Abstract Background Physiological pacing has gained significant interest due to its potential to achieve optimal hemodynamic response. This study aimed to assess left ventricular performance in terms of electrical parameters, specifically QRS duration, and mechanical performance, evaluated as myocardial work. We compared His Bundle Pacing (HBP) and Left Bundle Branch Area Pacing (LBBAP) to evaluate their effects. Methods Twenty-four patients with class I or IIa indications for pacing were enrolled in the study, with 12 patients undergoing HBP implantation and another 12 patients undergoing LBBAP implantation. A comprehensive analysis of myocardial work was conducted. Results Our findings indicate that there were no major differences in terms of spontaneous and HBP activation in myocardial work, except for global wasted work (217 mmHg% vs. 283 mmHg%; p 0.016) and global work efficiency (87 mmHg% vs. 82 mmHg%; p 0.049). There were no significant differences observed in myocardial work between spontaneous activation and LBBAP. Similarly, no significant differences in myocardial work were found between HBP and LBBAP. Conclusions Both pacing modalities provide physiological ventricular activation without significant differences when compared to each other. Moreover, there were no significant differences in QRS duration between HBP and LBBAP. However, LBBAP demonstrated advantages in terms of feasibility, as it achieved better lead electrical parameters compared to HBP (threshold@0.4 ms 0.6 V vs. 1 V; p=0.045. Sensing 9.4 mV vs. 2.4 mV; p<0.001). Additionally, LBBAP required less fluoroscopy time (6 min vs. 13 min; p=0.010) and procedural time (81 min vs. 125 min; p=0.004) compared to HBP. Clinical Perspective What is Known His Bundle Pacing (HBP) and Left Bundle Branch Area Pacing (LBBAP) have been recognized as more physiological alternatives to traditional right ventricular pacing. LBBAP has shown greater feasibility compared to HBP, although direct comparison data between the myocardial work in HBP and LBBAP are limited. What the Study Adds Our study contributes to the existing knowledge by demonstrating that both HBP and LBBAP provide physiological ventricular activation, with no significant differences observed between the two pacing modalities in terms of myocardial work and QRS duration. However, LBBAP showcased advantages such as reduced need for fluoroscopy, shorter procedural time, and improved electrical parameters. These findings further support the potential of LBBAP as a favorable pacing option. Graphical abstract
Little evidence to date has described the feasibility and diagnostic accuracy of coronary computed tomography angiography (CCTA) with noninvasive fractional flow reserve (CT-FFR) in coronary vessels with resorbable magnesium scaffold (RMS).The SHERPA-MAGIC is a prospective study enrolling patients receiving RMS. The present analysis considered patients undergoing CCTA 18 months after the index procedure. CCTA images were employed to investigate reabsorption status, luminal measurements, and noninvasive FFR. Three-year follow-up was available for all patients.Overall, 26 patients with a total of 29 coronary arteries treated with 35 RMS were considered. The most frequently involved vessel was left anterior descendent (LAD). Median stent length was 25 (20-25) mm, with a median diameter of 3 (3-3.5) mm. At 18-month CCTA, all scaffolded segments were patent. Complete RMS reabsorption was observed in 27 (93%, 95% CI 77-99%) cases. Median minimal lumen diameter (MLD) and area (MLA) of the scaffolded segments were 2.5 [2.1-2.8] mm and 6.4 [4.4-8.4] mm2, respectively. Median CT-FFR was 0.88 [0.81-0.91]. Only one (3.5%) vessel showed a flow-limiting CT-FFR value ≤0.80. During the 3-year follow-up, only one (4%) adverse event was observed. Conclusions: In patients undergoing RMS implantation, CCTA including noninvasive CT-FFR evaluation is feasible and allows investigation of long-term RMS performance.
Epicardial adipose tissue (EAT) has various metabolic functions aiming at heart protection. When abnormal, it is related to atherosclerotic plaque development and adverse cardiovascular outcome. Additionally, in recent years, several studies have demonstrated its role in other settings such as atrial fibrillation and heart failure with preserved ejection fraction. Future studies should aim to assess diagnostic role of EAT and the effect of medical therapy on EAT volume and attenuation.
