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Background The aim of the current study is to compare electrocardiographic and echocardiographic changes in patients with severe preeclampsia (PE) and those with uncomplicated pregnancies.Methods This is a case-controlled prospective study consisting of 21 pregnant women with severe preeclampsia and a control group consisting of age- and gestational age-matched 24 healthy pregnant women. All patients underwent electrocardiographic and echocardiographic investigation.Results QRS intervals were shorter and PR intervals were longer in the PE group (QRS duration: 80 (60–120) ms and 80 (40–110) ms, p=0.035; PR duration: 160 (100–240) ms and 120 (80–200) ms, respectively; p=0.046). The left ventricular end-systolic diameters of the patients with severe PE group were significantly larger than the control group (31 (24–36) mm and 30 (24–33) mm, respectively; p=0.05). Similarly, posterior wall thickness values of the PE group were significantly higher compared to the control group (9 (7–11) mm vs. 8 (6–10) mm, respectively; p=0.020). Left ventricular mass (146.63±27.73 g and 128.69±23.25 g, respectively; p=0.033) and relative wall thickness values (0.385±0.054 and 0.349±0.046, respectively; p=0.030) were also higher in the PE group. In addition, patients with early-onset severe PE had significantly a higher left ventricular end-diastolic diameter and volume compared with late-onset PE patients.Conclusions The structural changes detected in the severe PE group suggest a chronic process rather than an acute effect. In addition, diastolic dysfunction and left ventricular remodeling are most marked in patients with severe early-onset PE.

Cardiogenic shock, cardiac arrest, acute respiratory failure, or a combination of such events, are all potential complications after cardiac surgery which lead to high mortality. Use of extracorporeal temporary cardio-circulatory and respiratory support for progressive clinical deterioration can facilitate bridging the patient to recovery or to more durable support. Over the last decade, extracorporeal membrane oxygenation (ECMO) has emerged as the preferred temporary artificial support system in such circumstances. Many factors have contributed to widespread ECMO use, including the relative ease of implantation, effectiveness, versatility, low cost relative to alternative devices, and potential for full, not just partial circulatory support. While there have been numerous publications detailing the short and midterm outcomes of ECMO support, specific reports about post-cardiotomy ECMO (PC-ECMO), are limited, single-center experiences. Etiology of cardiorespiratory failure leading to ECMO implantation, associated ECMO complications, and overall patient outcomes may be unique to the PC-ECMO population. Despite the rise in PC-ECMO use over the past decade, short-term survival has not improved. This report, therefore, aims to present a comprehensive overview of the literature with respect to the prevalence of ECMO use, patient characteristics, ECMO management, and in-hospital and early post-discharge patient outcomes for those treated for post-cardiotomy heart, lung, or heart-lung failure. (C) 2019 International Society for Heart and Lung Transplantation. All rights reserved.

Veno-arterial extracorporeal membrane oxygenation (V-A ECMO) has been used to deal with life-threatening complications as well as back-up or active cardiovascular support during high-risk procedures in patients undergoing transcatheter aortic valve implantation (TAVI). PubMed and MEDLINE electronic databases were searched in order to identify studies with emergency or prophylactic V-A ECMO application in association with TAVI procedures. From November 2012 to November 2017, 14 relevant studies were identified that included 5,115 TAVI patients of whom 102 (2%) required V-A ECMO (22 prophylactically, 66 as an emergency and 14 without a reported indication). The reason for emergency V-A ECMO institution was detailed in 64 patients: left ventricle free wall rupture (n = 14), haemodynamic instability (n = 12), ventricular arrhythmias (n = 7), aortic annulus rupture (n = 6), coronary obstruction (n = 6), low left ventricular output (ejection fraction

