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Background/Objectives: The complexity of Minimally Invasive Mitral Valve Surgery (MIMVS) could cause a slow learning curve and potentially patient harm. We thus investigated if a novice mitral valve center encountered difficulties implementing MIMVS. Methods: We investigated seven hundred and forty-eight mitral valve surgery patients, two years before and after MIMVS introduction. Results: We propensity score matched two hundred and sixty elective mitral valve patients for comparison, with one hundred and thirty patients in each group. Surgical- (5.5 vs. 4.3 h), Cardiopulmonary bypass- (180 vs. 102 min) and aortic cross-clamp times (98 vs. 81 min) became longer after MIMVS introduction. One-year mortality and in-hospital outcomes remained unaffected. Hospital length of stay shortened significantly after MIMVS (5 d vs. 7 d; p < 0.001). Conclusions: Adopting MIMVS in a mitral valve center without prior experience in the procedure showed feasibility, equally good outcome and shorter hospital stay when compared to conventional sternotomy. Full article

Adult congenital heart disease (ACHD) represents a significant portion of congenital anomalies, and with improved treatments leading to an increased life expectancy, its prevalence has been increasing over the past few decades. Nonetheless, a considerable number of patients with ACHD require cardiac rhythm management devices during their lifetime. Traditionally, transvenous pacemaker placement has been the standard mode of treatment for these patients. However, some patients with ACHD have anatomical barriers that obscure this mode of treatment. Leadless pacing systems (LPSs) have changed the field of pacing. Currently, two different LPSs are available. In a real-world setting, implanting an LPS in patients after tricuspid valve (TV) surgery seems to be a straightforward procedure with a low risk of complications, with patients showing no valvular dysfunction after the intervention. LPS implantation is an option to avoid device-related complications in patients with previous TV surgery. Moreover, it has been demonstrated that even the jugular approach seems as safe as the femoral approach and could be considered an alternative implantation method for LPSs. The Aveir VR leadless pacemaker is a helix LPS with unique features, such as its capacity as a dual-chamber leadless pacemaker, the ability to map electrical parameters before releasing the device, and its possibility of being retrievable. Hereby, we present the case of Ebstein’s anomaly, atrial septal defect closure, and previous TV surgery with symptomatic intermittent advanced atrioventricular block. This case illustrates that a transjugular approach for LPSs is also feasible in patients with ACHD. Full article

Right heart failure (RHF) is a common manifestation after left ventricular assist device (LVAD) placement and is associated with a high mortality rate. Historically, RV failure requiring an RVAD at the time of LVAD implantation has been associated with an especially high mortality. However, more recently, some studies have shown reasonable outcomes after LVAD implantation even when an RVAD is required, especially if RV failure is recognized early and treated with RV mechanical support. This article analyzes the current trends and studies investigating the use of RVAD placement post-LVAD implantation with an emphasis on the newest devices and treatment paradigms. Full article

Cardiac arrest remains a leading cause of death worldwide and is a global health crisis. First described in the medical literature in the 18th century, modern cardiopulmonary resuscitation (CPR) with closed chest compressions has remained the standard of care since 1960. Despite exponential advances in basic science research and technological innovations, cardiac arrest survival remains a dismal 10%. The standard of care closed chest compressions provide only 20–30% of baseline cardiac output to the body. Have modern therapies plateaued in effectiveness? This article reviews the history of cardiac arrest, its therapies, and opportunities for future treatments. Through an exploration into the history of CPR and breakthroughs in its treatment paradigms, modern-day researchers and providers may find further inspiration to combat the cardiac arrest public health crisis. Full article

Background: The increased hospital morbidity and mortality associated with hyponatremia is well recognized in the critically ill pediatric population. Neonates and infants exposed to vasopressin following cardiopulmonary bypass (CPB) may be at increased risk for hyponatremia. We aimed to determine the associated effect and potential risk factors leading to hyponatremia and sodium variability in the immediate postoperative period in neonates and infants up to 90 days of age exposed to vasopressin following surgery for congenital heart disease. Methods: This was a retrospective review of 75 consecutive patients at a single tertiary cardiac intensive care unit (CICU) from 2018 to 2020. Using mixed-effects linear regression, we compared sodium trends and variability between the groups who did and did not receive vasopressin. Results: While sodium levels fell in both groups, beyond the first postoperative day, the group exposed to vasopressin had a significantly increased fall in sodium relative to the control (p < 0.001). Vasopressin exposure was associated with increased within-day sodium variability on postoperative days one and two (p < 0.05). Total incidents of moderate to severe hyponatremia (sodium < 130 mmol/L) were higher in the vasopressin group but did not reach statistical significance. Age, volume of modified ultrafiltration, and total diuretic dose were not risk factors for either effect in this study. Conclusions: While all patients in this study appeared to be at risk of postoperative hyponatremia, cumulative vasopressin dose appeared to increase the risk for absolute hyponatremia as well as greater sodium variability within the early postoperative period. Full article

