Ventricular pre-excitation (VP) is a cardiac disorder characterized by the presence of an accessory pathway (AP) that bypasses the atrioventricular node (AVN), which, although often asymptomatic, exposes individuals to an increased risk of re-entrant supraventricular tachycardias and sudden cardiac death (SCD) due to rapid atrial fibrillation (AF) conduction. This condition is particularly significant in sports cardiology, where preparticipation ECG screening is routinely performed on athletes. Professional athletes, given their elevated risk of developing malignant arrhythmias, require careful assessment. Early identification of VP and proper risk stratification are crucial for determining the most appropriate management strategy and ensuring the safety of these individuals during competitive sports. Non-invasive tools, such as resting electrocardiograms (ECGs), ambulatory ECG monitoring, and exercise stress tests, are commonly employed, although their interpretation can sometimes be challenging. This review aims to provide practical tips and electrocardiographic clues for detecting VP beyond the classical triad (short PR interval, delta wave, and prolonged QRS interval) and offers guidance on non-invasive risk stratification. Although the diagnostic gold standard remains invasive electrophysiological study, appropriate interpretation of the ECG can help limit unnecessary referrals for young, often asymptomatic, athletes.

The exploration of the cardiac conduction system evolved over a century, marked by groundbreaking discoveries in atrioventricular (AV) nodal physiology. Atrioventricular nodal re-entrant tachycardia (AVNRT), the most prevalent regular tachycardia in humans, remains enigmatic despite extensive research. Detailed examinations of AV nodal anatomy and histology reveal variations in location and shape, influencing electrophysiological properties. Variability in AV nodal extensions and their embryological origins contribute to the complexity of the conduction system. Physiologically, the AV node plays a crucial role in modulating AV conduction, introducing delays for ventricular filling and filtering atrial impulses. Dual-pathway physiology involving fast and slow pathways further complicates AVNRT circuitry. Integrated approaches combining pre-procedural imaging with electroanatomical mapping enhance our understanding of AV nodal structures and high-definition mapping improves precision in identifying ablation targets. Electrophysiological-anatomical correlations may unveil the specific roles of conduction axis components, aiding in the optimization of ablation strategies. This review traces the historical journey from Tawara's pioneering work to recent integrated approaches aimed at unraveling the intricacies of AV nodal structures while emphasizing the importance of a multidimensional approach, incorporating technological advancements, anatomical understanding, and clinical validation in human mapping studies.

We tested hypothesis that aerobic exercise with blood flow restriction (BFR) induced postexercise hypotension (PEH), and the reduction in blood pressure (BP) was due to peripheral vasodilation via the histamine receptors. Ten male subjects participated in this study. The subjects were randomly assigned to walk for 10 min at 6.4 km/h, 0% grade with or without BFR after taking histamine receptor blockade. Following exercise, BP was measured at 10 min interval for 60 min. Heart rate (HR), stroke volume (SV), cardiac output (CO), mean arterial pressure (MAP), and total peripheral resistance (TPR) were evaluated. Our results indicated that MAP was significantly lowered immediately after exercise at 20 min, 30 min, and 40 min before the blockade as opposed to after the blockade. A significant reduction in diastolic BP (DBP) occurred. There were no significant differences in HR, SV, CO, and TPR between before the blockade and after the blockade. MAP was substantially decreased at 20 min, 30 min, and 40 min before the blockade compared to resting (-3.2 ± 2.2, -3.3 ± 2.8, and -2.9 ± 2.5, respectively) while increasing MAP after the blockade. The current study demonstrated that low-intensity aerobic exercise with BFR lowered MAP via histamine receptor-induced peripheral vasodilation. In conclusion, BFR exercise training using short periods and low intensity would be greatly beneficial as a potential treatment to lower BP.

