a significantly positive correlation between the SYNTAX and the GRACE scores (r = 0.32, p < 0.001). The GRACE score predicted severe CAD (SYNTAX ≥ 33) moderately well (the area under the curve was 0.595 (0.522-0.667)). A GRACE score of 126 was documented as the optimal cut-off for the prediction of a SYNTAX score ≥ 33 (sensitivity = 53.5% and specificity = 66%). Therefore, our study reports a significantly positive correlation between the GRACE and the SYNTAX score in patients with ACS. Notably, NSTEMI patients with a high-risk coronary anatomy have higher calculated GRACE scores. A multidisciplinary approach by a heart team could possibly alter the therapeutic approach and management in patients presenting with ACS and a high calculated GRACE score.

Return-to-Sport Rate and Activity Level Are High Following Arthroscopic All-Inside Meniscal Repair With and Without Concomitant Anterior Cruciate Ligament Reconstruction: A Systematic Review.

PURPOSE: To systematically review the literature of return-to-sport outcomes following all-inside meniscus repair and evaluate whether concomitant anterior cruciate ligament reconstruction (ACLR) influenced these outcomes. METHODS: A systematic review of the MEDLINE, PubMed, Embase, and Cochrane Registry of Systematic Reviews databases was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Two reviewers examined all literature pertaining to sport outcomes following all-inside meniscal repair. Studies were included if they had a 12-month minimum follow-up and reported return to sport rate, Tegner, or Knee injury and Osteoarthritis Outcome Score (KOOS) Sport outcomes. Studies with meniscal repair techniques other than the all-inside technique were excluded. Studies were not excluded if they contained patients receiving concomitant ACLR. Study quality was evaluated with the Methodological Index for Nonrandomized Studies. RESULTS: Nineteen studies comprising 872 patients were included in this investigation. The weighted average patient age was 28.7 (range 14.1-42.1) years, and the weighted average follow-up was 56.0 (range 18.0-155.0) months. The mean Methodological Index for Nonrandomized Studies score was 14.4 ± 3.7. Ten investigations reported both preoperative (range 2.3-3.5) and postoperative (range 4.0-7.3) Tegner outcomes, with scores at final follow-up greater in each of the 10 reporting investigations. KOOS Sport outcomes were examined in 5 investigations, with scores at follow-up ranging from 63.6 to 91. Three studies reported a return to sport rate ranging from 89.6 to 90% at follow-up. Four investigations compared sport-related outcomes between isolated meniscal repair and meniscal repair with concomitant ACLR. Two such studies reported no difference between the 2 cohorts, 1 favored the isolated cohort, and 1 favored the combined cohort. CONCLUSIONS: This systematic review found a 90% return-to-sport rate and high postoperative activity level following all-inside meniscal repair, as assessed by KOOS Sport and Tegner activity scales. Further, concurrent ACLR did not significantly affect these outcomes. LEVEL OF EVIDENCE: IV, systematic review of level I-IV studies.

Ulnar trochlear notch articular surface has three morphological patterns: a neglected major anatomical feature.

PURPOSE: The typical anatomical illustration of the trochlear notch articular surface includes a transverse rough non-articular ridge which separates the olecranon and coronoid part of the joint. This transverse ridge, the "bare area", is not covered by cartilage and represents the optimal entry point for olecranon osteotomies. Aim of the present study was to encounter the anatomical variations in the morphology of the trochlear notch articular surface. METHODS: Two-hundred seventy-three dried ulnae were inspected and a qualitative classification of the variations of the trochlear notch articular surface was done. Correlation to gender and side was examined. RESULTS: Three distinct morphological patterns were observed. Separate olecranon and coronoid facets (Type I) were the most common pattern (165/273, 60.4%). Partial fusion of olecranon and coronoid facets (Type II) was observed in 75 out of 273 bones (27.5%), while a single olecranon and coronoid facet (Type III) was present in 33 out of 273 bones (12.1%). The occurrence of Type II and III was significantly more common in females (p < 0.001). CONCLUSIONS: The most common morphological pattern of the proximal ulna articular surface was the olecranon and coronoid facets separated by the transverse ridge, which is considered as the typical anatomical pattern. The partial fusion of olecranon and coronoid facets was the second most common pattern (27.5%) and the single olecranon and coronoid facet with no transverse ridge present was the rarest one (12.1%). These variations affect the area covered by cartilage. They are noticeable in an elbow MRI and they may have implications on olecranon osteotomy. Absence of the transverse ridge may confuse the surgeon during elbow arthroscopy.