Speckle Tracking Echocardiography in Patients with Non-Ischemic Dilated Cardiomyopathy Who Undergo Cardiac Resynchronization Therapy: A Narrative Review.

Non-ischemic dilated cardiomyopathy (DCM) represents a significant cause of heart failure, defined as the presence of left ventricular (LV) dilatation and systolic dysfunction unexplained solely by abnormal loading conditions or coronary artery disease. Cardiac resynchronization therapy (CRT) has emerged as a cornerstone in the management of heart failure, particularly in patients with DCM. However, identifying patients who will benefit the most from CRT remains challenging. Speckle tracking echocardiography (STE) has garnered attention as a non-invasive imaging modality that allows for the quantitative assessment of myocardial mechanics, offering insights into LV function beyond traditional echocardiographic parameters. This comprehensive review explores the role of STE in guiding patient selection and optimizing outcomes in CRT for DCM. By assessing parameters such as LV strain, strain rate, and dyssynchrony, STE enables a more precise evaluation of myocardial function and mechanical dyssynchrony, aiding in the identification of patients who are most likely to benefit from CRT. Furthermore, STE provides valuable prognostic information and facilitates post-CRT optimization by guiding lead placement and assessing response to therapy. Through an integration of STE with CRT, clinicians can enhance patient selection, improve procedural success rates, and ultimately, optimize clinical outcomes in patients with DCM. This review underscores the pivotal role of STE in advancing personalized management strategies for DCM patients undergoing CRT.

Burnout in healthcare - the Emperor's New Clothes.

Burnout is common among physicians; it severely alters their health and has a negative impact on functioning of healthcare systems. Hypertension, increased cortisol levels, maladaptive behaviors with negative social consequences, and suboptimal quality of care have been associated with healthcare providers' burnout. As the number of patients with cancers, psychiatric and neurodegenerative disorders will rise, we need new solutions to maintain physicians' health and, therefore, quality of care. Coping strategies before the COVID-19 pandemic seem ineffective in scaling all the deficits of the global healthcare systems. Examples of new initiatives include new collaborative projects, such as COH-FIT (The Collaborative Outcomes study on Health and Functioning during Infection Times - https://www.coh-fit.com), which aims to collect global data and understand the impact of the COVID-19 pandemic on physical and mental health in order to identify various coping strategies for patients and healthcare workers during infection times, or MEMO (Minimizing Error, Maximizing Outcome), funded by the Agency of Healthcare Research and Quality (AHRQ). Others: i) Rome Foundation GastroPsych undertake efforts dedicated to the science and practice of psychogastroenterology, a burgeoning field with roots in behavioral intervention, cognitive science and experimental psychology focused on fostering the professional growth and collaboration of those engaged in medical practices, or ii) World Gastroenterology Organisation (WGO), Train The Trainers (TTT) program including a new topic of the impact of burnout on career longevity in order to foster strategies for staying healthy and increasing career satisfaction. There is a need for continuous development of digital technologies (e.g. training simulators, telemedicine, robots and artificial intelligence). Their implementation into medical practice is inevitable. Now more than ever, there is a need for a new spirit in healthcare. Together with others in the field, we believe this article is a desperate call for maximizing the use of novel technologies supported by collaborative interactions among healthcare providers and medical professionals of diverse medical fields.

The Utility of Low-Dose-Dobutamine Stress Echocardiography in Patients with Heart Failure with Reduced Ejection Fraction: An Update.

Despite significant advancements in medical therapy, heart failure with reduced ejection fraction (HFrEF) continues to be a significant cause of death and disability. Reversible ischaemic left ventricular dysfunction due to viable myocardium is one such contributing factor. In these cases, coronary revascularization has shown promise in improving left ventricular function and prognosis. For patients with HFrEF and wide QRS, cardiac resynchronization therapy (CRT) is an effective option to address electromechanical dyssynchrony. However, approximately 30% of patients do not respond positively to CRT, highlighting the need to refine candidate selection for this treatment. In some patients with reduced HFrEF, there is a condition known as classical low-flow, low-gradient aortic stenosis (AS) that may be observed. This condition is characterized by a low transaortic flow, which leads to reductions in both the transaortic mean gradient and aortic valve area. Decision-making regarding revascularization, CRT, and pharmacological treatment play a crucial role in managing HFrEF. Cardiac imaging can be valuable in guiding decision-making processes and assessing the prognosis of patients with HFrEF. Among the imaging modalities, dobutamine stress echocardiography has come a long way in establishing itself as a feasible, safe, effective, relatively cheap non-invasive technique. The aim of this review is to explore the current literature on the utility of low-dose stress echocardiography in diagnosing and prognosticating patients with HFrEF.