The rationale for mechanical circulatory support (MCS) in cardiogenic shock is to restore cardiac output in selected patients when critically low or in case of refractory cardiac arrest. Furthermore, an MCS device that moves blood from either the left atrium or the left ventricle to the systemic circulation will potentially unload the ventricle. These devices are used alone or in combination with venoarterial extracorporeal membrane oxygenation (VA-ECMO). If a left-sided Impella device is used, it should be run at the highest possible performance level during treatment while avoiding suction events. When combined with VA-ECMO, the Impella device should be run at a lower performance level, ensuring sufficient left ventricular emptying but avoiding suction. Continuous monitoring is pivotal and patients managed outside the catheterization laboratory should be monitored with an arterial line, a central venous catheter, frequent use of pulmonary artery catheters and regular imaging by transthoracic echocardiogram. The rationale for mechanical circulatory support (MCS) in cardiogenic shock is to restore cardiac output in selected patients when critically low or in case of refractory cardiac arrest. Furthermore, an MCS device that moves blood from either the left atrium or the left ventricle to the systemic circulation will potentially unload the ventricle. These devices are used alone or in combination with venoarterial extracorporeal membrane oxygenation (VA-ECMO). If a left-sided Impella device is used, it should be run at the highest possible performance level during treatment while avoiding suction events. When combined with VA-ECMO, the Impella device should be run at a lower performance level, ensuring sufficient left ventricular emptying but avoiding suction. Continuous monitoring is pivotal and patients managed outside the catheterization laboratory should be monitored with an arterial line, a central venous catheter, frequent use of pulmonary artery catheters and regular imaging by transthoracic echocardiogram.

Veno-venous (VV) and veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) therapy is widely used in critically ill patients with refractory cardiogenic shock and cardiac arrest or suffering from severe respiratory failure. Besides traditional ECMO cannulation, changes in patients' conditions or the occurrence of specific complications (i.e., cerebral hypoxia or left ventricular dilation) may require modifications in cannulation strategies or the combination of ECMO with additional invasive or minimally invasive procedures, to improve organ function and ECMO efficiency. In this review, we described all these "hybrid" approaches, such as the addition of a third or fourth ECMO cannula to improve venous drainage and/or optimize systemic hemodynamics/oxygenation, or the implementation of surgical or percutaneous unloading of the left ventricle (LV), to reduce cardiac dilation and pulmonary edema. Although few data are still available about the effectiveness of such interventions, clinicians should be aware of these advances in ECMO management to improve the management of more complex cases.

Cardiac structure and function are complex and inter-related. Current in vivo techniques assess the heart on a macroscopic scale, but a novel technique called diffusion tensor cardiovascular magnetic resonance (DT-CMR) can now assess the cardiac microstructure non-invasively. It provides information on the helical arrangement of cardiomyocytes that drives torsion and offers dynamic assessment of the sheetlets (aggregated cardiomyocytes) that rotate through the cardiac cycle to facilitate wall thickening. Through diffusion biomarkers, the expansion and organisation of the underlying myocardium can be described. DT-CMR has already identified novel microstructural abnormalities in cardiomyopathy, and ischaemic and congenital heart disease. This new knowledge supports the potential of DT-CMR to improve diagnostics and prognostication in various cardiac diseases.

BACKGROUND Cardiomyocytes are organized in microstructures termed sheetlets that reorientate during left ventricular thickening. Diffusion tensor cardiac magnetic resonance (DT-CMR) may enable noninvasive interrogation of in vivo cardiac microstructural dynamics. Dilated cardiomyopathy (DCM) is a condition of abnormal myocardium with unknown sheetlet function. OBJECTIVES This study sought to validate in vivo DT-CMR measures of cardiac microstructure against histology, characterize microstructural dynamics during left ventricular wall thickening, and apply the technique in hypertrophic cardiomyopathy (HCM) and DCM. METHODS In vivo DT-CMR was acquired throughout the cardiac cycle in healthy swine, followed by in situ and ex vivo DT-CMR, then validated against histology. In vivo DT-CMR was performed in 19 control subjects, 19 DCM, and 13 HCM patients. RESULTS In swine, a DT-CMR index of sheetlet reorientation (E2A) changed substantially (E2A mobility ~46°). E2A changes correlated with wall thickness changes (in vivo r2 = 0.75; in situ r2 = 0.89), were consistently observed under all experimental conditions, and accorded closely with histological analyses in both relaxed and contracted states. The potential contribution of cyclical strain effects to in vivo E2A was ~17%. In healthy human control subjects, E2A increased from diastole (18°) to systole (65°; p < 0.001; E2A mobility = 45°). HCM patients showed significantly greater E2A in diastole than control subjects did (48 ; p < 0.001) with impaired E2A mobility (23°; p < 0.001). In DCM, E2A was similar to control subjects in diastole, but systolic values were markedly lower (40° ; p < 0.001) with impaired E2A mobility (20°; p < 0.001). CONCLUSIONS Myocardial microstructure dynamics can be characterized by in vivo DT-CMR. Sheetlet function was abnormal in DCM with altered systolic conformation and reduced mobility, contrasting with HCM, which showed reduced mobility with altered diastolic conformation. These novel insights significantly improve understanding of contractile dysfunction at a level of noninvasive interrogation not previously available in humans. (J Am Coll Cardiol 2017;69:661–76) Published by Elsevier on behalf of the American College of Cardiology Foundation.