(1) Background: The novel SARS-CoV-2 virus infects the endothelium. Vasculitis may lead to specific coronary artery wall lesions. Coronary computed tomography angiography (CTA) imaging findings have not been systematically reported. The aim of this study was to describe a case series using CTA. (2) Methods: Patients with recent RT-PCR confirmed SARS-CoV-2 infection referred for coronary CTA for clinical indications (e.g., chest pain, troponin+, and ECG abnormalities) were included. Coronary CTA findings, such as atypical coronary lesions suggestive of vasculitis, perivascular inflammation measured by using pericoronary fat attenuation (PCAT) index, coronary artery disease, and extracoronary findings were collected. (3) Results: Results for 12 patients (54.8 ± 22 years; four females) with SARS-CoV-2 infection within 60 days (four acute care and eight stable patients) are reported. Time to positive RT-PCR was a mean of 15.1 days (range, 0-51). In four acute patients with signs of myocardial injury, plaque rupture (n = 1), hyperenhancing myocardium/MINOCA (n = 1), MINOCA (n = 1), and pericarditis with acute heart failure (LVEF 20%) (n = 1) were found. All (100%) had pericardial effusion and signs of perivascular inflammation. Among eight stable patients, pericardial effusion or perivascular inflammation were found in only two (25%). Coronary artery disease was ruled out in five (62.5%) (4) Conclusions: Coronary CTA is a useful imaging modality in the diagnostic work up of patients with COVID-19 infection, and is able to describe coronary and other cardiac abnormalities.

High-sensitivity cardiac troponin (hs-cTn) assays have significantly refined the resolution of biomarker-level detection and have emerged as the gold standard cardiac biomarker in evaluating myocardial injury. Since its introduction, hs-cTn has been integrated into the Fourth Universal Definition of Myocardial Infarction and various European Society of Cardiology (ESC) and American College of Cardiology/American Heart Association (ACC/AHA) guidelines for the evaluation and diagnosis of chest pain syndromes. However, despite its integral role in caring for patients with chest pain, there are still substantive gaps in our knowledge of the clinical interpretation of dynamic changes in hs-cTn values. Whether a relative or absolute hs-cTn delta should be used to detect acute myocardial injury remains debatable. There are also emerging considerations of possible sex and racial/ethnic differences in clinically significant troponin deltas. In the emergency department, there is debate about the optimal time frame to recheck hs-cTn after symptom onset for myocardial infarction rule-out and whether hs-cTn deltas should be integrated into clinical risk scores. In this review, we will provide an overview of the history of clinical utilization of cardiac biomarkers, the development of hs-cTn assays, and the ongoing search for a meaningful delta that can be clinically applicable.

Wearable Activity Trackers (WATs) offer real-time feedback on activity levels. We assessed the impact of WAT usage on physicians' exercise habits.

Assessment of the right ventricular outflow tract and pulmonary arteries (RVOT) for percutaneous pulmonary valve implantation (PPVI) uses discrete measurements (diameters and lengths) from medical images. This multi-centre study identified the 3D RVOT shape features prevalent in patients late after surgical repair of congenital heart disease (CHD). A 3D RVOT statistical shape model (SSM) was computed from 81 retrospectively selected CHD patients (14.7 ± 6.8 years) who required pulmonary valve replacement late after surgical repair. A principal component analysis identified prevalent shape features (modes) within the population which were compared with standard geometric measurements (diameter, length and surface area) and between sub-groups of diagnosis, RVOT type and dysfunction. Shape mode 1 and 2 represented RVOT size and curvature and tapering and length, respectively. Shape modes 3-5 related to branch pulmonary artery calibre, conical vs. bulbous RVOTs and RVOT curvature, respectively. Tetralogy of Fallot, transannular patch type and regurgitant RVOTs were larger and straighter while conduit and stenotic types were longer and more cylindrical than other subgroups. This SSM analysed the main 3D shape features present in a population of RVOTs, exploiting the wide 3D anatomical information provided by routine imaging. This morphological information may have implications for PPVI patient selection and device design.