Robotic-Assisted Solutions for Invasive Cardiology, Cardiac Surgery and Routine On-Ward Tasks: A Narrative Review.

Robots are defined as programmable machines that can perform specified tasks. Medical robots are emerging solutions in the field of cardiology leveraging recent technological innovations of control systems, sensors, actuators, and imaging modalities. Robotic platforms are successfully applied for percutaneous coronary intervention, invasive cardiac electrophysiology procedures as well as surgical operations including minimally invasive aortic and mitral valve repair, coronary artery bypass procedures, and structural heart diseases. Furthermore, machines are used as staff-assisting tools to support nurses with repetitive clinical duties i.e., food delivery. High precision and resolution allow for excellent maneuverability, enabling the performance of medical procedures in challenging anatomies that are difficult or impossible using conventional approaches. Moreover, robot-assisted techniques protect operators from occupational hazards, reducing exposure to ionizing radiation, and limiting risk of orthopedic injuries. Novel automatic systems provide advantages for patients, ensuring device stability with optimized utilization of fluoroscopy. The acceptance of robotic technology among healthcare providers as well as patients paves the way for widespread clinical application in the field of cardiovascular medicine. However, incorporation of robotic systems is associated with some disadvantages including high costs of installation and expensive disposable instrumentations, the need for large operating room space, and the necessity of dedicated training for operators due to the challenging learning curve of robotic-assisted interventional systems.

Artificial Intelligence in Cardiology-A Narrative Review of Current Status.

Artificial intelligence (AI) is an integral part of clinical decision support systems (CDSS), offering methods to approximate human reasoning and computationally infer decisions. Such methods are generally based on medical knowledge, either directly encoded with rules or automatically extracted from medical data using machine learning (ML). ML techniques, such as Artificial Neural Networks (ANNs) and support vector machines (SVMs), are based on mathematical models with parameters that can be optimally tuned using appropriate algorithms. The ever-increasing computational capacity of today's computer systems enables more complex ML systems with millions of parameters, bringing AI closer to human intelligence. With this objective, the term deep learning (DL) has been introduced to characterize ML based on deep ANN (DNN) architectures with multiple layers of artificial neurons. Despite all of these promises, the impact of AI in current clinical practice is still limited. However, this could change shortly, as the significantly increased papers in AI, machine learning and deep learning in cardiology show. We highlight the significant achievements of recent years in nearly all areas of cardiology and underscore the mounting evidence suggesting how AI will take a central stage in the field.

Association of non-alcoholic fatty liver disease with coronary artery calcification progression: a systematic review and meta-analysis.

INTRODUCTION: Non-alcoholic fatty liver disease (NAFLD) is the most common chronic liver disease, which is estimated to affect 20-30% of the adult population in Europe. Several studies have shown an association of NAFLD with multiple cardiovascular risk factors such as abdominal obesity, atherogenic dyslipidaemia, hypertension, insulin resistance, and impaired glucose tolerance. Atherosclerosis is a chronic, progressive, inflammatory disease, which begins early in life and follows a long asymptomatic phase. Coronary artery calcification (CAC) is the radiological confirmation of the presence of atherosclerotic coronary artery disease. The predictive value of CAC for future cardiac events is well established. Also, the progression of CAC is strongly associated with the development of cardiovascular events. AIM: To assess the association of NAFLD with the progression of subclinical atherosclerotic activity, reflected as the dynamic changes in CAC score over time. MATERIAL AND METHODS: The databases PubMed/Medline/Embase from inception until 31 December 2020 were searched for observational studies investigating NAFLD and CAC progression in adults. RESULTS: In total, 5 studies were included, 4 of which, including 10,060 patients, provided data regarding the association of NAFLD with the progression of CAC. The analysis showed that NAFLD is associated with significant odds of progression of CAC; OR = 1.5, 95% CI: 1.34-1.68, p = 0.001. No publication bias was detected (Egger's test p = 0.6). Meta-regression analyses proved that OR toward CAC progression is not significantly influenced by the time of follow-up (coefficient = 0.0083, Z = 1.14, p = 0.25). CONCLUSIONS: NAFLD increases the risk toward CAC progression over time.

