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Ischemic heart disease, a major risk factor for myocardial infarction (MI), occurs when the blood vessels supplying oxygen-rich blood to the heart become partially or fully occluded by lipid-rich plaques, resulting in myocardial cell death, remodeling, and scarring. In addition, MI occurs as result of lipid-rich plaque rupture, resulting in thrombosis and vessel occlusion. Cardiac fibroblasts (CFs) and CF-derived growth factors are crucial post-MI in myocardial remodeling. Information regarding the regenerative phenotypes of CFs is scarce; however, regenerative CFs are translationally relevant in myocardial regeneration following MI. The emerging technologies in regenerative cardiology offer cutting-edge translational opportunities, including synthetic cells. In this review, we critically reviewed the current knowledge and the ongoing research efforts on application of synthetic cells for improving cardiac regeneration post-MI. Impact statement Synthetic cells offer tremendous regenerative potential in otherwise deleterious cardiac remodeling postmyocardial infarction. Understanding the role of fibroblasts in cardiac healing and the therapeutic applications of synthetic cells would open a multitude of novel cardiac regenerative approaches. The novel concept of synthetic fibroblasts that emulate native cardiac fibroblasts can provide an effective solution in cardiac healing.

Coronary no-reflow phenomenon is a lethal mechanism of ongoing myocardial injury following successful revascularization of an infarct-related coronary artery. Incidence of this phenomenon is high following percutaneous intervention and is associated with adverse in-hospital and long-term outcomes. Several mechanisms such as ischemia-reperfusion injury and distal microthromboembolism in genetically susceptible patients and those with preexisting endothelial dysfunction have been implicated. However, the exact mechanism in humans is still poorly understood. Several investigative and treatment strategies within and outside the cardiac catheterization laboratory have been proposed, but they have not uniformly shown success in reducing mortality or in preventing adverse left ventricular remodeling resulting from this condition. The aim of this article is to provide a brief and concise review of the current understanding of the pathophysiology, clinical predictors, and investigations and management of coronary no-reflow phenomenon.

Vegetarians have less hypertension, diabetes mellitus and obesity, hence possibly lower risk of congestive heart failure (HF). We studied associations between vegetarian diets and echocardiographic markers of stage B HF. In a cross-sectional study, dietary pattern was ascertained by a validated FFQ. Echocardiograms were interpreted using standardised criteria. Participants were free-living subjects in Southern California who were older Adventist Health Study-2 cohort members. After exclusions, 133 subjects aged >60 years were enrolled. Their mean age was 72·7 (sd 8·7) years, 48·1 % were female, 32 % were African American and 71 % were vegetarian. Non-vegetarians had higher body weight (80·3 (sd 15·17) kg v. 71·3 (sd 16·2), P < 0·005), body surface area (1·92 (sd 0·24) m2v. 1·81 (sd 0·22) m2, P = 0·01) and prevalence of hypertension (63 % v. 47 %, P = 0·10). Adjusting for age, sex, race and physical activity, it is found that vegetarians had greater echocardiographic mitral annular e’ velocity (a measure of left ventricular (LV) relaxation) 7·44 v. 6·48 (non-vegetarian) cm/s (P = 0·011) and a yet greater contrast when vegans (7·66 cm/s, P = 0·011) were the group of interest. The ratio mid-to-late-diastolic mitral flow velocity (E/A) was also higher in vegans compared with non-vegetarians (1·02 and 0·84, respectively, P = 0·008). Mediation analyses suggested these associations may be partly related to higher blood pressures and BMI in the non-vegetarians. We conclude that vegetarians, especially vegans, appear to have better LV relaxation and fewer diastolic abnormalities than others. As dietary exposure is modifiable, one may speculate pending further investigation about the potential for reduction of stage B HF and later mortality.

AV canal defects (AVCD) are caused by maldevelopment of the endocardial cushions and typically include a primum atrial septal defect (ASD), an inlet ventricular septal defect (VSD), and a common atrioventricular valve. The variations in deformities provide the basis for the many terms used in the anatomical classifications: partial, transitional, intermediate, and complete common AVCD (balanced or unbalanced). The balanced complete common AVCDs are classified as Rastelli A, B, C depending on the anomaly of the anterior bridging leaflet division and attachments. Unbalanced complete AVCDs occur when the common AV valve leads primarily into the RV or LV. Echocardiographic apical, subcostal, and parasternal views are the best views to image AV canal defects. These views can help determine the type of repair required for the various AV canal defects.

Atrial septal defects (ASD) are among the most common congenital heart diseases encountered in adulthood. Patent foramen ovale (PFO) is present in up to 25% of the population. ASD could present as isolated lesion or in association with more complex congenital heart disease form as tetralogy of Fallot, or Ebstein's anomaly of tricuspid valve. There is a wide range of clinical presentation ranging from asymptomatic subjects surviving to adulthood undiagnosed to subjects presenting with right heart failure and severe pulmonary vascular disease (Eisenmenger syndrome). This manuscript is an in depth review of the complex atrial septation, the variable clinical presentation of ASD and PFO, and its clinical and therapeutic implications.

