Significance of balloon aortic valvuloplasty as palliative procedure for symptom benefit in patients with severe aortic stenosis

Aortic stenosis(AS)stands out as the most prevalent individual valvular defect globally.The onset and progression of AS mirror an active process akin to atherosclerosis,and the traditional triad of symptoms includes chest pain,breathlessness,and loss of consciousness.Prognosis takes a significant downturn when symptoms manifest,with mortality reaching approximately 50%-85% within the subsequent 5 years after symptom onset.

Acute myocardial injury in patients with COVID-19:Possible mechanisms and clinical implications

Severe acute respiratory syndrome coronavirus 2 infection affects not only the lungs,but also the cardiovascular system,having a major impact on patients’outcomes.Myocardial injury(MI)occurs in the context of coronavirus infectious disease 2019(COVID-19)and is associated with a higher risk of severe clinical outcome and mortality.COVID-19-related MI can have various clinical manifestations,of which the main ones are myocarditis,stress cardiomyopathy,acute coronary syndrome,and pulmonary embolism.The exact mechanisms of how MI occurs in these patients are not yet fully known.Direct injury,through direct viral myocardial invasion,and indirect injury,through interaction with angiotensin I converting enzyme 2,increased inflammation,and thrombocyte and endothelial dysfunction,could be involved in acute MI in patients with COVID-19.A better understanding of these multiple potential mechanisms may help to develop new targeted therapeutic strategies.The purpose of this review is to provide the current understanding of the potential mechanisms involved in MI induced by COVID-19 and to discuss the current progress in the therapeutic strategies.

Stem/progenitor cells and obstructive sleep apnea syndrome - new insights for clinical applications

Obstructive sleep apnea syndrome(OSAS) is a widespread disorder, characterized by recurrent upper airway obstruction during sleep, mostly as a result of complete or partial pharyngeal obstruction. Due to the occurrence of frequent and regular hypoxic events, patients with OSAS are at increased risk of cardiovascular disease, stroke, metabolic disorders, occupational errors, motor vehicle accidents and even death. Thus, OSAS has severe consequences and represents a significant economic burden. However, some of the consequences, as well as their costs can be reduced with appropriate detection and treatment. In this context, the recent advances that were made in stem cell biology knowledge and stem cell- based technologies hold a great promise for various medical conditions, including respiratory diseases. However, the investigation of the role of stem cells in OSAS is still recent and rather limited, requiring further studies, both in animal models and humans. The goal of this review is to summarize the current state of knowledge regarding both lung resident as well as circulating stem/progenitor cells and discuss existing controversies in the field in order to identify future research directions for clinical applications in OSAS. Also, the paper highlights the requisite for inter-institutional, multi-disciplinary research collaborations in order to achieve breakthrough results in the field.

Cardiac arrest and cardiopulmonary resuscitation in“hostile”environments:Using automated compression devices to minimize the rescuers’danger

Mechanical automated compression devices are being used in cardiopulmonary resuscitation instead of manual,“hands-on”,rescuer-delivered chest compressions.The-theoretical-advantages include high-quality non-stop compressions,thus freeing the rescuer performing the compressions and additionally the ability of the rescuer to stand reasonably away from a potentially“hazardous”victim,or from hazardous and/or difficult resuscitation conditions.Such circumstances involve cardiopulmonary resuscitation(CPR)in the Cardiac Catheterization Laboratory,especially directly under the fluoroscopy panel,where radiation is well known to cause detrimental effects to the rescuer,and CPR during/after land or air transportation of cardiac arrest victims.Lastly,CPR in a coronavirus disease 2019 patient/ward,where the danger of contamination and further serious illness of the health provider is very existent.The scope of this review is to review and present literature and current guidelines regarding the use of mechanical compressions in these“hostile”and dangerous settings,while comparing them to manual compressions.