Conventional cardiac risk factors associated with trastuzumab-induced cardiotoxicity in breast cancer: Systematic review and meta-analysis.

BACKGROUND: Trastuzumab has had a major impact on the treatment of human epidermal growth factor receptor 2 (HER2) positive breast cancer patients. However, it is associated with cardiotoxicity, expressed as an asymptomatic decrease in left ventricular ejection fraction (LVEF) and less often as clinical HF. The aim of this meta-analysis is to identify the association of conventional cardiovascular risk factors with the development of trastuzumab-induced cardiotoxicity (TIC). METHODS: A literature search of PubMed was conducted to identify studies examining the association between cardiovascular risk factors and TIC. Data were extracted and pooled odds ratios (ORs) with 95% confidence intervals (CIs) were calculated examining the odds of developing TIC for each of the risk factors. RESULTS: A total of 35 studies were included in the analysis. Age (OR:0.7; 95%CI 0.318-1.09; P= 0.0004), hypertension (OR:0.69; 95%CI 0.26-1.12; P = 0.001), smoking(OR:0.35; 95%CI 0.01- 0.69; P = 0.038), diabetes mellitus (OR:0.44; 95%CI 0.24- 0.68; P = 0.0001) and family history of CAD (OR:5.51, 95%CI 1.76-17.25; P< 0.00001)were significantly associated with the development of cardiotoxicity. Known history of CAD (OR: 3.72; 95%CI 2.11-6.57; P = 0.0005) was also associated with the development of TIC. CONCLUSION(S): Identifying women at risk for TIC have several important potential applications. Clinicians may decide to assess LVEF more frequently in patients at highest risk for TIC in order to detect LV systolic dysfunction earlier. Additionally, this could help identify patients who would benefit most from prophylactic therapy for preventing TIC.

Reversed Apico-Basal Myocardial Relaxation Sequence During Exercise in Long QT Syndrome Mutations Carriers With History of Previous Cardiac Events.

BACKGROUND: Recent echocardiography studies in inherited long QT syndrome (LQTS) have shown left ventricular (LV) myocardial relaxation disturbances to follow markedly prolonged and dispersed mechanical contraction. AIM: We used speckle-tracking echocardiography to assess disturbances in LV myocardial relaxation sequence during exercise and their relationship to symptoms. METHODS: Forty seven LQTS patients (45 ± 15 years, 25 female and 20 symptomatic, LVEF: 65 ± 6%) and 35 controls underwent exercise echocardiogram using Bruce protocol. ECG and echo parameters were recorded at rest, peak exercise (p.e.) and recovery. RESULTS: Between patients and controls there were no differences in age, gender, HR or LVEF. At p.e, patients had longer time to LV longitudinal ESR (tESR) at all three LV segments; basal (p < 0.0001), mid- cavity (p = 0.03) and apical (p = 0.03) whereas at rest such difference was noted only at base (p = 0.0007). Patients showed reversed apico-basal relaxation sequence (ΔtESRbase-apex) with early relaxation onset occurring later at base than at apex, both at rest (49 ± 43 vs. -29 ± 19 ms, p < 0.0001) and at p.e. (46 ± 38 vs. -40 ± 22 ms, p < 0.0001), particularly in symptomatic patients (69 ± 44 vs. 32 ± 26, p < 0.0007). ΔtESRbase-apex correlated with longer QTc interval, lower ESR and attenuated LV stroke volume. CONCLUSION: LQTS patients show reversed longitudinal relaxation sequence, which worsens with exercise, particularly in those with previous cardiac events.

Exercise Induced Worsening of Mechanical Heterogeneity and Diastolic Impairment in Long QT Syndrome.