Transthyretin cardiac amyloidosis (TTR-CA) is a pathological condition characterized by the accumulation of misfolded transthyretin (TTR) protein in the heart, leading to restrictive cardiomyopathy. TTR-CA has gained increasing recognition in recent years due to its significant impact on morbidity and mortality. It is typically diagnosed when symptoms of heart failure appear. However, with advancements in non-invasive imaging, early and precise diagnosis of TTR-CA is now possible, enabling clinicians to take advantage of current therapeutic interventions that are more effective when initiated at an earlier stage of the disease. Moreover, genetic testing can now assist clinicians in identifying asymptomatic individuals who are at risk of developing the disease before clinical features manifest. In this review, we provide a general overview of TTR-CA and summarize expert opinions on pre-symptomatic testing and the management of asymptomatic patients, with a particular focus on the V122I mutation. This article aims to provide clinicians with a better understanding of TTR-CA and the current best practices for managing asymptomatic patients with this genetic predisposition. Full article

Background: Obesity presents a significant global health impact and is linked to cardiovascular diseases. While obesity often exacerbates the severity of cardiovascular conditions, an “obesity paradox” has previously been observed, where patients with higher body mass index (BMI) exhibit improved in-hospital and long-term outcomes in certain contexts. As minimally invasive procedures such as percutaneous coronary intervention (PCI) continue to become more relevant, understanding the impact of different patient characteristics on clinical outcomes becomes increasingly important. Methods: A comprehensive analysis was conducted using a large cohort of patients who underwent PCI. In this study, we identified patients who underwent PCI in the year 2020 using the International Classification of Disease (ICD) codes. Patients were categorized into five groups based on their Body Mass Index (BMI). This study aimed to examine the impact of BMI on inpatient outcomes among patients undergoing PCI, focusing on mortality, length of stay, and hospitalization costs across different BMI categories. Results: Our analysis revealed a U-shaped relationship between BMI and inpatient outcomes. Patients with a BMI ≥ 25 demonstrated significantly reduced inpatient mortality (adjusted odds ratio 0.31, 95% CI: 0.18 to 0.54 for BMI 25–29.9 group and adjusted odds ratio 0.32, 95% CI: 0.20 to 0.51 for the BMI 30–39.9 group, with p ≤ 0.001); shorter hospital stays (BMI of 25 or higher with mean reduction of −2.40 to −3.66 days, with p ≤ 0.001); and lower hospitalization costs with a cost reduction of −$40,881 (95% CI: −$64,540 to −$17,223) for the BMI 25–29.9 group, −$57,900 (95% CI: −$80,308 to −$35,492) for the BMI 30–39.9 group, and −$41,463 (95% CI: −$65,151 to −$17,775) for the BMI ≥40 group compared to those with normal BMI (20–24.9). However, these benefits diminished for patients with a BMI ≥ 40, where no significant differences in mortality or cost reductions were observed. Conclusions: These findings underscore the complexity of the obesity paradox and its limitations in extreme obesity. This study highlights the need for tailored management strategies in PCI patients with varying BMI profiles. Full article

The prevalence of cardiac amyloidosis (CA), especially as a cause of heart failure, has significantly increased in recent years. Early detection and accurate assessment of the disease burden are crucial for initiating timely treatment and ensuring precise prognosis. CA primarily results from the infiltration of the myocardium by either immunoglobulin light chain fibrils (AL) or transthyretin fibrils (ATTR), leading to restrictive cardiomyopathy and eventual death if untreated. Over the past decade, advancements in diagnostic imaging and heightened clinical awareness have revealed a substantial presence of CA, particularly ATTR, among the elderly. These diagnostic improvements encompass echocardiography, cardiac computerized tomography scans, magnetic resonance imaging, and radionuclide scintigraphy with bone-avid tracers. Concurrently, significant progress has been made in therapeutic options, with new disease-modifying treatments now available that can dramatically alter the disease trajectory and improve survival rates when administered early. However, despite these advancements, there remains an urgent need for the early and accurate detection of CA to ensure that patients can fully benefit from these emerging therapies. Full article