Diabetes mellitus and atrial fibrillation-from pathophysiology to treatment

Type 2 diabetes mellitus(T2DM)is a leading risk factor for cardiovascular complications around the globe and one of the most common medical conditions.Atrial fibrillation(AF)is the most common supraventricular arrhythmia,with a rapidly increasing prevalence.T2DM has been closely associated with the risk of AF development,identified as an independent risk factor.Regarding cardiovascular complications,both AF and T2DM have been linked with high mortality.The underlying pathophysiology has not been fully determined yet;however,it is multifactorial,including structural,electrical,and autonomic pathways.Novel therapies include pharmaceutical agents in sodium-glucose cotransporter-2 inhibitors,as well as antiarrhythmic strategies,such as cardioversion and ablation.Of interest,glucose-lowering therapies may affect the prevalence of AF.This review presents the current evidence regarding the connection between the two entities,the pathophysiological pathways that link them,and the therapeutic options that exist.

Current knowledge and contemporary management of non-A non-B aortic dissections

Non-A non-B aortic dissection(AAD)is an infrequently documented condition,comprising of only a small proportion of all AADs.The unique anatomy of the aortic arch and the failure of the existing classifications to adequately define individuals with non-A non-B AAD,have led to an ongoing controversy around the topic.It seems that the clinical progression of acute non-A non-B AAD diverges from the typical type A and B dissections,frequently leading to serious complications and thus mandating early intervention.Currently,the available treatment methods in the surgical armamentarium are conventional open,endovascular techniques and combined hybrid methods.The optimum approach is tailored in every individual case and may be determined by the dissection’s location,extent,the aortic diameter,the associated complications and the patient’s status.The management of non-A non-B dissections still remains challenging and a unanimous consensus defining the gold standard treatment has yet to be reached.In an attempt to provide further insight into this perplexing entity,we performed a minireview of the literature,aiming to elucidate the epidemiology,clinical course and the optimal treatment modality.

Significance of lead aVR in acute coronary syndrome

The 12-lead electrocardiogram(ECG)is a crucial tool in the diagnosis and risk stratification of acute coronary syndrome(ACS).Unlike other 11 leads,lead aVR has been long neglected until recent years.However,recent investigations have shown that an analysis of ST-segment shift in lead aVR provides useful information on the coronary angiographic anatomy and risk stratification in ACS.ST-segment elevation in lead aVR can be caused by(1)transmural ischemia in the basal part of the interventricular septum caused by impaired coronary blood flow of the first major branch originating from the left anterior descending coronary artery;(2)transmural ischemia in the right ventricular outflow tract caused by impaired coronary blood flow of the large conal branch originating from the right coronary artery;and(3)reciprocal changes opposite to ischemic or non-ischemic ST-segment depression in the lateral limb and precordial leads.On the other hand,ST-segment depression in lead aVR can be caused by transmural ischemia in the inferolateral and apical regions.It has been recently shown that an analysis of T wave in lead aVR also provides useful prognostic information in the general population and patients with prior myocardial infarction.Cardiologists should pay more attention to the tracing of lead aVR when interpreting the12-lead ECG in clinical practice.

Portopulmonary hypertension in liver transplant candidates

Pulmonary vascular disorders including portopulmonary hypertension(PoPHT) are among the common complications of liver disease and are prognostically significant. Survival is very low without medical treatment and liver transplantation. With advances in medical therapy for elevated pulmonary artery pressure(PAP) and liver transplant surgery, survival of patients with Po PHT and advanced liver disease is significantly improved. Because of the prognostic significance of Po PHT and the limited donor pool, a comprehensive preoperative cardio-pulmonary assessment is of great importance in cirrhotic patients prior to transplant surgery. Therefore, a detailed transthoracic Doppler echocardiographic examination must be an essential component of this evaluation. Patients with mild Po PHT can safely undergo liver transplant surgery. In cases of moderate to severe Po PHT, right heart catheterization(RHC) should be performed. In patients with moderate to severe Po PHT on RHC(mean PAP 35-45 mm Hg), vasodilator therapy should be attempted. Liver transplantation should be encouraged in cases that demonstrate a positive response. Bridging therapy with specific pulmonary arterial hypertension treatment agents should be considered until the transplant surgery and should be continued during the peri- and post-operative periods as needed.

