Heart failure (HF) is a complex, multifactorial, progressive clinical condition affecting 64.3 million people worldwide, with a strong impact in terms of morbidity, mortality and public health costs. In the last 50 years, along with a better understanding of HF physiopathology and in agreement with the four main models of HF, many therapeutic options have been developed. Recently, the European Society of Cardiology (ESC) HF guidelines enthusiastically introduced inhibitors of the sodium-glucose cotransporter (SGLT2i) as first line therapy for HF with reduced ejection fraction (HFrEF) in order to reduce hospitalizations and mortality. Despite drugs developed as hypoglycemic agents, data from the EMPA-REG OUTCOME trial encouraged the evaluation of the possible cardiovascular effects, showing SGLT2i beneficial effects on loading conditions, neurohormonal axes, heart cells’ biochemistry and vascular stiffness, determining an improvement of each HF model. We want to give a boost to their use by increasing the knowledge of SGLT2-I and understanding the probable mechanisms of this new class of drugs, highlighting strengths and weaknesses, and providing a brief comment on major trials that made Gliflozins a cornerstone in HF therapy. Finally, aspects that may hinder SGLT2-i widespread utilization among different types of specialists, despite the guidelines’ indications, will be discussed.
Introduction: Cardiac resynchronization therapy (CRT) reduces heart failure (HF) hospitalization and all-cause mortality in HF patients with left bundle branch block (LBBB).Biventricular pacing (BVP) is the gold standard for achieving CRT, but about 30%-40% of patients do not respond to BVP-CRT. Recent studies showed that left bundle branch pacing (LBBP) provided remarkable results in CRT. Therefore, we conducted a meta-analysis aiming to compare LBBP-CRT versus BVP-CRT in HF patients.
Methods:We systematically searched the electronic databases for studies published from inception to December 29, 2022 and focusing on LBBP-CRT versus BVP-CRT in HF patients. The primary endpoint was HF hospitalization. The effect size was estimated using a random-effect model as Risk Ratio (RR) and mean difference (MD).Results: Ten studies enrolling 1063 patients met the inclusion criteria. Compared to BVP-CRT, LBBP-CRT led to significant reduction in HF hospitalization [7.9% vs.14.5%;
Bileaflet Mitral Valve Prolapse (bMVP) has been linked to major arrhythmic events and sudden cardiac death (SCD). Consistent predictors in this field are still lacking. Echocardiography is the best tool for the analysis of the prolapse and its impact on the ventricular mechanics. The aim of this study was to find new echocardiographic predictors of malignant events within an arrhythmic MVP population. We evaluated 22 patients with bMVP with a transthoracic echocardiogram focused on mitral valve anatomy and ventricular contraction. Six of them had major arrhythmic events who required ICD implantation (ICD-MVP group), while sixteen of them presented with a high arrhythmic burden without major events (A-MVP group). The best predictors of malignant events were the AML length and MD of basal and mid-ventricular segments, while other significant predictors were the larger mitral valve annulus (MVA) indexed area, lower MVA anteroposterior diameter/AML length ratio, higher inferolateral basal S3 velocity and a greater mechanical dispersion (MD) of the basal and mid-ventricular segments.
Introduction
Transvenous lead implantation for pacemaker implantation is commonly performed by the cephalic vein cutdown (CVC), subclavian (SVP), or axillary vein puncture (AVP)(1). However, the CVC or AVP should be considered as first choice, according to the last guidelines, due to high rate of lead complications and pneumothorax of SVP.
Objective
To compare efficacy and safety of AVP compared with CVC for CIED implantation by a meta-analysis.
Methods
We systematically searched Medline, Embase and Cochrane electronic databases up to September 5th, 2022, for studies that evaluated the efficacy and safety of AVP and CVC reporting at least one clinical outcome of interest. The primary outcome was acute procedural success. The secondary outcomes were pneumothorax, lead failure, pocket hematoma/bleeding, device infection, total procedure time, venous access time and fluoroscopy time. The effect size was estimated using a random-effect model as Risk Ratio (RR) and relative 95% Confidence Interval (CI).
Results
A total of 8 studies were included enrolling 1926 patients with 3532 leads and average age of 72.3±14.8 years. AVP compared to CVC showed a significant increase in the procedural success (95.7% vs 76.1%; RR: 1.24; 95% CI: 1.09-1.40; p=0.001), (Figure 1). Total procedural time (Mean Difference [MD]: -8.25 min; 95%CI: -10.23- -6.27; p<0.0001) and Venous access time (MD: -6.24 min; 95%CI: -7.01- -5.47; p<0.0001) were significantly shorter with AVP compared with CVC. No differences were found between AVP and CVC for pneumothorax (RR: 0.72; 95% CI: 0.13 - 4.0; p=0.71), lead failure (RR: 0.58; 95% CI: 0.23-1.48; p=0.26), pocket hematoma/bleeding (RR: 0.58; 95% CI: 0.15- 2.23; p=0.43), device infection (RR: 0.95; 95% CI: 0.14- 6.60; p=0.96) and fluoroscopy time (MD: -0.24 min; 95%CI: -0.75- 0.28; p=0.36).
Conclusion
Our meta-analysis proved that AVP improves procedural success and reduces total procedural time and venous access time compared to CVC.
Figure 1 – Forest plots comparing Acute Procedural Success between Axillary Vein Puncture Versus Cephalic Vein Cutdown.
TakoTsubo Syndrome (TTS) is a stress-induced cardiac disease characterized by temporary and segmental left ventricle dysfunction, typically involving the apex. Post-menopause women are more frequently affected. ECG and clinical features at presentation may be similar to those observed in acute coronary syndrome (ACS). However underlying pathomechanisms are completely different and, for what concerns TTS, extremely debated and not yet completely understood. Some hypotheses have been proposed during years, mostly regarding catecholamine-induced cardiotoxicity and microvascular dysfunction, usually following a trigger event which may be either "emotional" (primary TTS) or "physical" (secondary TTS). Additional modulators like neuroendocrine disorders (particularly hypothalamic-pituitary-adrenal axis dysfunction and estrogen drop in menopause) may play a crucial role in TTS onset. Despite being originally considered more benign than ACS, several studies have enlightened that TTS and STEMI are burdened by the same inhospital mortality and complications. However, TTS and ACS complications somehow differ for what concerns incidence, the underlying mechanisms, and both long-and short-term outcomes. Full recovery in TTS requires weeks to months and cases of recurrences have been described, but no single clinical feature seems to predict subsequent episodes so far. By now, apart from inhibitors of the Renin-Angiotensin-Aldosterone System (RAASi), no drug has proved to be effective either in the acute or chronic phase in reducing mortality, improving outcome, or preventing recurrences.
Lipomatous hypertrophy of the interatrial septum (LHIS) is a histologically benign cardiac lesion that is defined by excessive fat accumulation in the area of the interatrial septum (IAS) that does not include the fossa ovalis. Another unusual illness is lipomatosis, which is defined as a broad overgrowth of mature adipose tissue that involves a large portion of an extremity or trunk. We describe a rare case with significant LHIS accompanied by subcutaneous lipomatosis. Echocardiography revealed a mass in the right atrium in this patient. Magnetic resonance imaging revealed that this mass was composed of the adipose tissue and was an extension of a huge thickened IAS. Furthermore, this significant hypertrophy of the IAS was in direct continuation with the excessive mediastinal and epicardial fat.
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