Atrial fibrillation is a prevalent cardiac arrhythmia influenced by multifactorial mechanisms, including the emerging role of epicardial adipose tissue. Left atrial epicardial adipose tissue, through its endocrine and paracrine activities, contributes to atrial remodeling by fostering inflammation, fibrosis, and electrical remodeling. Objectives: This review aims to explore the interaction between left atrial epicardial adipose tissue and atrial dysfunction, highlighting the utility of strain imaging as a diagnostic and prognostic tool in atrial fibrillation management. Additionally, it examines emerging therapeutic strategies targeting epicardial adipose tissue to improve outcomes. Methods: We analyzed recent advances in imaging techniques, with a specific focus on speckle-tracking echocardiography for non-invasive strain assessment. Strain imaging parameters, including atrial reservoir, conduit, and contractile strain, were evaluated alongside volumetric measures of epicardial adipose tissue. Emerging therapies, such as weight management and GLP-1 receptor agonists, were reviewed for their impact on left atrial epicardial adipose tissue and atrial remodeling. Results: Strain imaging demonstrates a significant association between reduced strain parameters and atrial remodeling induced by left atrial epicardial adipose tissue. Combining strain assessment with volumetric measures enhances diagnostic accuracy and stratification of patients at risk for recurrent or progressive atrial fibrillation. Emerging therapies, particularly GLP-1 receptor agonists, show promise in reducing epicardial adipose tissue volume and mitigating atrial remodeling, thereby improving catheter ablation outcomes. Conclusions: Strain imaging is a valuable tool for the early detection of atrial dysfunction and personalized treatment planning in atrial fibrillation. Integrating these imaging approaches into routine clinical practice can optimize atrial fibrillation management and improve patient outcomes. Full article

Introduction: Risk factors, a 75-year-old concept, are instrumental in the management of the general population. Newer biomarkers can explain residual risk and protection from risk. The population needs a new platform to make more comprehensible the importance of managing risk. Biologic age, the number of years left to live, is the platform that will receive the attention of patients. Method: Risk factor odds ratios are used to approximate the years lost to the modifiable risk, calculating a biologic age. Newer biomarkers confirm the predication and can be used to explain the pleomorphic properties of medications and unrealized risk. The biomarkers represent the following biologic processes: repair, inflammation, immune function, hematologic, clotting factors, metabolic-nutritional, organ maintenance, anthropomorphic, environmental, endothelial function, sleep, co-morbidities, frailty, and electromagnetic. Risk factors and biomarkers are ranked in the order of significance in reducing biologic age. Results: A six-step method of patient management using biologic age and biomarkers is presented. Conclusions: Knowledge of risk factors and therapies to improve risk has increased over the last 75 years. Biologic age is more appropriate in explaining the significance of this knowledge and may improve patient compliance to lifestyle changes and medication compliance. Appropriate counseling with utilization of biomarkers of biologic processes, such as high sensitivity-CRP, circulating stem cells, number of co-morbidities, frailty, electrocardiogram, and pulse wave velocity will improve compliance and personalize care. The 6-minute walk should be incorporated into the vital signs due to prognostic significance. Full article

Cardiac Contractility Modulation (CCM) is an electrical therapy based on an implantable device. This device is approved for patients with heart failure with reduced ejection fraction (HFrEF). Randomized clinical trials and thousands of described cases and studies have shown how CCM can improve exercise tolerance, quality of life, re-hospitalization for HF, and cardiac function by reverse left ventricular modelling. In this case report, we describe a patient candidate for a cardiac transplant based on dilated cardiomyopathy with severe LV dysfunction and narrow QRS. The patient had frequent heart failure-related hospitalizations, despite the optimal medical therapy. The strategy was to adopt the Cardiac Contractility Modulation (CCM) therapy while waiting for a cardiac transplant. During a consultation on all prospective therapy options, the patient refused the LVAD therapy, and was more confident in adopting a less invasive device therapy like CCM. This strategy had a very fast and beneficial impact on the patient’s health; the CCM improved heart failure symptoms, hemodynamics flow and cardiac functionality. Moreover, after a relatively short time, the patient went from persistent AF to Sinus Rhythm, although he started with a severe bi-atrial dilatation. These parameters were stable during an extended follow-up of 18 months. Full article