Cardiomyopathies:Evolution of pathogenesis concepts and potential for new therapies

Cardiomyopathies are defined as diseases of the myocardium with associated structural and functional abnormalities. Knowledge of these pathologies for a long period was not clear in clinical practice due to uncertainties regarding definition,classification and clinical diagnosis. In recent decades,major advances have been made in the understanding of the molecular and genetic issues,pathophysiology,and clinical and radiological assessment of the diseases. Progress has been made also in management of several types of cardiomyopathy. Advances in the understanding of these diseases show that cardiomyopathies represent complex entities. Here,special attention is given to evolution of classification of cardiomyopathies,with the aim of assisting clinicians to look beyond schematic diagnostic labels in order to achieve more specific diagnosis. Knowledge of the genotype of cardiomyopathies has changed the pathophysiological understanding of their etiology and clinical course,and has become more important in clinical practice for diagnosis and prevention of cardiomyopathies. New approaches for clinical and prognostic assessment are provided based on contemporary molecular mechanisms of contribution in the pathogenesis of cardiomyopathies. The genotype-phe-notype complex approach for assessment improves the clinical evaluation and management strategies of these pathologies. The review covers also the important role of imaging methods,particularly echocardiography,and cardiac magnetic resonance imaging in the evaluation of different types of cardiomyopathies. In summary,this review provides complex presentation of current state of cardiomyopathies from genetics to management aspects for cardiovascular specialists.

Fifteen years of bone marrow mononuclear cell therapy in acute myocardial infarction

In spite of modern treatment, acute myocardial infarction(AMI) still carries significant morbidity and mortality worldwide. Even though standard of care therapy improves symptoms and also long-term prognosis of patients with AMI, it does not solve the critical issue, specifically the permanent damage of cardiomyocytes. As a result, a complex process occurs, namely cardiac remodeling, which leads to alterations in cardiac size, shape and function. This is what has driven the quest for unconventional therapeutic strategies aiming to regenerate the injured cardiac and vascular tissue. One of the latest breakthroughs in this regard is stem cell(SC) therapy. Based on favorable data obtained in experimental studies, therapeutic effectiveness of this innovative therapy has been investigated in clinical settings. Of various cell types used in the clinic, autologous bone marrow derived SCs were the first used to treat an AMI patient, 15 years ago. Since then, we have witnessed an increasing body of data as regards this cutting-edge therapy. Although feasibility and safety of SC transplant have been clearly proved, it's efficacy is still under dispute. Conducted studies and meta-analysis reported conflicting results, but there is hope for conclusive answer to be provided by the largest ongoing trial designed to demonstrate whether this treatment saves lives. In the meantime, strategies to enhance the SCs regenerative potential have been applied and/or suggested, position papers and recommendations have been published. But what have we learned so far and how can we properly use the knowledge gained? This review will analytically discuss each of the above topics, summarizing the current state of knowledge in the field.

Cardiac autonomic dysfunction in patients with gastroesophageal reflux disease

AIM: To investigate autonomic nervous function in patients with a diagnosis of gastroesophageal reflux disease(GERD).METHODS: The investigation was performed on 29patients(14 men), aged 18-80 years(51.14 ± 18.34),who were referred to our Neurocardiology Laboratory at the Clinical and Hospital Center "Bezanijska Kosa"with a diagnosis of GERD. One hundred sixteen healthy volunteers matched in age and sex with the examinees served as the control group. The study protocol included the evaluation of autonomic function and hemodynamic status, short-term heart rate variability(HRV) analysis, 24 h ambulatory ECG monitoring with long-term HRV analysis and 24 h ambulatory blood pressure monitoring.RESULTS: Pathologic results of cardiovascular reflex test were more common among patients with reflux compared to the control group. Severe autonomic dysfunction was detected in 44.4% of patients and in7.9% of controls(P < 0.001). Parameters of short-term analysis of RR variability, which are the indicators ofvagal activity, had lower values in patients with GERD than in the control group. Long-term HRV analysis of time-domain parameters indicated lower values in patients with reflux disease when compared to the control group. Power spectral analysis of long-term HRV revealed lower low- and high-frequency values.Detailed 24 h ambulatory blood pressure analysis showed significantly higher values of systolic blood pressure and pulse pressure in the reflux group than in the control group.CONCLUSION: Patients with GERD have distortion of sympathetic and parasympathetic components of the autonomic nervous system, but impaired parasympathetic function appears more congruent to GERD.