Abstract Aims To investigate the distribution of left atrioventricular coupling index (LACI) among patients with heart failure and left ventricular ejection fraction (LVEF) < 50% and to explore its association with the combined endpoint of all-cause death or HF hospitalization at long-term follow-up. Methods and results Patients with HF and LVEF < 50% undergoing cardiac magnetic resonance were evaluated. Patients with atrial fibrillation or flutter were excluded. Left atrioventricular coupling index was measured as the ratio between the left atrial (LA) and the LV end-diastolic volumes. Patient population was divided according to LACI tertiles and followed up. Total of 478 patients (mean age 62 ± 12 years, 78% male) were included. The median value of LACI was 27.1% (interquartile range 19.9–34.5). Patients within the worst LACI tertile (≥30.9%) showed smaller LV volumes and larger LA volumes as compared with patients in the first or second tertile (LACI 6.2–22.2 and LACI 22.3–30.9, respectively). Left atrioventricular coupling index was significantly associated with the combined endpoint [hazard ratio (HR) 1.87, P = 0.01]. After adjusting for sex, age, ischaemic HF aetiology, LVEF, LA reservoir strain, diabetes mellitus, LV scar, mitral regurgitation, and LVEDVi, LACI remained significantly associated with the combined endpoint (HR 1.77, P = 0.02). Patients with the highest LACI values had worse outcomes compared with patients in first and second tertiles (HR 1.69, P = 0.02 and HR 1.77, P = 0.02, respectively). Conclusion In patients with HF and LVEF <50%, LACI is independently associated with adverse events. Patients with most impaired left atrioventricular coupling have the worst clinical outcomes.
Abstract Background Discordant grading of severe aortic stenosis can result from a tight aortic valve area (<1cm2) with a low transvalvular mean gradient (<40 mmHg). Small aortic annulus dimensions and low flow status may contribute to discordant grading of severe aortic stenosis. However, the frequency of patients with small aortic annulus and discordant grading, along with their characteristics and outcomes after intervention, remains unknown. Purpose To investigate the frequency of discordant grading severe aortic stenosis in patients with a small aortic annulus and to evaluate their clinical characteristics, as well as outcomes after transcatheter aortic valve implantation (TAVI). Methods Patients with an aortic annulus diameter < 23 mm determined by cardiac computed tomography who underwent TAVI between 2018 to 2023 were retrospectively evaluated. Patients were followed for the occurrence of the composite endpoint of of all-cause mortality, rehospitalizations for heart failure, non-fatal myocardial infarction, and non-fatal stroke. Results Among 230 patients with severe aortic stenosis and a small aortic annulus, 52 (23%) had discordant gradient (24 with low flow low gradient (LFLG) and 28 with normal flow low gradient (NFLG)) while 120 (52%) exhibited normal flow high gradient (NFHG) and 58 (25%) had low flow high gradient (LFHG). The majority of the patients were female (Table 1). Differences were noted among the three groups regarding aortic transvalvular gradients, stroke volume index and ejection fraction. During a median follow-up of 2 years, the composite endpoint occurred in 20% of the total cohort. Patients with discordant grading severe aortic stenosis experienced the worse outcome (Figure1). Conclusions Most patients with severe aortic stenosis and small annulus have high gradient and only 23% of patients presented discordant grading. Patients with discordant grading severe aortic stenosis showed worse outcomes, suggesting potential delays in referral due to challenges in diagnosing severe aortic stenosis among patients with small aortic annulus.Basal clinical characteristicsKaplan-Meier survival curves
Abstract Background Left atrial (LA) dysfunction is an important marker of disease progression in hypertrophic cardiomyopathy (HCM). LA volumes and functional parameters are associated with new-onset atrial fibrillation (AF) and its complications including stroke. The association between left atrioventricular coupling (LACI), a parameter reflecting the contribution of the left ventricular and LA remodeling to LA dysfunction, with the occurrence of new-onset AF and stroke has not been evaluated. Aim To investigate the association between LACI and the occurrence of new-onset AF or stroke in patients with HCM. Methods In patients with an established diagnosis of HCM and cardiac magnetic resonance (CMR) data, LACI was calculated as the ratio between the LA and the LV end-diastolic volumes. New-onset AF or occurrence of stroke comprised the primary combined endpoint. Cumulative event-free survival rates for the occurrence of the primary endpoint were estimated with the population divided according to a LACI cut-off value of 40%. The association between clinical and CMR variables and the primary endpoint was assessed with univariable and multivariable Cox proportional hazard regression models. Results Of 114 patients with HCM, (mean age 54±16 years, 33 (29%) female, LV ejection fraction 67.0±8.4%), 71 patients (49%) had a LACI > 40% (left atrioventricular uncoupling). During a median follow-up of 4.1 (1.8-6.4) years, 19 (16.7%) patients experienced new-onset AF or stroke. Patients with preserved left atrioventricular coupling (LACI ≤ 40%) had a lower cumulative rate of events compared to those with left atrioventricular uncoupling (log-rank p=0.031, Fig. 1). LACI was independently associated with new-onset AF or stroke after adjusting by the presence of late gadolinium enhancement (LGE) sex and age (HR=23.27, p=0.016). Conclusions In patients with HCM, the presence of left atrioventricular uncoupling is independently associated with the occurrence of new-onset AF or stroke.
