The Role of Prognostic Scores in Assessing the Prognosis of Patients Admitted in the Cardiac Intensive Care Unit: Emphasis on Heart Failure Patients.

Background/Objectives: Patient care in Cardiac Intensive Care Units (CICU) has evolved but data on patient characteristics and outcomes are sparse. This retrospective observational study aimed to define clinical characteristics and risk factors of CICU patients, their in-hospital and 30-day mortality, and compare it with established risk scores. Methods: Consecutive patients (n = 294, mean age 70 years, 74% males) hospitalized within 15 months were studied; APACHE II, EHMRG, GWTG-HF, and GRACE II were calculated on admission. Results: Most patients were admitted for ACS (48.3%) and acute decompensated heart failure (ADHF) (31.3%). Median duration of hospitalization was 2 days (IQR = 1, 4). In-hospital infection occurred in 20%, 18% needed mechanical ventilation, 10% renal replacement therapy and 4% percutaneous ventricular assist devices (33%, 29%, 20% and 4%, respectively, for ADHF). In-hospital and 30-day mortality was 18% and 11% for all patients (29% and 23%, respectively, for ADHF). Established scores (especially APACHE II) had a good diagnostic accuracy (area under the curve-AUC). In univariate and multivariate analyses in-hospital intubation and infection, history of coronary artery disease, hypotension, uremia and hypoxemia on admission were the most important risk factors. Based on these, a proposed new score showed a diagnostic accuracy of 0.954 (AUC) for in-hospital mortality, outperforming previous scores. Conclusions: Patients are admitted mainly with ACS or ADHF, the latter with worse prognosis. Several patients need advanced support; intubation and infections adversely affect prognosis. Established scores predict mortality satisfactorily, but larger studies are needed to develop CICU-directed scores to identify risk factors, improve prediction, guide treatment and staff training.

Large pericardial effusion in a woman in the second trimester of pregnancy: a case report.

Background: Pericardial effusion is common in pregnancy, with causes similar to the general population. Usually, it is found in the third trimester and disappears spontaneously after labour; however, there is a risk of progression to tamponade. Management is based on expert opinion, since few studies have been published. Case summary: A woman with enlargement of a known, chronic, presumably idiopathic pericardial effusion, in the 17th gestation week, presented with mild dyspnoea, without specific echocardiographic signs of cardiac tamponade. She received double antithrombotic treatment with aspirin 100 mg, started before conception, and a prophylactic dose of tinzaparin 4500 IU, started at the beginning of the pregnancy due to obstetrical antiphospholipid syndrome. A multidisciplinary team consisting of the treating obstetrician-gynaecologist, haematologist, cardiothoracic surgeon, and cardiologist discussed the management, taking into account the large size of the effusion and the significant increase during pregnancy, the possibility of further increase during the third trimester, the antiplatelet and antithrombotic treatment, which increased the haemorrhagic risk, and the difficulty and risk to intervene later in pregnancy. A surgical pericardial window was proposed to the patient and family and was performed uneventfully. Discussion: This case demonstrates the importance of a multidisciplinary team approach and shared decision-making in the management of these complex cardio-obstetric patients in order to achieve optimal therapeutic results.

Myocardial Perfusion Imaging and C-Reactive Protein in Myocardial Ischemia: A Retrospective Single-Center Study.

BACKGROUND: Inflammation is an important mechanism in atherosclerosis and plaque formation. C-reactive protein (CRP) is a common inflammatory biomarker associated with the risk of coronary heart disease. We investigated the relationship of CRP with findings from myocardial perfusion imaging (MPI). METHODS: In this retrospective study, 102 consecutive patients (mean age 71 years, 68% males) who underwent MPI (for diagnostic reasons or quantification of myocardial ischemia) and CRP determination (upper limit: 6 mg/L) within 1 month from MPI were included. The patients had no infection or recent acute coronary syndrome. RESULTS: The median CRP level was 4 mg/L (2, 10) among the study population. Patients with raised CRP had higher summed stress score (SSS) (p = 0.006) and summed rest score (SRS) (p = 0.001) and higher risk for SSS > 3 (OR 9.25, 95% CI 2.03-42.13, p = 0.001) compared to those with low CRP. The association of SSS and SRS with CRP levels was more evident in patients over 70 years (p = 0.027 and p = 0.005, respectively). No significant difference in summed difference score was shown. The two groups had no difference in other risk factors (p > 0.05 for all comparisons). CONCLUSION: a high level of CRP was associated with the presence and extent of stress-induced myocardial ischemia in MPI.