Coronary artery disease in women:From the yentl syndrome to contemporary treatment

In recent years attention has been raised to the fact of increased morbidity and mortality between women who suffer from coronary disease. The identification of the so called Yentl Syndrome has emerged the deeper investigation of the true incidence of coronary disease in women and its outcomes. In this review an effort has been undertaken to understand the interaction of coronary disease and female gender after the implementation of newer therapeutic interventional and pharmaceutics' approaches of the modern era.

Arrhythmogenic epilepsy and pacing need: A matter of controversy

There is increasing awareness among the cardiology community regarding ictal bradyarrhythmias as a cause of loss of consciousness. A high degree of suspicion is necessary when diagnosing ictal bradyarrhythmias, and delay in diagnosing this condition may lead to morbidity associated with falls and trauma. Ictal bradyarrhythmias have also been suggested to be associated with sudden unexplained death in epilepsy, although evidence related to this association is limited. There is no guidelinedirected therapy for symptomatic ictal bradyarrhythmias due to a lack of randomized, controlled trials. Cardiac pacemaker therapy is commonly used for these patients; however, currently, there is no universal agreement on the pacing indications for these patients. In this review, we focus on the pathophysiology and clinical presentation of ictal bradyarrhythmias and then discuss the pacing need based on the available literature data.

Intermediate-term mortality and incidence of ICD therapy in octogenarians after cardiac resynchronization therapy

在超过 80 岁的病人的心脏的再同步治疗(CRT ) 的 BackgroundClinical 结果一直不是回顾地识别的井 described.MethodsWe 96 连续病人 &#x02265；80 岁经历了一起始植入或升级到 CRT，与或没有使用高压脉冲来消减心脏(CRT-D 对 CRT-P ) ，在我们在 2003 年 1 月和 2008 年 7 月之间的机构。控制队由 177 随机选择的病人 &#x0003c 组成了；经历 CRT 的 80 岁在一样的时间时期期间植入。主要功效端点是在 36 个月的所有原因死亡，到第一事件 curves.ResultsIn 的 Kaplan-Meier 时间估计了八十至八十九岁的队，在 CRT 的吝啬的年龄植入是 83.1 &#x000b1；2.9 年对 60.1 &#x000b1；在控制之中的 8.8 年(P &#x0003c；0.001 ) 。越过两个组， 70% 是男性的，吝啬的左室的喷射部分(LVEF ) 是 24.8%&#x000b1；14.1% 并且 QRS 持续时间是 154 &#x000b1；24.8 ms，没有组之间的重要差别。Octogenarians 是更可能的有 ischemic 心肌症(74% 对 37% ， P &#x0003c；0.001 ) 并且可能经历的更多升级到 CRT 而不是一起始植入(42% 对 19% ， P &#x0003c；0.001 ) 。适当使用高压脉冲来消减心脏震动的率在 octogenarians 之中是更低的(14% 对 27% ， P = 0.02 ) 而不恰当的震动的率是类似的(3% 对 6% ， P = 0.55 ) 。在 36 个月，处于在 octogenarians (11%) 和控制之间的所有原因死亡的率没有重要差别(8% ， P = 0.381 ).ConclusionAppropriately 选择的 octogenarians 是 CRT 的候选人与收到 CRT 的更年轻的病人相比有类似的中间术语的死亡。

Contemporary perspective on endogenous myocardial regeneration

Considering the complex nature of the adult heart, it is no wonder that innate regenerative processes, while maintaining adequate cardiac function, fall short in myocardial jeopardy. In spite of these enchaininglimitations, cardiac rejuvenation occurs as well as restricted regeneration. In this review, the background as well as potential mechanisms of endogenous myocardial regeneration are summarized. We present and analyze the available evidence in three subsequent steps. First, we examine the experimental research data that provide insights into the mechanisms and origins of the replicating cardiac myocytes, including cell populations referred to as cardiac progenitor cells(i.e., c-kit+ cells). Second, we describe the role of clinical settings such as acute or chronic myocardial ischemia, as initiators of pathways of endogenous myocardial regeneration. Third, the hitherto conducted clinical studies that examined different approaches of initiating endogenous myocardial regeneration in failing human hearts are analyzed. In conclusion, we present the evidence in support of the notion that regaining cardiac function beyond cellular replacement of dysfunctional myocardium via initiation of innate regenerative pathways could create a new perspective and a paradigm change in heart failure therapeutics. Reinitiating cardiac morphogenesis by reintroducing developmental pathways in the adult failing heart might provide a feasible way of tissue regeneration. Based on our hypothesis "embryonic recall", we present first supporting evidence on regenerative impulses in the myocardium, as induced by developmental processes.