Objective Next to myocardial perfusion, single-photon emission computed tomography (SPECT) also allows for assessment of non-perfusion parameters such as transient ischemic dilatation (TID) and a reduction of ejection fraction (EF) with stress imaging. The present study aimed to evaluate the diagnostic value of TID and EF reserve for the detection of significant multivessel coronary artery disease (CAD). Methods A total of 206 patients with suspected stable coronary artery disease prospectively underwent gated stress-rest 99mTc-tetrofosmin SPECT and invasive coronary angiography with routine fractional flow reserve (FFR) measurements, regardless of imaging results. Left ventricular (LV) volumes, TID and EF reserve were assessed and compared with FFR defined severity of CAD. Results According to FFR, 92 (45%) patients had significant CAD, whereas 25 (12%) showed two vessel disease and 22 (11%) showed three vessel disease (3-VD). With an increasing extent of CAD, TID values and EF reserve did not significantly change (p = 0.07 and p = 0.42 for trend, respectively). Conversely, absolute LV volumes and EF differed significantly among groups of CAD severity (p < 0.01 for all trends). Conclusion SPECT derived TID and EF reserve did not differ between patients with high risk CAD (3-VD) and low risk or no significant CAD. Therefore the present results advocate exert caution when using these ancillary findings in clinical practice.

Image-based patient-specific Computational Fluid Dynamics (CFD) models of the Left Ventricle (LV) can be used to quantify hemodynamics-based biomarkers that can support the clinicians in the early diagnosis, follow-up and treatment planning of patients, beyond the capabilities of the current imaging modalities. We propose a workflow to build patient-specific CFD models of the LV with moving boundaries based on the Chimera technique to overcome the convergence issues previously encountered by means of the Arbitrarian Lagrangian Eulerian approach. The workflow was tested while investigating whether the torsional motion has an impact on LV fluid dynamics. Starting from 3D cine MRI scans of a healthy volunteer, six cardiac cycles were simulated in three CFD LV models: with no, physiological, and exaggerated torsion. The Chimera technique was robust in handling the impulsive motion of the LV endocardium, allowing to notice cycle-to-cycle variations in every simulated case. Torsion affected slightly velocity, vorticity, WSS. It did not affect energy loss and induced a double-sided effect in terms of residence time: the particles ejected in one beat decreased, whereas the motility of the particles remaining in the LV was affected only in the exaggerated torsion case, indicating that implementation of torsion can be discarded in case of physiological levels. Nonetheless, caution is warranted when interpreting these results given the absence of the mitral valve, the papillary muscles, and the trabeculae. The effects of the mitral valve will be evaluated within an Fluid Structure Interaction simulation framework as further development of the current model.