The Potential Role of Salivary NT-proBNP in Heart Failure.

BACKGROUND: Serum natriuretic peptides (NPs) have an established role in heart failure (HF) diagnosis. Saliva NT-proBNP that may be easily acquired has been studied little. METHODS: Ninety-nine subjects were enrolled; thirty-six obese or hypertensive with dyspnoea but no echocardiographic HF findings or raised NPs served as controls, thirteen chronic HF (CHF) patients and fifty patients with acute decompensated HF (ADHF) requiring hospital admission. Electrocardiogram, echocardiogram, 6 min walking distance (6MWD), blood and saliva samples, were acquired in all participants. RESULTS: Serum NT-proBNP ranged from 60-9000 pg/mL and saliva NT-proBNP from 0.64-93.32 pg/mL. Serum NT-proBNP was significantly higher in ADHF compared to CHF (p = 0.007) and in CHF compared to controls (p < 0.05). There was no significant difference in saliva values between ADHF and CHF, or between CHF and controls. Saliva and serum levels were positively associated only in ADHF patients (R = 0.352, p = 0.012). Serum NT-proBNP was positively associated with NYHA class (R = 0.506, p < 0.001) and inversely with 6MWD (R = -0.401, p = 0.004) in ADHF. Saliva NT-proBNP only correlated with age in ADHF patients. CONCLUSIONS: In the current study, saliva NT-proBNP correlated with serum values in ADHF patients, but could not discriminate between HF and other causes of dyspnoea. Further research is needed to explore the value of saliva NT-proBNP.

Transcatheter Aortic Valve Implantation with the Portico Valve: 2-Year Outcomes of a Multicenter, Real-World Registry.

INTRODUCTION: The self-expanding, resheathable, repositionable transcatheter aortic heart valve Portico is being used successfully for transcatheter aortic valve implantation procedures (TAVI) in patients with severe aortic stenosis. The aim of this study was to evaluate outcomes at 2 years after TAVI with the Portico valve. METHODS: Multicenter registry of clinical, echocardiographic and survival data from consecutive patients treated with the Portico TAVI system (Abbott, Chicago, IL, USA) in three cath labs in Northern Greece and Epirus during 2017-2020. The primary end point was all-cause mortality at 24 months. Secondary end points included procedural outcomes (efficacy and safety) and echocardiographic measurements. RESULTS: A total of 90 patients (81 ± 6 years, 50% females, mean age 81 ± 6 years) were included in the registry. The indication for implantation was severe, symptomatic aortic stenosis (NYHA III, IV) in eighty-two (91.1%) and degeneration of a prosthetic aortic valve in eight (8.9%) patients. All patients were categorized as high surgical risk (mean Logistic Euroscore 25.9 ± 10, Euroscore II 7.7 ± 4.4 and STS score 10.8 ± 8.9). The procedure was performed transfemorally in all patients, under general anesthesia in 95.6%, under TOE guidance in 21.1%, with native valve predilatation in 46.7%, and the "resheath" option was used in 31.1% of the cases. The implantation was successful in 97.8% and there was a need for a second valve in 2.2% of the cases. Complications included permanent pacemaker implantation (16.7%), access cite complications (15.6%), arrythmias (23.3%), paravalvular leak (moderate 7.8%, severe 1.1%), acute kidney injury (7.8%), no strokes and one death during the procedure. Aortic valve peak velocity, peak and mean pressure gradients, were significantly reduced after the procedure. All-cause mortality at 1, 12 and 24 months was 4.4%, 6.7% and 7.8%, respectively. CONCLUSIONS: TAVI with the Portico system comprises an effective and safe solution for the management of severe, symptomatic aortic stenosis in high-risk surgical patients.

The Role of Myocardial Perfusion Imaging in the Prediction of Major Adverse Cardiovascular Events at 1 Year Follow-Up: A Single Center's Experience.