Abstract Aims How the underlying etiology and pathophysiology of left ventricular (LV) hypertrophy affects LA remodeling and function remains unexplored. The present study aims to investigate the influence of various hypertrophic phenotypes on LA remodeling and function. Methods and Results Patients with LV hypertrophy who underwent cardiac magnetic resonance (CMR) were compared to a control group. CMR data were analyzed retrospectively to assess LA strain, volume, sphericity and left atrioventricular coupling index (LACI). Independent clinical associates of LA strain were assessed using multivariable linear regression analysis. A total of 375 individuals were included: 148 hypertrophic cardiomyopathy (HCM), 35 cardiac amyloidosis (CA), 41 hypertensive heart disease (HTN), 97 severe asymptomatic aortic stenosis (AS) and 54 with normal CMR. Indexed LA end-systolic (iLVmax), diastolic volumes and LA sphericity were the largest in patients with CA (59.1±16.9ml/m2, 46.8±16.4ml/m2 and 83.2±2.1%, respectively). CA patients presented higher LACI when compared to other groups (58±2% vs 42±2% in HCM, 39±2% in HTN, 37±2% in AS and 22±1% in normal), while no differences were observed across others. CA patients showed the lowest LA reservoir (9.6%[0.6-18.6%]) and booster strain (9.1±5.4%), whereas no differences were observed across other groups. LACI and iLAVmax were independently correlated to LA reservoir (β=0.15 and β=-39.33, respectively), LA conduit (β=0.08 and β =-17.08, respectively) and LA booster strains (β=0.1 and β=-28.69, respectively). LA sphericity was independently correlated with LA reservoir strain (β=-0.51). Finally, LV global longitudinal strain was independently correlated with LA reservoir (β=-0.43), conduit (β=-0.20) and booster strain (β=-0.24). Conclusions LA characteristics differ among LV hypertrophic phenotypes. LACI and iLAVmax are independently correlated with LA function while LA sphericity correlates independently with LA reservoir strain.
Abstract Background Left atrial (LA) dysfunction is a common feature in hypertrophic cardiomyopathies. How the underlying etiology and pathophysiology of different cardiomyopathies affects LA remodeling and function remains unexplored. Purpose The aim of our study is to investigate the influence of various cardiomyopathies with hypertrophic phenotype on LA remodeling and function. Methods Patients with left ventricular (LV) hypertrophic phenotype who underwent cardiac magnetic resonance (CMR) were included. A group of patients with a normal CMR was included as a control group. CMR acquisitions used for clinical indication of heart failure diagnosis and etiology were retrospectively analyzed to obtain LA reservoir, conduit, and booster strain, left atrioventricular coupling index (LACI) and LA sphericity. Differences between groups were assessed. To investigate the independent clinical associates of LA reservoir, conduit and booster strain, multivariable linear regression analyses were performed. Results A total of 375 individuals were analyzed including 321 patients diagnosed with LV hypertrophy and 54 patients with a normal CMR. Of the 321 patients with LV hypertrophy, 148 were diagnosed with hypertrophic cardiomyopathy (HCM), 35 with cardiac amyloidosis (CA), 41 with hypertensive cardiomyopathy (HTN) and 97 with severe asymptomatic aortic stenosis (AS). CMR LA characteristic and strain analysis results are summarized in Figure 1. The indexed LA end-systolic volume (iLAVmax), indexed LA end-diastolic volume (iLAVmin) and LA sphericity were larger in patients with CA when compared to other groups (all p<0.05). CA patients displayed more left atrioventricular uncoupling (lower LACI) when compared to individuals with HCM, HTN, AS, and controls (all p<0.001), while no significant differences were observed across other groups. CA patients exhibited lower LA reservoir and booster strains compared to the other groups (all p<0.05), whereas no significant differences were observed across other hypertrophic phenotype diseases. Age, iLAVMax and LACI were independently associated with all the three LA strain components (Figure 2, all p<0.05). Conclusions LA remodeling and function are affected differently across the various etiologies of LV hypertrophy. CA patients exhibit more pronounced atrial involvement, whereas those with HCM, asymptomatic AS, and HTN display similar patterns of atrial dysfunction and remodeling. Additionally, CMR-derived iLAVmax and LACI are independently correlated with LA function.
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