Fibroblast growth factor (FGF) 23 is a bone-derived hormone that promotes renal phosphate excretion. Serum FGF23 is increased in chronic kidney disease (CKD) and contributes to pathologic cardiac hypertrophy by activating FGF receptor (FGFR) 4 on cardiac myocytes, which might lead to the high cardiovascular mortality in CKD patients. Increases in serum FGF23 levels have also been observed following endurance exercise and in pregnancy, which are scenarios of physiologic cardiac hypertrophy as an adaptive response of the heart to increased demand. To determine whether FGF23/FGFR4 contributes to physiologic cardiac hypertrophy, we studied FGFR4 knockout mice (FGFR4) during late pregnancy. In comparison to virgin littermates, pregnant wild-type and FGFR4 mice showed increases in serum FGF23 levels and heart weight; however, the elevation in myocyte area observed in pregnant wild-type mice was abrogated in pregnant FGFR4 mice. This outcome was supported by treatments of cultured cardiac myocytes with serum from fed Burmese pythons, another model of physiologic hypertrophy, where the co-treatment with an FGFR4-specific inhibitor abrogated the serum-induced increase in cell area. Interestingly, we found that in pregnant mice, the heart, and not the bone, shows elevated FGF23 expression, and that increases in serum FGF23 are not accompanied by changes in phosphate metabolism. Our study suggests that in physiologic cardiac hypertrophy, the heart produces FGF23 that contributes to hypertrophic growth of cardiac myocytes in a paracrine and FGFR4-dependent manner, and that the kidney does not respond to heart-derived FGF23.

Device-assisted left atrial appendage exclusion plays a crucial role in the prevention of fatal ischemic complications in patients with atrial fibrillation and contraindications to anticoagulation treatment. Various devices with different safety profiles and device-related complications are available in daily practice to perform this procedure. In this review, the anatomy, physiology, and functions of the left atrial appendage were detailed, and all available devices used for epicardial and endocardial exclusion of the left atrial appendage and their clinical outcomes were discussed. Future research should aim to further investigate the long-term effects of left atrial appendage exclusion on body homeostasis, blood coagulation, and cardiac function.

Whole-body positron emission tomography (PET)-computed tomography (CT) imaging performed for oncological purposes may provide additional parameters such as the coronary artery calcium (CAC) and epicardial adipose tissue (EAT) volume with cost-effective prognostic information in asymptomatic people beyond traditional cardiovascular risk factors. We evaluated the feasibility of measuring the CAC score and EAT volume in cancer patients without known coronary artery disease (CAD) referred to whole-body F-FDG PET-CT imaging, regardless of the main clinical problem. We also investigated the potential relationships between traditional cardiovascular risk factors and CAC with EAT volume. A total of 109 oncological patients without overt CAD underwent whole-body PET-CT imaging with F-fluorodeoxyglucose (FDG). Unenhanced CT images were retrospectively viewed for CAC and EAT measurements on a dedicated platform. Overall, the mean EAT volume was 99 ± 49 cm. Patients with a CAC score ≥ 1 were older than those with a CAC = 0 ( < 0.001) and the prevalence of hypertension was higher in patients with detectable CAC as compared to those without ( < 0.005). The EAT volume was higher in patients with CAC than in those without ( < 0.001). For univariable age, body mass index (BMI), hypertension, and CAC were associated with increasing EAT values (all < 0.005). However, the correlation between the CAC score and EAT volume was weak, and in multivariable analysis only age and BMI were independently associated with increased EAT (both < 0.001), suggesting that potential prognostic information on CAC and EAT is not redundant. This study demonstrates the feasibility of a cost-effective assessment of CAC scores and EAT volumes in oncological patients undergoing whole-body F-FDG PET-CT imaging, enabling staging cancer disease and atherosclerotic burden by a single test already included in the diagnostic work program, with optimization of the radiation dose and without additional costs.