BACKGROUND: Myocardial perfusion imaging via single-photon emission computed tomography (SPECT MPI) is a well-established method of diagnosing coronary artery disease (CAD). The purpose of this study was to assess the role of SPECT MPI in predicting major cardiovascular events. METHODS: The study population was composed of 614 consecutive patients (mean age: 67 years, 55% male) referred for SPECT MPI due to symptoms of stable CAD. The SPECT MPI was performed using a single-day protocol. We conducted a follow-up on all patients at 12 months via a telephone interview. RESULTS: The majority of our patients (78%) presented findings suggestive of reversible ischemia, fixed defects or both. Extensive perfusion defects were found in 18% of the population, while LV dilation was found in 7%. During the 12-month follow-up, 16 deaths, 8 non-fatal MIs and 20 non-fatal strokes were recorded. There was no significant association of SPECT findings with the combined endpoint of all-cause death, non-fatal MI and non-fatal stroke. The presence of extensive perfusion defects was an independent predictor of mortality at 12 months (HR: 2.90, 95% CI: 1.05, 8.06, p = 0.041). CONCLUSIONS: In a high-risk patient population with suspected stable CAD, only large reversible perfusion defects in SPECT MPI were independently associated with mortality at 1 year. Further trials are needed to validate our findings and refine the role of SPECT MPI findings in the diagnosis and prognosis of cardiovascular patients.

Body Mass Index Is Independently Associated with the Presence of Ischemia in Myocardial Perfusion Imaging.

Background and Objectives: Obesity has been linked to various cardiovascular risk factors, increased incidence of coronary artery disease, and myocardial perfusion defects. The aim of this study was to investigate if body mass index (BMI) and waist circumference (WC) were associated with myocardial perfusion defects. Materials and Methods: A total of 308 consecutive patients who had myocardial perfusion imaging (MPI) with single photon emission computed tomography (SPECT) and a complete medical record on file were studied retrospectively. Results: The median age was 69 (61−76) years, the BMI was 27.6 (24.4−30.7) kg/m2, and the WC was 110 (102−118) cm. Of the 308 patients, 239 patients (77.6%) had myocardial ischemia. A positive test for ischemia was more frequent in men compared to women (72 vs. 28%, p < 0.001). Within the male group, BMI and WC were not significantly different between the ischemia and non-ischemia groups. In contrast, within the female group, both BMI (30.2 vs. 27.1 kg/m2, p = 0.002) and WC (112 vs. 105.5 cm, p = 0.020) were significantly higher in the ischemia group. Multivariable logistic regression showed that male sex and BMI were the only two independent predictors of ischemia in our patient population. Conclusions: This study showed that BMI was an independent predictor of ischemia in our patient population.

Two Cases of Arrhythmic Mitral Valve Prolapse: Evil Has Many Faces.

Mitral valve prolapse (MVP) is one of the most common valvular heart diseases. Although MVP is generally considered benign, it can be associated with important complications, including sudden cardiac death (SCD), owing to ventricular arrhythmias (VAs). Several clinical, electrocardiographic, and imaging findings have been associated with MVP-related SCD, including female sex, T-wave inversions in the inferior leads, complex ventricular ectopy, leaflet redundancy (classic MVP), mitral annular disjunction, pickelhaube sign (a spiked configuration of the lateral annular velocities), and evidence of myocardial fibrosis in cardiac magnetic resonance (CMR) imaging. However, neither of these markers, nor any specific combination of them, have proved to be a consistent predictor of malignant VAs and SCD. In this context, we present 2 interesting cases of arrhythmic MVP, highlighting the broad clinical spectrum of this condition, the potential underlying arrhythmogenic mechanisms, and the merit of identifying patients at high arrhythmic risk.

Three-vessel spontaneous coronary artery dissection in a patient with hyperhomocysteinemia.

Increased homocysteine has been related to the occurrence of dissections in the coronary circulation, aorta, and cervical arteries. Spontaneous coronary artery dissection (SCAD) is a relatively rare phenomenon, and data on the long-term follow-up of patients with SCAD are extremely limited. Herein, we describe a case of a young male patient with 3-vessel SCAD (presence of radiolucent linear defects indicating the presence of dissections in all three major coronary arteries) who was found to have hyperhomocysteinemia and a concurrent methylenetetrahydrofolate reductase prothrombotic mutation. Despite the presence of multi-vessel SCAD, the patient had clinically stable coronary artery disease for a long period. .

Venous Thromboembolism in Patients with Heart Failure.

