Using Three-Dimensional Lorenz Scatter Plots to Detect Patients with Atrioventricular Node Double Path Caused by Interpolated Ventricular Premature Systoles: A Case Study

A series of related electrophysiology phenomena can be caused by the occurrence of interpolated ventricular premature contraction.In our recent three-dimensional Lorenz R-R scatter plot research,we found that atrioventricular node double path caused by interpolated ventricular premature contraction imprints a specifi c pattern on three-dimensional Lorenz plots generated from 24-hour Holter recordings.We found two independent subclusters separated from the interpolated premature beat precluster,the interpolated premature beat cluster,and the interpolated premature beat postcluster,respectively.Combined with use of the trajectory tracking function and the leap phenomenon,our results reveal the presence of the atrioventricular node double conduction path.

Echocardiographic Measures of Strain and Prognosis

Echocardiography is the most frequently used imaging modality to determine cardiac function.Left ventricular ejection fraction the most widely used parameter for evaluation of systolic function,provides important prognostic value in clinical practice,and forms part of the evidence base for many decisions about cardiovascular care.However,ejection fraction has several substantial limitations and is insensitive to subtle changes in systolic function.The assessment of myocardial deformation with echocardiography has been studied for two decades,and is increasingly used in the clinical setting.This technique can precisely characterize the mechanics of myocardial contraction and relaxation.The most commonly used parameter is global longitudinal strain,which is more sensitive than ejection fraction for the measurement of systolic function.This review focuses on the prognostic value of global longitudinal strain in predicting adverse outcomes in cardiovascular disease.

Valve-in-Valve Transcatheter Aortic Valve Replacement in a High-Risk Patient with a Biocor Bioprosthesis and a Flail Prosthetic Valve Leaflet

An 80-year-old woman with a history of surgical aortic valve replacement with a 21 mm St.Jude Medical Biocor porcine aortic valve 14 years prior presented with New York Heart Association(NYHA)class III symptoms,severe aortic insufficiency from a degenerated prosthesis,and a large echocardiographic mobile mass representing a highly mobile prosthetic leaflet.The patient worsened to NYHA class IV symptoms despite medical management.The So-ciety of Thoracic Surgery mortality risk score was extremely high.However,a valve-in-valve transcatheter aortic valve replacement(TAVR)was found to be a reasonable option.We used a 20 mm SAPIEN 3 Ultra valve(Edwards Lifesciences Inc.,Irvine,CA,USA)with a SENTINEL embolic protection device(Boston Scientific,Marlborough,MA,USA).During valve deployment,the echocardiographic mobile mass was visually pinned between the new TAVR valve and the surgical bioprosthetic valve.No large embolic debris was noted within the embolic protection device,and the patient remained without any new focal neurologic deficits in the perioperative period and at the 30-day follow-up.The severe aortic insufficiency resolved,and the patient clinically improved to NYHA class II symptoms.

CTO (Chronic Total Occlusion)

Introduction Chronic total occlusion(CTO),is a common abnor-mality in patients with known coronary artery dis-ease.Many of these patients have been undertreated because of the poor prognosis associated with other known coronary artery disease;e.g.,multivessel CAD(MVCAD).

Pulmonary Arterial Hypertension Medical Management of the Adult Patient with Congenital Heart Disease

Congenital heart disease(CHD)-associated pulmonary arterial hypertension(PAH)includes a heterogeneous patient population that can be characterized by the underlying cardiac malformation.CHD-associated PAH has an estimated prevalence of 5– 10% in adult patients,with an increasing number of patients surviving to adulthood because of advances in the surgical management and the development of pulmonary arterial hypertension(PAH)-targeted pharmacotherapy.Although limited data exist,targeted PAH pharmacotherapy has proven to be benefi cial in patients with CHD-associated PAH,with observed improvement in functional class,increase in exercise capacity,and improvement in quality of life and cardiopulmonary hemodynamics.Additionally,there has been increasing interest in the“treat-to-close”strategy.PAH-targeted pharmacotherapy may be used to optimize cardiopulmonary hemodynamics so as to improve patients’operability in repairing the cardiac defect.Although there have been signifi cant advances in the management of this disease state in the past 2 decades,mortality remains high,and ongoing clinical trials are needed to better understand the treat-to-close strategy.