A very rare case of late diagnosis of cor triatriatum sinistrum

我们为动脉的高血压和永久 atrial 纤维性颤动象治疗一样为心失败与住院的历史介绍了一个 73 岁的病人并且被发现与二头齿在联合有英国管 triatriatum sinistrum 大动脉的阀门。耐心的拒绝的外科的修正，而是他的条件为心失败和 atrial 纤维性颤动在保守治疗上改善了。

Dangerous triplet: Polycystic ovary syndrome, oral contraceptives and Kounis syndrome

Polycystic ovary syndrome is characterized by ovulatory dysfunction, androgen excess and polycystic ovaries and is associated with hypertension, diabetes, metabolic syndrome and cardiovascular events. Oral contraceptives constitute first-line treatment, particularly when symptomatic hyperandrogenism is present. However, these drugs are associated with cardiovascular events and hypersensitivity reactions that pose problem in differential diagnosis and therapy. We present a 14 year-old female with polycystic ovary syndrome taking oral contraceptive and suffering from recurrent coronary ischemic attacks with increased eosinophils, and troponin levels suggesting Kounis syndrome.

Differential diagnosis of tachycardia with a typical left bundle branch block morphology

The evaluation of wide QRS complex tachycardias (WCT)remains a common dilemma for clinicians.Numerous algorithms exist to aid in arriving at the correct diagnosis.Unfortunately,these algorithms are difficult to remember,and overreliance on them may prevent cardiologists from understanding the mechanisms underlying these arrhythmias.One distinct subcategory of WCTs are those that present with a"typical"or"classic" left bundle branch block pattern.These tachycardias may be supraventricular or ventricular in origin and arise from functional or fixed aberrancy,bystander or participating atriofascicular pre-excitation,and bundle branch reentry.This review will describe these arrhythmias,illustrate their mechanisms,and discuss their clinical features and treatment strategies.

Changes in coronary bifurcations after stent placement in the main vessel and balloon opening of stent cells:theory and practical verification on a bench-test model

Objective To describe changes that occur in stent morphology and structure after its implantation in coronary bifurcation.Side branch (SB) compromise after stenting of main vessel in coronary bifurcation is a major intraprocedural problem and for the long term,as a place of restenosis.Methods We created an elastic wall model (parent vessel diameter 3.5mm,daughter branches 3.5mm and 2.75mm)with 30,45 and 60 degree distal angulation between branches.After stent implantation,struts to the side branch were opened with 2.0mm and consequently 3.0mm diameter balloons.Subsequent balloon redilatations and kissing balloon inflations (KBI) were performed.All stages of the procedure were photographed with magnification up to 100 times.Results We found that the leading mechanism for side branch compromise was carina displacement,and discovered theoretical description for expected ostial stenosis severity.Based on our model we found that displacement of bifurcation flow divider cause SB stenosis with almost perfect coincidence with our theoretical predictions.Opening of stent cells through the proximal and distal stent struts always increased interslrut distance,but never achieved good apposition to the wall.Balloon diameter increase didn't give proportional enlargement in stent cell diameters.KBI leads to some small better stent positioning,correcting main vessel strut dislodgment from wall,but never gave full strut-wall contact.Distance between struts and wall was minimal only when the stent cell perfectly faced ostium of SB.This was also our observation that the shape of ostium of SB becomed eUiptically-bean shaped after stent implantation and generally kept that shape during consequent stages of experiment.Measured diameter and area stenosis were perfectly fitted and theoretically predicted from our concept Conclusion We have described stent-wall deformations in stent-balloon technique for treatment of coronary bifurcation demonstrating carina displacement as possibly main mechanism of side branch compromise after main vessel stenting.We have shown that KBI could not give full strut-wall contact if there is no perfect facing of stem cell and SB ostium.(J Geroatr Cardool 2008;5(1):43-49)