Heart failure (HF) and venous thromboembolism (VTE) are common clinical entities, closely interrelated, sharing multiple pathophysiological mechanisms. Their co-incidence is associated with further worsening of the prognosis of one another. Despite their frequent co-existence, important clinical questions still remain unanswered. The risk of VTE especially in chronic HF patients appears to vary widely in clinical studies, while the VTE-associated risk in HF patients is still not well determined and cannot be accurately predicted. Although scientific guidelines recommend venous thromboprophylaxis in patients hospitalized with an acute HF syndrome, venous thromboprophylaxis has not been studied adequately in prospective trials in ambulatory HF patients. In the present review, we aimed to summarize the current knowledge on the epidemiology of VTE and HF, the risk prediction for VTE occurrence in HF patients, the impact on patient outcome, and the need for anticoagulation in certain HF subgroups to improve prognosis, while we sought to identify gaps in knowledge that need to be addressed in the future.

Heart Failure diagnosis based on deep learning techniques.

The aim of the study is to address the heart failure (HF) diagnosis with the application of deep learning approaches. Seven deep learning architectures are implemented, where stacked Restricted Boltzman Machines (RBMs) and stacked Autoencoders (AEs) are used to pre-train Deep Belief Networks (DBN) and Deep Neural Networks (DNN). The data is provided by the University College Dublin and the 2nd Department of Cardiology from the University Hospital of Ioannina. The features recorded are grouped into: general demographic information, physical examination, classical cardiovascular risk factors, personal history of cardiovascular disease, symptoms, medications, echocardiographic features, laboratory findings, lifestyle/habits and other diseases. The total number of subjects utilized is 422. The deep learning methods provide quite high results with the Autoencoder plus DNN approach to demonstrate accuracy 91.71%, sensitivity 90.74%, specificity 92.31% and f-score 89.36%.

Comparison of three U-Net family architectures for left ventricular myocardial wall automatic segmentation.

Left ventricular (LV) segmentation is an important process which can provide quantitative clinical measurements such as volume, wall thickness and ejection fraction. The development of an automatic LV segmentation procedure is a challenging and complicated task mainly due to the variation of the heart shape from patient to patient, especially for those with pathological and physiological changes. In this study, we focus on the implementation, evaluation and comparison of three different Deep Learning architectures of the U-Net family: the custom 2-D U-Net, the ResU-Net++ and the DenseU-Net, in order to segment the LV myocardial wall. Our approach was applied to cardiac CT datasets specifically derived from patients with hypertrophic cardiomyopathy. The results of the models demonstrated high performance in the segmentation process with minor losses. The model revealed a dice score for U-Net, Res-U-net++ and Dense U-Net, 0.81, 0.82 and 0.84, respectively.

A Machine Learning Approach for Chronic Heart Failure Diagnosis.

The aim of this study was to address chronic heart failure (HF) diagnosis with the application of machine learning (ML) approaches. In the present study, we simulated the procedure that is followed in clinical practice, as the models we built are based on various combinations of feature categories, e.g., clinical features, echocardiogram, and laboratory findings. We also investigated the incremental value of each feature type. The total number of subjects utilized was 422. An ML approach is proposed, comprising of feature selection, handling class imbalance, and classification steps. The results for HF diagnosis were quite satisfactory with a high accuracy (91.23%), sensitivity (93.83%), and specificity (89.62%) when features from all categories were utilized. The results remained quite high, even in cases where single feature types were employed.

Salivary Biomarkers for Diagnosis and Therapy Monitoring in Patients with Heart Failure. A Systematic Review.

The aim of this study was to perform a systematic review on the potential value of saliva biomarkers in the diagnosis, management and prognosis of heart failure (HF). The correlation between saliva and plasma values of these biomarkers was also studied. PubMed was searched to collect relevant literature, i.e., case-control, cross-sectional studies that either compared the values of salivary biomarkers among healthy subjects and HF patients, or investigated their role in risk stratification and prognosis in HF patients. No randomized control trials were included. The search ended on 31st of December 2020. A total of 15 studies met the inclusion criteria. 18 salivary biomarkers were analyzed and the levels of all biomarkers studied were found to be higher in HF patients compared to controls, except for amylase, sodium, and chloride that had smaller saliva concentrations in HF patients. Natriuretic peptides are the most commonly used plasma biomarkers in the management of HF. Their saliva levels show promising results, although the correlation of saliva to plasma values is weakened in higher plasma values. In most of the publications, differences in biomarker levels between HF patients and controls were found to be statistically significant. Due to the small number of patients included, larger studies need to be conducted in order to facilitate the use of saliva biomarkers in clinical practice.