Cardiovascular Innovations and Applications Instructions for Authors

Instructions for Authors,Journal Publication Policy Cardiovascular Innovations and Applications(CVIA)supports the ethical principles set out by the Committee on Publication Ethics(COPE).All journal stakeholders and authors are required to observe high standards with respect to publication ethics as set out by COPE and International Committee of Medical Journal Editors(ICMJE).

Traditional Chinese Medicine Is Widely Used for Cardiovascular Disease

A review article by Hao et al.(J Am Coll Cardiol 2017;69(24):2952– 66)has had huge repercussions among those familiar with traditional Chinese medicine(TCM)in the international academic community.It evaluated the effi cacy and safety of TCM for cardiovascular disease and the pharmacological effect of active TCM ingredients on the cardiovascular system and potential mechanisms.We have several comments:Firstly,we give a brief summary addressing nonpharmacotherapy in TCM,including acupuncture,moxibustion,Qigong,and Tai Chi.Secondly,we have added traditional antiarrhythmic drug– related randomized controlled trials to make the coverage more comprehensive.Lastly,we support the concept that research into,development of,and application of active ingredients is part of modern TCM.

Athletes and Arrhythmias

Sudden cardiac death related to athletic competition is a rare but tragic event.The victims are typically young with no previous cardiovascular symptoms or limitations.The majority of sudden cardiac death events in athletes are due to ventricular arrhythmias as a result of underlying molecular and/or structural level pathologic substrate.In this article,we will review the physiologic cardiac adaptations to exercise along with arrhythmias seen in athletes with a focus on those commonly associated with sudden cardiac death.

Adult Congenital Heart Disease in the Veteran Population:A Case-Based Report

Simple forms of congenital heart disease can allow patients to go undiagnosed until they reach adulthood.Furthermore,improvements in care of patients with complex congenital heart disease are now allowing most patients to reach adulthood.As some patients with adult congenital heart disease can remain asymptomatic until later in life,it is possible for them to serve in the military and eventually fall under the care of Veterans Administration(VA)providers.Therefore it is important for providers,especially cardiologists at VA centers,to have fundamental understanding of the management of adult congenital heart disease.This article provides multiple cases of adult congenital heart disease experienced at a single VA medical center and reviews the anatomy,physiology,and surgical management of each condition.

The Role of Cardiac Catheterization after Cardiac Arrest

Coronary angiography after cardiac arrest is important to ascertain potential treatable causes of cardiac arrest,salvage myocardium,and potentially increase long-term survival.The cause of adult out-of-hospital cardiac arrest is typically myocardial ischemia.More than 50% of such resuscitated individuals will have an acutely occluded epicardial coronary on emergency coronary angiography.This includes three in four with ST-segment elevation and one in three without STsegment elevation.In the latter the only reliable method of detection is coronary angiography.Numerous cohort studies,now including more than 8000 patients,have shown an association between survival and early coronary angiography and/or percutaneous coronary intervention.Public reporting of percutaneous coronary intervention 30-day mortality rates has been an impediment for extending this therapy to all resuscitated individuals who experienced out-of-hospital cardiac arrest,since current databases to do fully risk-adjust rates for this subgroup.Sincere efforts are under way to correct this situation.

Biodegradable Stents

In 2006 Professor Patrick W.Serruys introduced the use of fully biodegradable drug-eluting scaffolds.This new stent was to eliminate the presence of a metal stent which was a permanent metallic foreign body in the coronary circulation.This revolutionized the then field of interventional cardiology.

Contemporary Management of Patients with Stable Ischemic Heart Disease

The overall goals of therapy for patients with stable ischemic heart disease are to minimize the likelihood of death while maximizing health and function.Initial risk assessment with noninvasive testing is indicated to determine whether invasive evaluation is needed in addition to medical therapy.All patients with stable ischemic heart disease need optimal medical therapy,which includes risk factor management with lifestyle modifi cations and pharmacologic therapy.First-line pharmacologic therapy is focused on preventing myocardial infarction and death with antiplatelet agents,lipid-lowering therapy,and antihypertensive therapies.In addition,antianginal therapy and anti-ischemic therapy are indicated to alleviate symptoms,reduce ischemia,and improve quality of life.The commonly used antianginal agents include nitrates,beta-blockers,calcium channel blockers,and ranolazine.When medical therapy is not adequate to relieve angina,revascularization with percutaneous coronary intervention or coronary artery bypass grafting is indicated.We review the indications and evidence for antianginal agents and other therapies for angina.