Symptomatic aortic stenosis and frailty reduce health-related quality of life (HrQoL). Transcatheter aortic valve implantation (TAVI) in patients at high to extreme risk has been proven to have a beneficial effect on HrQoL. Currently, TAVI is also considered in patients at intermediate risk. Our meta-analysis investigates whether benefits to HrQoL after TAVI is more pronounced in frail patients and patients at high to extreme vs. intermediate surgical risk. A systematic search of the literature was performed in November 2021 and updated in November 2023 in PUBMED, EMBASE, and the Cochrane Controlled Trials Register. Statistical analysis was performed according to the inverse variance method and the random effects model. A total of 951 studies were assessed, of which 19 studies were included. Meta-analysis showed a mean increase in the Kansas City Cardiomyopathy Questionnaire (KCCQ) score of 29.6 points (6.0, 33.1) in high to extreme risk patients versus 21.0 (20.9, 21.1) in intermediate risk patients ( < 0.00001) and 24.6 points (21.5, 27.8) in frail patients versus 26.8 (20.2, 33.4) in the general TAVI population ( = 0.55). However, qualitative analyses of non-randomized studies showed the opposite results. In conclusion, TAVI improves HrQoL more in high to extreme than intermediate risk patients. Frailty's impact on HrQoL post-TAVI is inconclusive due to varying outcomes in RCTs vs. non-RCTs.

The incidence of left atrial (LA) supraventricular arrhythmias is increasing. Even after LA ablation, recurrence of these tachycardias is common. MRI studies show that LA cardiomyopathy is a significant risk factor for recurrence and correlates with low voltage areas detected via 3D electroanatomic mapping (EAM). There are limited data on the impact of low voltage extent detected by EAM on recurrence-free survival. Voltage thresholds defining low voltage vary across different studies. This study aims to investigate the impact of the extent of low voltage areas in the LA on recurrence-free survival and to assess whether defining low voltage areas using thresholds of 0.5, 0.4, or 0.3 mV offers better predictive performance. Patients with atrial arrhythmia who underwent LA EAM at Ulm University Heart Center between September 2018 and September 2022 were included from the ATRIUM registry. ROC analysis determined the voltage threshold for predicting recurrence-free survival. Kaplan-Meier and logistic regression models adjusted for patient variables were used to analyze recurrence-free survival. Of 1089 screened patients, 108 met the inclusion criteria. ROC analysis indicated that a 0.4 mV threshold for low voltage provided the best predictive performance. Logistic regression showed a 1.039-fold increase in recurrence risk per percent increase in LA low voltage area (odds ratio = 1.039, 95% CI 1.014-1.064). Low voltage extent in EAM correlates with 1-year recurrence rate after ablation of left atrial supraventricular arrhythmias. The threshold of 0.4 mV is the most suitable for predicting recurrences of those examined.

Routine chest CT is not essential for the diagnostic workup for infective endocarditis (IE), but this type of study may be the initial imaging modality in the evaluation of patients ultimately proven to have IE who present to the emergency department with nonspecific clinical symptoms. Although routine chest CT cannot directly assess valvular oscillating motion due to the lack of cine images, we hypothesized that a combination of elongated nodular valve thickening and abnormal orientation to the normal valve with a blind end on routine CT (indirect-oscillation sign) might suggest movable vegetation indirectly. To evaluate this possibility, we studied 27 patients with IE and 35 controls who underwent both routine chest CT and echocardiography. CT scanning was initiated following a delay of 60-80 s after the administration of the contrast medium. Two cardiothoracic radiologists retrospectively analyzed the CT images to assess the indirect-oscillation sign with consensus. The sensitivity, specificity, positive predictive value, and negative predictive value of the indirect-oscillation sign on routine chest CT were 29.6% (8/27), 100% (35/35), 100% (8/8), and 64.8% (35/54), respectively. Although uncommon, the presence of the indirect-oscillation sign involving the aortic or mitral valve on routine chest CT is a suggestive finding for IE.