Author(s): Ferreira, Pedro F; Nielles-Vallespin, Sonia; Scott, Andrew D; de Silva, Ranil; Kilner, Philip J; Ennis, Daniel B; Auger, Daniel A; Suever, Jonathan D; Zhong, Xiaodong; Spottiswoode, Bruce S; Pennell, Dudley J; Arai, Andrew E; Firmin, David N | Abstract: PurposeTo evaluate the importance of strain-correcting stimulated echo acquisition mode echo-planar imaging cardiac diffusion tensor imaging.MethodsHealthy pigs (n = 11) were successfully scanned with a 3D cine displacement-encoded imaging with stimulated echoes and a monopolar-stimulated echo-planar imaging diffusion tensor imaging sequence at 3 T during diastasis, peak systole, and strain sweet spots in a midventricular short-axis slice. The same diffusion tensor imaging sequence was repeated ex vivo after arresting the hearts in either a relaxed (KCl-induced) or contracted (BaCl2 -induced) state. The displacement-encoded imaging with stimulated echoes data were used to strain-correct the in vivo cardiac diffusion tensor imaging in diastole and systole. The orientation of the primary (helix angles) and secondary (E2A) diffusion eigenvectors was compared with and without strain correction and to the strain-free ex vivo data.ResultsStrain correction reduces systolic E2A significantly when compared without strain correction and ex vivo (median absolute E2A = 34.3° versus E2A = 57.1° (P = 0.01), E2A = 60.5° (P = 0.006), respectively). The systolic distribution of E2A without strain correction is closer to the contracted ex vivo distribution than with strain correction, root mean square deviation of 0.027 versus 0.038.ConclusionsThe current strain-correction model amplifies the contribution of microscopic strain to diffusion resulting in an overcorrection of E2A. Results show that a new model that considers cellular rearrangement is required. Magn Reson Med 79:2205-2215, 2018. © 2017 International Society for Magnetic Resonance in Medicine.

Abstract The present study investigated whether functional, molecular, and biochemical alterations occurring in chronic heart failure can already be detected in compensated hypertensive cardiac hypertrophy. Force of contraction (isolated papillary muscle strip preparations), sarcoplasmic reticulum (SR) protein and myosin heavy chain isoform expression (Northern and Western blot analysis), myocardial fibrosis (collagen stains, hydroxyproline quantification), myocardial renin mRNA (RT-PCR), and angiotensin II levels and plasma aldosterone concentrations (radioimmunoassay) were studied in hypertrophied myocardium from transgenic rats harboring the mouse Ren -2d gene. Contraction and relaxation velocities of isolated papillary muscle strips were significantly reduced in cardiac hypertrophy. The β-/α-myosin heavy chain ratio was significantly increased in the hypertrophied left ventricles, whereas SR Ca 2+ -ATPase (SERCA 2a) and phospholamban mRNA and protein levels were significantly decreased. The decrease in SERCA 2a was more pronounced than the decrease in phospholamban levels. There was no increased myocardial fibrosis. Left ventricular myocardial renin mRNA and angiotensin II concentrations, as well as plasma aldosterone levels, were higher in transgenic than in control rats. In hypertensive cardiac hypertrophy, myosin heavy chain isoform shift and reduction of SR protein levels are related to systolic and diastolic dysfunction, respectively. These alterations precede the development of myocardial fibrosis. Increased myocardial renin mRNA and angiotensin II concentrations suggest that an activated tissue renin-angiotensin system might contribute to these alterations. Since the alterations in compensated cardiac hypertrophy apparently precede those in chronic heart failure, they might accelerate the transition from hypertrophy to failure and could therefore be targets for pharmacological interventions.

Pre-eclampsia (PE) is strongly associated with heart failure (HF) later in life. During PE pregnancy, the left ventricle undergoes concentric remodeling which often persists after delivery. This aberrant remodeling can induce a molecular signature that can be evaluated in terms of microRNAs (miRNAs) and which may help to explain the associated increased risk of HF. For this review, we performed a literature search of PubMed (National Center for Biotechnology Information), identifying studies on miRNA expression in concentric remodeling and on miRNA expression in PE. The miRNA data were stratified based on origin (isolated from humans or animals and from tissue or the circulation) and both datasets compared in order to generate a list of miRNA expression patterns in concentric remodeling and in PE. The nine miRNAs identified in both concentric remodeling and PE-complicated pregnancy were: miR-1, miR-18, miR-21, miR-29b, miR-30, miR-125b, miR-181b, miR-195 and miR-499-5p. We found five of these miRNAs (miR-18, miR-21, miR-125b, miR-195 and miR-499-5p) to be upregulated in both PE pregnancy and cardiac remodeling and two (miR-1 and miR-30) to be downregulated in both; the remaining two miRNAs (miR-29b and miR-181b) showed upregulation during PE but downregulation in cardiac remodeling. This innovative approach may be a step towards finding relevant biomarkers for complicated pregnancy and elucidating their relationship with remote cardiovascular disease. Copyright (c) 2017 ISUOG. Published by John Wiley & Sons Ltd.