Left Ventricular Dysfunction in Ischemic Heart Disease

Ischemic heart disease is a growing cause of heart failure owing to the increasing prevalence of diabetes,hypertension,and obesity.It is important to understand the concepts of myocardial stunning and hibernation so we as physicians can order appropriate testing on patients with ischemic heart disease,such as myocardial viability studies.Ventricular remodeling is associated with an elevated risk of death after myocardial infarction.The extent of myocardial viability determines the clinical outcome of patients after myocardial infarction.Multiple impactful clinical trials have changed the way we manage ischemic cardiomyopathy over the past few decades,and medications such as angiotensin-converting enzyme inhibitors,angiotensin II receptor blockers,beta-blockers,and aldosterone antagonists have improved outcomes in this patient population.Similarly,much has been reported on the effect of coronary artery bypass surgery on outcomes in patients with ischemic heart disease and heart failure,but further research studies are needed on the role of percutaneous coronary intervention.

The Role of Clinical Cardiac Magnetic Resonance Imaging in China:Current Status and the Future

Cardiac magnetic resonance(CMR)imaging plays an important role in the diagnosis and management of cardiovascular diseases.The state-of-the-art CMR imaging has many advantages in cardiac imaging,including excellent spatial and temporal resolution,unrestricted imaging fi eld,no exposure to ionizing radiation,excellent tissue contrast,and unique myocardial tissue characterization.Clinical CMR imaging is used during the cardiovascular diagnostic workup in the United States and some European countries.Use of CMR imaging is emerging in hospitals in China and has a promising future.This review briefl y describes the real-world clinical application of CMR imaging in China and discuss obstacles for its future development.

A Tale of Two STEMI’s

Introduction Occasionally a clinical dilemma occurs when two patients with a myocardial infarction associated with ST segment elevation on the electrocardiogram,arrive in the emergency department at the same time.Since most cardiologists would consider that these patients have an occlusion of an epicardial coronary,and should undergo an immediate revascularization,a decision must be made as to who should go to the catheterization laboratory fi rst.

Circadian Misalignment and Cardiovascular Risk

All organisms,ranging from single-celled organisms to humans,demonstrate circadian rhythms that are near 24-h patterns that are present independent of environmental cues.Disruption of this process,called circadian misalignment,is associated with deleterious health outcomes.The most extreme example of this misalignment is shift work,and there is evidence suggesting a strong association between shift work and certain cardiovascular outcomes.The outcomes of most studies include obesity,metabolic syndrome,hypertension,type 2 diabetes mellitus,atrial fibrillation,and cardiovascular events.In this article we review the current literature with an emphasis on women’s cardiovascular health.The data are confl icting,and there is a paucity of robust evidence with regard to women’s cardiovascular health and circadian misalignment.More studies are needed to better delineate the sex differences as well as the pathophysiology of the associations between circadian misalignment and cardiovascular diseases so that we can provide patients with more personalized care.

T1 and ECV Mapping in Myocardial Disease

T1 mapping using cardiovascular magnetic resonance(CMR)introduces novel techniques for myocardial tissue characterization to detect and quantify disease processes occurring at the microscopic level.Even though T1 mapping has limited spatial resolution,cellular and molecular changes occurring within each voxel can affect the aggregate T1 signal rendering them quantifi able.The estimated T1-based parameters quantifi ed on a“map”demonstrate the spatial localization of these changes whereby each pixel expresses the quantitative value of that parameter.This quantifi cation permits detection of diffuse disease even if it is not directly visible.Rather than relying on nonspecifi c functional measures,T1 mapping focuses on intrinsic changes of myocardial composition that advances understanding about specifi c disease pathways.These changes in myocardial tissue composition inform diagnosis and prognosis.T1 mapping encompasses two key parameters:native(i.e.,precontrast)T1 and extracellular volume fraction(ECV)derived from additional postcontrast T1 and blood T1 measurements.These advances introduce new tools to detect focal and diffuse myocardial derangements occurring in cardiac disease that can be otherwise diffi cult to detect.T1 and ECV mapping foster precision medicine and personalized care,promising to improve patient outcomes through targeted therapy.Capitalizing on the opportunities introduced by T1 mapping and ECV requires further investigation.