BACKGROUND: Electromechanical heterogeneities due to marked dispersion of ventricular repolarisation and mechanical function have been associated with symptoms in long QT syndrome (LQTS) patients; Aim: To examine the exercise response of longitudinal LV systolic and diastolic myocardial function and synchronicity in LQTS patients and its relationship with symptoms; Methods: Forty seven (age 45 ± 15 yrs, 25 female, 20 symptomatic) LQTS patients and 35 healthy individuals underwent an exercise test (Bruce protocol). ECG and echo parameters were recorded at rest, peak exercise (p.e.), and recovery; Results: LQTS patients had prolonged and markedly dispersed myocardial contraction, delayed early relaxation phase, and significantly decreased filling time at all exercise phases. Unlike controls, these electromechanical disturbances deteriorated further with exercise, during which additional decrease of the LV diastolic myocardial function and attenuated LV stroke volume were noted. Such abnormal responses to exercise were seen to a greater degree in symptomatic patients and in the LQT1 subgroup and improved with B-blocker therapy. Worsening myocardial contraction dispersion at p.e. was the strongest discriminator for previous clinical events, and its discriminating power excelled further by adding early relaxation delay; Conclusions: Electromechanical disturbances were shown to worsen during exercise in LQTS patients and were more pronounced in those with previous arrhythmic events.

Repair of isolated atrial septal defect in infants less than 12 months improves symptoms of chronic lung disease or shunt-related pulmonary hypertension.

INTRODUCTION: Infants with isolated atrial septal defects are usually minimally symptomatic, and repair is typically performed after infancy. Early repair may be considered if there is high pulmonary blood flow and reduced respiratory reserve or early signs of pulmonary hypertension. Our aim was to review the characteristics and outcomes of a cohort of patients who underwent infant repair at our institute. METHODS: The study included 56 infants (28 female, 19 trisomy 21) with isolated atrial septal defect (age: 8 months (1.5-12), weight: 6 kg (2.8-7.5), echo Qp/Qs: 1.9 ± 0.1) who underwent surgical closure (20 fenestrated). Three groups were identified: 1) chronic lung disease and pulmonary hypertension (group A: n = 28%); 2) acutely unwell infants with pulmonary hypertension but no chronic lung disease (group B: n = 20, 36%); and 3) infants with refractory congestive heart failure without either pulmonary hypertension or chronic lung disease (group C: n = 9, 16%). RESULTS: Post-operatively, pulmonary hypertension infants (47/56) showed improvement in tricuspid annular plane systolic excursion z-score (p < 0.001) and right ventricular systolic/diastolic duration ratio (p < 0.05). All ventilator (14.3%) or oxygen-dependent (31.6%) infants could be weaned within 2 weeks after repair. One year later, weight z-score increased in all patients and by +1 in group A, +1.3 in group B and +2 in group C. Over a median follow-up of 1.4 years, three patients died, four patients continued to have pulmonary hypertension evidence and two remained on targeted pulmonary hypertension therapy. CONCLUSION: Atrial septal defect repair within the first year may improve the clinical status and growth in infants with early signs of pulmonary hypertension or those requiring respiratory support and facilitate respiratory management.

Right atrial and ventricular echocardiographic strain analysis predicts requirement for right ventricular support after left ventricular assist device implantation.

Aims: The need for right ventricular assist device (RVAD) support after left ventricular assist device (LVAD) therapy is associated with increased morbidity and mortality. We used 2D echocardiographic strain analysis to assess right atrial (RA) and right ventricular (RV) mechanics and predict the need for RV mechanical support after LVAD implantation. Methods and results: Seventy advanced chronic heart failure (ACHF) patients [59 male, age 47 ± 12 years, 79% dilated cardiomyopathy, left ventricular ejection fraction 23 ± 10%] received continuous-flow LVAD as a bridge to transplantation over an 18 month period. A retrospective analysis of RV and RA strain and right heart dyssynchrony was performed comparing those requiring RVAD (20%, n = 14) with those who did not (non-RVAD 80%, n = 56). One-year survival was significantly lower in the RVAD group (50% vs. 79%; P < 0.03). Independent predictors of RVAD support were: low peak RA longitudinal strain (RALS) [odds ratio (OR) 2.5, 95% confidence interval (95% CI) 1.37-2.0; P = 0.03], low RV free-wall longitudinal strain (RVFWLS) (OR 1.3, 95% CI 1.03-2.3; P = 0.04), and degree of intra-RV dyssynchrony (DRVFW-IVS, OR 1.3, 95% CI 1.02-1.3; P = 0.04). Conclusion: In LVAD recipients needing RVAD support, there was lower RALS and RVFWLS in addition to greater RV free-wall mechanical delay. We conclude that RA and RV strain and dyssynchrony analysis have the potential to add incremental value to the pre-VAD-implantation assessment made using conventional echo measurements.