D-transposition of the great arteries (D-TGA) is a common cyanotic critical congenital heart disease. An arterial switch operation (ASO) with/without a ventricular septal defect (VSD) closure is the preferred surgical approach, with an added challenge when an intramural coronary artery (IMC) is present (1), with a reported increased incidence of postoperative complications and mortality (2,3). We present our recent D-TGA with intramural coronary artery (TGA-IMC) experience, focusing on the salient features identified on echocardiography, computed tomography (CT) angiography, and invasive angiograms, as well as variations in ASO surgical techniques for repair. Diagnostic imaging evaluation allowed for identification of the lesion, as well as planning for and undertaking of two different surgical approaches. While the two patients had differing immediate postoperative courses, both were asymptomatic at discharge, with normal biventricular systolic function. Our experience demonstrates that the suspicion for a coronary anomaly in TGA can be raised prenatally and confirmed postnatally with focused trans-thoracic echocardiography and ECG-gated CT angiogram evaluation while also aiding in operative planning. Moreover, suggesting further exploration of the optimal surgical technique for the repair of TGA-IMC. Full article

Coronavirus disease 19 (COVID-19) is responsible for one of the worst pandemics in human history. The causative virus, the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), can invade host cells in multiple organs by binding the angiotensin-converting enzyme (ACE) II expressed on the cell surface. Once inside the host cell, viral replication takes place, leading to cellular disruption and the release of signal molecules that are recognised by the innate immune system. Innate immunity activation leads to the release of proinflammatory cytokines and primes the adaptive immune system. The proinflammatory environment defends against further viral entry and replication. SARS-CoV-2 infection is thought to lead to myocardial injury through several mechanisms. Firstly, direct viral-mediated cellular invasion of cardiomyocytes has been shown in in vitro and histological studies, which is related to cellular injury. Secondly, the proinflammatory state during COVID-19 can lead to myocardial injury and the release of protein remnants of the cardiac contractile machinery. Thirdly, the hypercoagulable state of COVID-19 is associated with thromboembolism of coronary arteries and/or other vascular systems. COVID-19 patients can also develop heart failure; however, the underlying mechanism is much less well-characterised than for myocardial injury. Several questions remain regarding COVID-19-related heart failure, including its potential reversibility, the role of anti-viral medications in its prevention, and the mechanisms underlying heart failure pathogenesis in long COVID-19. Further work is required to improve our understanding of the mechanism of cardiac sequelae in COVID-19, which may enable us to target SARS-CoV-2 and protect patients against longer-lasting cardiovascular complications. Full article

Background: Cardiovascular disease (CVD) is the leading cause of mortality and disability worldwide. While sex differences in CVD have been well documented, the physiological mechanisms of those sex differences remain unclear. As important components of the cardiovascular system, cardiac vagal control and baroreflex serve as mechanisms of sex differences in CVD and are modifiable factors for gender-specific CVD preventions. Methods: Ninety-four healthy adults (18–44 years of age; M_age = 21.09 years; 46 female) were recruited to complete the assessments of heart rate variability (HRV) at a resting baseline and the cardiac timing effect on an R-wave-locked reaction time (RT) task, which were used as the indicator of cardiac vagal control and a novel behavioral measure of baroreflex activity, respectively. HRV metrics (including the root mean square of successive R-R interval differences, high frequency and low frequency heart rate variability, and low frequency-to-high frequency ratio), the cardiac timing effect (the inhibition of RT response at the phase of cardiac systole compared to diastole), and their associations were compared between female and male participants. Results: Female participants showed higher levels of vagally mediated HRV after adjusting for basal resting heart rate. Importantly, the cardiac timing effect on RT responses was positively correlated with vagally mediated HRV among males but not among females. Conclusions: Females and males exhibited different physiological processes to regulate cardiovascular functions and behavioral outcomes. The present findings will help to reduce gender disparities in the preventive care of CVD and improve cardiovascular health for both women and men. Full article