The goal of this study was to identify the spatial resolution requirements for accurate rotor detection and localization in human right ventricular tachyarrhythmias. Poor spatial resolution is often cited as a reason for the inaccuracy of cardiac mapping catheters in detecting and localizing arrhythmia rotors. High-resolution (0.7 mm) arrhythmia data from optical recordings obtained from human donor hearts (n = 12) were uniformly downsampled to lower resolutions (1.4-7 mm) to approximate the spatial resolution (4 mm) of clinical mapping catheters. Rotors were tracked at various subresolutions and compared to the rotors in the original data by computing F1-scores to create accuracy profiles for both rotor detection and localization. Further comparisons were made according to arrhythmia type, donor sex, anatomical region, and mapped surface: endocardium or epicardium. For a spatial resolution of 4.2 mm, the accuracies of rotor detection and localization were 57% ± 4% and 61% ± 7%, respectively. Arrhythmia type affected the accuracy of rotor detection (monomorphic ventricular tachycardia, 58% ± 4%; ventricular fibrillation, 56% ± 8%) and localization (monomorphic ventricular tachycardia, 70% ± 4%; ventricular fibrillation, 54% ± 13%). However, donor sex, anatomical region (right ventricular outflow tract, mid, and apical), and mapped surface (epicardium and endocardium) did not significantly affect rotor detection or localization accuracy. To achieve rotor detection accuracy of 80%, a spatial resolution of 1.4 mm or better is needed. The accuracy profiles provided here serve as a guideline for future mapping device development.

Little is known about gender-dependent outcomes after aortic valve replacement (AVR) through right anterior thoracotomy (RAST). The aim of our study was to analyze the mid-term outcomes of our cohort.

Age-related differences in twist may be mitigated with exercise training, although this remains inconclusive. Moreover, temporal left ventricular (LV) systolic twist mechanics, including early-systolic (twist), and beyond peak twist (twist) alone, have not been considered. Therefore, further insights are required to ascertain the influence of age and training status on twist mechanics across systole. Forty males were included and allocated into 1 of 4 groups based on age and training status: young recreationally active (Y, n = 9; 28 ± 5 years), old recreationally active (O, n = 10; 68 ± 6 years), young trained (Y, n = 10; 27 ± 6 years), and old trained (O, n = 11, 64 ± 4 years) groups. Two-dimensional speckle-tracking echocardiography was performed to determine LV twist mechanics, including twist, twist, and total twist (twist), by considering the nadir on the twist time-curve during early systole. Twist was calculated by subtracting twist from their peak values. LV twist was higher in older than younger men ( = 0.036), while twist was lower in the trained than recreationally-active ( = 0.004). Twist is underestimated compared with twist ( < 0.001), and when early-systolic mechanics were considered, to calculate twist, the age effect ( = 0.186) was dampened. LV twist was higher in older than younger age, with lower twist in exercise-trained than recreationally-active males. Twist is underestimated when twist is not considered, with novel observations demonstrating that the age effect was dampened when considering twist. These findings elucidated a smaller age effect when early phases of systole are considered, while lower LV systolic mechanics were observed in older aged trained than recreationally-active males.

to investigate how body mass index (BMI) affects the outcome in patients treated surgically for infective endocarditis (IE). This is a single-center observational analysis of consecutive patients treated surgically for IE. We divided the cohort into six groups, according to the WHO classification of BMI, and performed subsequent outcome analysis. The patient population consisted of 17 (2.6%) underweight, 249 (38.3%) normal weight, 252 (38.8%) overweight, 83 (12.8%) class I obese, 28 (4.3%) class II obese, and 21 (3.8%) class III, or morbidly obese, patients. The median age of the entire cohort was 64.5 [52.5-73.6] years. While only 168 (25.9%) patients were female, women significantly more often exhibited extremes in regards to BMI, including underweight (47.1%) and morbid obesity (52.4%), = 0.026. Class II and III obese patients displayed more postoperative acute kidney injury (47.9%), = 0.003, more sternal wound infection (12.9%), < 0.001, worse 30-day survival (20.4%), = 0.031, and worse long-term survival, = 0.026, compared to the results for the other groups. However, the multivariable analysis did not identify obesity as an independent risk factor for 30-day mortality, with an odds ratio of 1.257 [0.613-2.579], = 0.533. Rather, age > 60, reduced LVEF < 30%, staphylococcal infection, and prosthetic valve endocarditis correlated with mortality. While BMI showed poor discrimination in predicting 30-day mortality on the ROC curve (AUC = 0.609), it showed a fair degree of discrimination in predicting sternal wound infection (AUC = 0.723). Obesity was associated with increased comorbidities, complications, and higher postoperative mortality in IE patients, but it is not an independent mortality risk factor. While BMI is a poor predictor of death, it is a good predictor of sternal wound infections.