Point-of-Care Testing Devices for Heart Failure Analyzing Blood and Saliva Samples.

Heart failure (HF) is the most rapidly growing cardiovascular condition with an estimated prevalence of >37.7 million individuals globally. HF is associated with increased mortality and morbidity and confers a substantial burden, in terms of cost and quality of life, for the individuals and the healthcare systems, highlighting thus the need for early and accurate diagnosis of HF. The accuracy of HF diagnosis, severity estimation, and prediction of adverse events has improved by the utilization of blood tests measuring biomarkers. The contribution of biomarkers for HF management is intensified by the fact that they can be measured in short time at the point-of-care. This is allowed by the development of portable analytical devices, commonly known as point-of-care testing (POCT) devices, which exploit the advancements in the area of microfluidics and nanotechnology. The aim of this review paper is to present a review of POCT devices used for the measurement of biomarkers facilitating decision making when managing HF patients. The devices are either commercially available or in the form of prototypes under development. Both blood and saliva samples are considered. The challenges concerning the implementation of POCT devices and the barriers for their adoption in clinical practice are discussed.

KardiaSoft Architecture - A Software Supporting Diagnosis and Therapy Monitoring of Heart Failure Patients Exploiting Saliva Biomarkers.

The aim of this work is to present the architecture of the KardiaSoft software, a clinical decision support tool allowing the healthcare professionals to monitor patients with heart failure by providing useful information and suggestions in terms of the estimation of the presence of heart failure (heart failure diagnosis), stratification-patient profiling, long term patient condition evaluation and therapy response monitoring. KardiaSoft is based on predictive modeling techniques that analyze data that correspond to four saliva biomarkers, measured by a point-of-care device, along with other patient's data. The KardiaSoft is designed based on the results of a user requirements elicitation process. A small clinical scale study with 135 subjects and an early clinical study with 90 subjects will take place in order to build and validate the predictive models, respectively.

Restrictive Cardiomyopathies: The Importance of Noninvasive Cardiac Imaging Modalities in Diagnosis and Treatment-A Systematic Review.

Restrictive cardiomyopathy (RCM) is the least common among cardiomyopathies. It can be idiopathic, familial, or secondary to systematic disorders. Marked increase in left and/or right ventricular filling pressures causes symptoms and signs of congestive heart failure. Electrocardiographic findings are nonspecific and include atrioventricular conduction and QRS complex abnormalities and supraventricular and ventricular arrhythmias. Echocardiography and cardiac magnetic resonance (CMR) play a major role in diagnosis. Echocardiography reveals normal or hypertrophied ventricles, preserved systolic function, marked biatrial enlargement, and impaired diastolic function, often with restrictive filling pattern. CMR offering a higher spatial resolution than echocardiography can provide detailed information about anatomic structures, perfusion, ventricular function, and tissue characterization. CMR with late gadolinium enhancement (LGE) and novel approaches (myocardial mapping) can direct the diagnosis to specific subtypes of RCM, depending on the pattern of scar formation. When noninvasive studies have failed, endomyocardial biopsy is required. Differentiation between RCM and constrictive pericarditis (CP), nowadays by echocardiography, is important since both present as heart failure with normal-sized ventricles and preserved ejection fraction but CP can be treated by means of anti-inflammatory and surgical treatment, while the treatment options of RCM are dictated by the underlying condition. Prognosis is generally poor despite optimal medical treatment.

A Case of Human Infection by Rickettsia slovaca in Greece.

Although tick-borne rickettsiosis is endemic in Greece, until recently, human samples arriving at the National Reference Centre under suspicion of rickettsial infection were routinely tested only for Rickettsia typhi and R. conorii. However, identification of additional rickettsia species in ticks prompted revision of the protocol in 2010. Until that year, all human samples received by the laboratory were tested for antibodies against R. conorii and R. typhi only. Now, tests for R. slovaca, R. felis, and R. mongolotimonae are all included in routine analysis. The current description of a human R. slovaca case is possible as a result of these changes in routine testing.