Exercise worsening of electromechanical disturbances: A predictor of arrhythmia in long QT syndrome.

BACKGROUND: Electromechanical (EM) coupling heterogeneity is significant in long QT syndrome (LQTS), particularly in symptomatic patients; EM window (EMW) has been proposed as an indicator of interaction and a better predictor of arrhythmia than QTc. HYPOTHESIS: To investigate the dynamic response of EMW to exercise in LQTS and its predictive value of arrhythmia. METHODS: Forty-seven LQTS carriers (45 ± 15 years, 20 with arrhythmic events), and 35 controls underwent exercise echocardiogram. EMW was measured as the time difference between aortic valve closure on Doppler and the end of QT interval on the superimposed electrocardiogram (ECG). Measurements were obtained at rest, peak exercise (PE) and 4 minutes into recovery. RESULTS: Patients did not differ in age, gender, heart rate, or left ventricular ejection fraction but had a negative resting EMW compared with controls (-42 ± 22 vs 17 ± 5 ms, P < 0.0001). EMW became more negative at PE (-89 ± 43 vs 16 ± 7 ms, P = 0.0001) and recovery (-65 ± 39 vs 16 ± 6 ms, P = 0.001) in patients, particularly the symptomatic, but remained unchanged in controls. PE EMW was a stronger predictor of arrhythmic events than QTc (AUC:0.765 vs 0.569, P < 0.001). B-blockers did not affect EMW at rest but was less negative at PE (BB: -66 ± 21 vs no-BB: -113 ± 25 ms, P < 0.001). LQT1 patients had worse PE EMW negativity than LQT2. CONCLUSION: LQTS patients have significantly negative EMW, which worsens with exercise. These changes are more pronounced in patients with documented arrhythmic events and decrease with B-blocker therapy. Thus, EMW assessment during exercise may help improve risk stratification and management of LQTS patients.

Abnormal ventricular repolarization in long QT syndrome carriers is related to short left ventricular filling time and attenuated stroke volume response during exercise.

BACKGROUND: Long QT syndrome (LQTS) carriers are characterized by abnormal ventricular repolarization, prolonged systole, and mechanical dispersion. Prolonged left ventricular (LV) systole has been shown to result in disproportionate shortening of LV filling in other conditions. The aim of this study was to assess LV filling, diastolic function, and stroke volume (SV) response to dynamic exercise, in a group of LQTS carriers. METHODS: Forty-seven LQTS carriers (45 ± 15 years, 20 symptomatic) and 35 healthy individuals underwent bicycle stress echocardiogram. Electrocardiographic and echocardiographic measurements were obtained at rest, peak exercise, and 4 minutes into recovery. RESULTS: Long QT syndrome carriers and controls did not differ in age, gender, heart rate, QRS duration, or LV ejection fraction. At rest, LQTS carriers had longer QTc and shorter filling time (FT). At peak exercise, QTc increased and remained longer than controls at recovery. A negative correlation was found between QTc and FT (r = -.398, P = .001) with greater fall in FT in LQTS carriers than in controls at peak exercise (-23% ± 10 vs +2% ± 3, P < .0001). FT correlated with SV (r = +.27, P = .001), which increased more in controls than in LQTS carriers (+32% ± 4 vs +2% ± 1, P < .05). These differences were more pronounced in symptomatic LQTS carriers who had shorter FT and smaller SV at peak exercise and during recovery compared to asymptomatics (P < .05). CONCLUSIONS: Long QT syndrome carriers have longer QTc, but also shorter FT. These disturbances worsen at peak exercise (particularly in symptomatics) compromising LV filling and SV, hence a potential pathomechanism for adverse events.