Patients suffering from coronavirus disease-19 (COVID-19)-related interstitial pneumonia have variable outcomes, and the risk factors for a more severe course have yet to be comprehensively identified. Cohort studies have suggested that coronary artery calcium (CAC), as estimated at chest computed tomography (CT) scan, correlated with patient outcomes. However, given that the prevalence of CAC is gender- and age-dependent, the influence of baseline confounders cannot be completely excluded. We designed a retrospective, multicenter case-control study including patients with COVID-19, with severe course cases selected based on death within 30 days or requiring invasive ventilation, whereas controls were age- and sex-matched patients surviving up to 30 days without invasive ventilation. The primary outcome was the analysis of moderate-to-severe CAC prevalence between cases and controls. A total of 65 cases and 130 controls were included in the study. Cases had a significantly higher median pulmonary severity score at chest CT scan compared to controls (10 vs. 8, respectively; = 0.0001), as well as a higher CAC score (5 vs. 2; = 0.009). The prevalence of moderate-to-severe CAC in cases was significantly greater (41.5% vs. 23.8%; = 0.013), a difference mainly driven by a higher prevalence in those who died within 30 days ( = 0.000), rather than those requiring invasive ventilation ( = 0.847). White blood cell count, moderate-to-severe CAC, the need for antibiotic therapy, and severe pneumonia at CT scan were independent primary endpoint predictors. This case-control study demonstrated that the CAC burden was higher in COVID-19 patients who did not survive 30 days or who required mechanical ventilation, and CAC played an independent prognostic role.

Cardiovascular disease is the leading cause of death in the European Union (EU), and while the mortality rates of diabetes, myocardial infarction, and the total fat intake have been extensively studied, we believe that understanding the interaction between such closely correlated determinants is crucial to the development of effective health policies in the EU. Our paper's novelty is represented by the econometric modelling, and its ability to capture both temporal and unit variations. The research methodology consists of using a panel data model with fixed effects for the 27 EU member states over the period 2010-2021. The results of the study show that the standardized mortality rate for deaths preventable by prevention and treatment and diabetes-related mortality are significant predictors of total mortality in the EU. The standardized mortality rate for deaths preventable by prevention and treatment had a significant positive impact, suggesting that improved preventive and therapeutic interventions can significantly reduce total mortality. Diabetes-associated mortality also showed a strong positive correlation with total mortality, emphasizing the need for effective diabetes management and prevention strategies. These results are useful for the formulation of public health strategies aimed at improving life expectancy and reducing the burden of chronic diseases.

Bicuspid aortic valve disease is the most prevalent congenital heart disease, affecting up to 2% of the general population. The presentation of symptoms may vary based on the patient's anatomy of fusion, with transthoracic echocardiography being the primary diagnostic tool. Bicuspid aortic valves may also appear with concomitant aortopathy, featuring fundamental structural changes which can lead to valve dysfunction and/or aortic dilatation over time. This article seeks to give a comprehensive overview of the presentation, treatment possibilities and long-term effects of this condition. The databases MEDLINE, Embase, and the Cochrane Library were searched using the terms "endocarditis" or "bicuspid aortic valve" in combination with "epidemiology", "pathogenesis", "manifestations", "imaging", "treatment", or "surgery" to retrieve relevant articles. We have identified two types of bicuspid aortic valve disease: aortic stenosis and aortic regurgitation. Valve replacement or repair is often necessary. Patients need to be informed about the benefits and drawbacks of different valve substitutes, particularly with regard to life-long anticoagulation and female patients of childbearing age. Depending on the expertise of the surgeon and institution, the Ross procedure may be a viable alternative. Management of these patients should take into account the likelihood of somatic growth, risk of re-intervention, and anticoagulation risks that are specific to the patient, alongside the expertise of the surgeon or centre. Further research is required on the secondary prevention of patients with bicuspid aortic valve (BAV), such as lifestyle advice and antibiotics to prevent infections, as the guidelines are unclear and lack strong evidence.

In the original publication [...].