Background: Coronary microvascular disease is associated with adverse prognosis in a range of cardiovascular diseases, but its prognostic role in patients with aortic stenosis (AS) is unclear. The aim of this systematic review and meta-analysis is to determine the prognostic role of myocardial perfusion and coronary flow reserve, assessed using non-invasive imaging modalities, in patients with AS. Methods: We conducted a systematic review and meta-analysis of all studies assessing myocardial perfusion reserve (MPR) or coronary flow reserve (CFR) in patients with AS and reporting clinical outcomes, from inception to January 2024. The definition of abnormal MPR/CFR and major adverse cardiovascular events (MACE) was that used in each study. Estimates of effect were calculated from hazard ratios (HRs) and 95% confidence intervals (CIs) using a random-effects model. Results: Four studies comprising 384 participants met the inclusion criteria. Myocardial/coronary blood flow was assessed using Doppler echocardiography (n = 2), PET (n = 1), or cardiac magnetic resonance (n = 1). The median optimal cutoff for MPR/CFR across all studies was 2.01 (range 1.85–2.13), with 109 events. Impaired MPR/CFR was associated with a higher incidence of MACE (HR 3.67, 95% CI: 1.66, 8.09, I² = 63%) in the overall population. Conclusions: Reduced MPR/CFR is associated with increased risk of MACE in patients with AS, although significant heterogeneity exists in published studies. Further studies are required to establish its role in the risk stratification of asymptomatic patients with AS. Full article

Background/objectives: Acute coronary syndrome (ACS) is a major global health issue primarily caused by the rupture or erosion of vulnerable coronary plaques. Non-invasive identification of these plaques through coronary computed tomography angiography (CCTA) can be improved with radiomics, which extracts and analyses quantitative features from medical images. This systematic review aims to comprehensively evaluate the literature surrounding the role of radiomics in assessing coronary plaques via CCTA. Methods: A systematic search of Medline, EMBASE, and Web of Science was conducted up to July 2024. Nine studies met the inclusion criteria, and their methodological quality was assessed using the radiomic quality score (RQS) and the QUADAS-2 tool. Results: All studies that evaluated radiomic models for plaque vulnerability reported area under the curve (AUC) values exceeding 0.7, indicating at least modest diagnostic performance. In the four studies that made direct comparisons, radiomic models consistently outperformed conventional CCTA markers. However, RQS scores ranged from 2.7% to 41.7%, reflecting variability in study quality and underscoring the need for more robust validation. Conclusions: Radiomics has the potential to enhance CCTA-based identification of vulnerable coronary plaques, offering a promising non-invasive approach to predicting major adverse cardiovascular events. However, the current body of research is limited by the lack of external validation, reliance on small, single-centre retrospective studies, and methodological inconsistencies, which impact the generalisability and reproducibility of findings. Future research should prioritise prospective, multi-centre studies with standardised protocols and rigorous validation frameworks to effectively incorporate radiomics into clinical practice. Full article

Background: Recent studies have suggested an increased risk of acute myocardial infarction (AMI) following daylight saving time (DST) transitions in cohorts of American and European patients. We aim to validate this finding in a Canadian population. Methods: We performed a retrospective cohort study of patients admitted to the Hôpital du Sacré-Coeur de Montréal with a diagnosis of AMI requiring a coronary angiogram from 28 February 2016 to 3 December 2022. The transition period was defined as two weeks following DST, while the control periods were two weeks before and two weeks after the transition period. Patients aged 18 years or older were included. The primary endpoint was the incidence rate ratio (IRR) of AMI following DST transitions while the secondary endpoint was infarct size by biomarkers. A subgroup analysis compared the pre-COVID-19 period (2016–2019) to the post-COVID-19 period (2020–2022). Results: A total of 1058 patients were included (362 in the transition group and 696 in the control group). The baseline clinical characteristics were comparable between both groups. The rate of AMI per day following the DST transitions was 1.85 compared to 1.78 during control periods. The DST transitions were not associated with an increase in AMI (IRR = 1.04, 95% CI 0.91–1.18, p = 0.56) nor with infarct size. In the subgroup analysis, DST was associated with a significant increase in the incidence of AMI only in the pre-COVID-19 period, with a rate of 2.04 AMI per day in the transition group compared to 1.71 in the control group (IRR = 1.19, 95% CI 1.01–1.41, p = 0.041). In contrast, there was a significant increase in the size of AMI following DST in the post-COVID-19 period subgroup, with a creatine phosphokinase-MB (CK-MB) concentration of 137 ± 229 µg/L compared to 93 ± 142 µg/L (p = 0.013). Conclusions: In this Canadian cohort, there was a significant increase in the incidence of AMI in the pre-COVID-19 period, and infarct sizes were significantly larger following the DST transitions in the post-COVID-19 period. No significant associations emerged when pre- and post-COVID-19 periods were pooled. Full article