A Meta-analysis of Major Complications between Traditional Pacemakers and Leadless Pacemakers

Objectives:We aim to compare the major complications between leadless pacemakers and traditional pacemakers.Background:Leadless pacemakers,which are increasingly used in clinical practice,have several advantages compared with traditional pacemakers in avoiding pocket-and lead-related complications.However,the clinical effect of leadless pacemakers remains controversial.Methods:PubMed,Embase,the Cochrane Central Register of Controlled Trials(CENTRAL),the CNKI database,and the Wanfang database were searched from July 2013 to December 2019.Studies comparing leadless pacemakers and traditional pacemakers were included.The primary end point was major complications.The secondary end points were cardiac perforation/pericardial effusion,device revision or extraction,loss of device function,and death.Results:Six studies fulfi lled the inclusion criteria.Only four of the six studies reported data on major complications.Leadless pacemakers were associated with a lower incidence of major complications(risk ratio 0.33,95%confi dence interval 0.25–0.44,P<0.00001,I²=49%).We extracted data on cardiac perforation/pericardial effusion,device revision or extraction,loss of device function,and death from six studies.Our meta-analysis showed that leadless pacemakers have a higher risk of cardiac perforation or pericardial effusion(risk ratio 4.28,95%confi dence interval 1.66–11.08,P=0.003,I²=0%).No statistically signifi cant differences were found for mortality,device revision or extraction,and loss of device function.Conclusion:Compared with traditional pacemakers,leadless pacemakers have a signifi cantly decreased risk of major complications,but have a higher risk of cardiac perforation or pericardial effusion.

WeChat Group of Chest Pain Center for Patients with Acute ST-segment Elevation Myocardial Infarction:Faster Treatment Speed and Better Prognosis

Objective:To explore the effect of establishing a WeChat platform for a chest pain center as a medium to increase the treatment speed and improve the prognosis of patients with acute ST-segment elevation myocardial infarction(STEMI)undergoing primary percutaneous coronary intervention(PPCI).Methods:The chest pain center,established by the creation of a WeChat group,included primary hospitals in Chongqing that are not able to perform PPCI and the First Affi liated Hospital of Chongqing Medical University,which is the core of the center and which includes medical staff of the catheter laboratory,the cardiology department,the emergency,the vascular surgery department,and the cardiothoracic surgery department.Patients with acute STEMI who underwent PPCI from January 2017 to November 2018 in the First Affi liated Hospital of Chongqing Medical University were enrolled.The patients(including emergency department visitors,120 callers,and patients transferred from the critical care unit or other departments)were divided into a WeChat pre-admission startup group(n=311)and a non-WeChat pre-admission startup group(control group,n=172).Patients’door-to-balloon time,standard door-toballoon time achievement rate,artery puncture to balloon dilation time,heart failure rate,length of stay,and incidence of adverse events(including fatal arrhythmia,cardiogenic shock,and death)during hospitalization were compared between the two groups.Results:Four hundred eight-three consecutive patients were enrolled.There was no signifi cant difference in patients’sex,age,length of stay,and cardiovascular events during hospitalization between the two groups(P>0.05).The door-to-balloon time of the patients in the WeChat pre-admission startup group was much shorter than that of patients in the non-WeChat pre-admission startup group(27.35±10.58 min vs.88.15±53.79 min,P<0.05).The standard door-to-balloon time achievement rate was signifi cantly higher in the WeChat pre-admission startup group than in the non-WeChat pre-admission startup group(100%vs.72.09%,P<0.05).Conclusion:The application of a WeChat platform signifi cantly shortened the door-to-balloon time of patients receiving PPCI and increased the standard door-to-balloon time achievement rate for patients with STEMI.In addition,the platform is also conducive to integrating medical resources and sharing medical information.The establishment of the platform increased the treatment speed and improved the prognosis of patients with STEMI.

Recent Advances in Noninvasive Cardiac Imaging

In the last several years,the rate of innovation in cardiac imaging techniques has accelerated signifi cantly.Advances have been seen in all 4 major modalities;echocardiography,nuclear(positron emission tomography(PET)and single photon emission computed tomography(SPECT),cardiac magnetic resonance imaging(CMR),and computed tomographic angiography(CTA).This issue of Cardiovascular Innovations and Applications will highlight many of these advances.