Background Volume excess is common in patients with end stage renal disease (ESRD). We examined the prognostic value of clinical and echocardiographic measures of left (LA) and right atrial (RA) hypertension in this population. Method We prospectively collected demographic, clinical, pharmacological, echocardiographic data on 575 consecutive ESRD patients on hemodialysis undergoing cardiac evaluation before renal transplantation in a dedicated cardiac clinic. Survival was analyzed as a function of clinical and echocardiographic measures of LA and (RA) hypertension. Result Elevated LA pressure was seen in 48% of the patients based on E/e' velocity ratio of ≥ 15, and 28% had elevated RA pressure based on inferior vena caval size. Physical examination grossly underestimated the prevalence of both LA and RA hypertension. Atrial pressures were normal in 46% and both atrial pressures were elevated in 20% of the patients. Elevated LA pressure in the presence of normal RA pressure was found in 30%. Over a period of 20 ± 8 months, there were 43 deaths. There was a graded increase in mortality with increases in LA and bi-atrial hypertension (p = .009). The 2-year mortality rate was 6% in those with normal atrial pressures, 13% in those with isolated LA hypertension and 28% in those with bi-atrial hypertension. Conclusion Mitral E/e' ratio and inferior vena caval size are vastly more sensitive than physical examination for recognition of elevated atrial pressures and are strong predictors of survival in ESRD patients. Limited echocardiographic examination may have a role in ESRD patients undergoing dialysis to help achieve euvolemic status.

ST-segment elevation myocardial infarction (STEMI) is a life-threatening condition that requires emergent, complex, well-coordinated treatment. Although the primary goal of treatment is simple to describe—reperfusion as quickly as possible—the management process is complicated and is affected by multiple factors including location, patient, and practitioner characteristics. Hence, this narrative review will discuss the recommended management and treatment strategies of STEMI in the circumstances.

BACKGROUND Cognitive impairment has been known to be associated with negative health impacts. Several studies recently demonstrated inconsistent outcomes among cognitive impaired patients with acute coronary syndrome (ACS). Our study aimed to determine the impact of cognitive impairment for patients with ACS. METHODS Databases were searched through October 2020. Studies reporting revascularization rates, short- and long-term mortality among ACS patients with cognitive impairment were included. Effect estimates from the individual studies were extracted and combined using random effect and generic inverse variance method of DerSimonian and Laird. RESULTS In total, 11 observational studies were included in the analysis consisting of 810 122 ACS patients, with 3.5% cognitive impairment patients. Our analysis suggested that cognitive impairment was associated with a lower rate of percutaneous coronary intervention (PCI) [odds ratio (OR), 0.63; 95% confidence interval (CI), 0.42-0.96; I2 = 98.5%; P = 0.033]. Among patients undergoing PCI, cognitive impairment was statistically associated with increased 30-day mortality (OR, 1.34; 95% CI, 1.14-1.57; I2 = 83.1%; P

Myocardial infarction with nonobstructive coronary arteries (MINOCA) is a complex clinical syndrome that is characterized by evidence of acute myocardial infarction in the absence of significant epicardial coronary artery disease on angiography. The term “MINOCA” encompasses a group of heterogeneous diseases with varying underlying mechanisms and each with its own pathophysiology. Overlooked plaque rupture or erosion and coronary vasospasm are the most common causes of MINOCA and can be diagnosed by routine intracoronary imaging and vasoreactivity testing, respectively. Coronary microvascular dysfunction is a less recognized, albeit an important cause of morbidity in patients presenting with MINOCA. Although MINOCA is a rare presentation of acute coronary syndrome, it is not a benign disorder and can have adverse consequences if untreated. In this article, we aim to review the pathogenesis, clinical characteristics, and finally propose a systematic approach in the diagnosis and management of patients with MINOCA.

Angiography is inaccurate in assessing functional significance of coronary lesions, and often stenoses deemed severe on angiographic assessment do not restrict coronary blood flow at rest or with maximal dilatation. Angiography-guided revascularization has not shown improvement in hard clinical outcomes in stable ischemic heart disease (SIHD). Most current guidelines for SIHD recommend invasive functional assessment of lesions to guide revascularization if prior evidence of ischemia is not available. There has been several recent advances and development of novel methods in this arena. Various contemporary clinical trials have been undertaken for validation of these indices. Here we review the physiological basis, tools, techniques, and evidence base for various invasive (resting as well as hyperemic) and noninvasive methods for functional assessment of coronary lesions. Left main stenosis, bifurcation lesions, serial stenosis, and acute coronary syndrome each causes unique disequilibrium that may affect measurements and require special considerations for accurate functional assessment.

Patent ductus arteriosus is a common congenital heart anomaly in the newborn and children. It is often diagnosed and treated in childhood; however, there are a subset of patients who survive to adulthood undiagnosed, and it is present in adulthood with various clinical presentations. The clinical presentation, hemodynamics, and management of PDA presentation in adults depend on various factors, primarily the size of PDA, magnitude of shunting, and status of pulmonary vasculature. Echocardiography is often the primary imaging modality in the evaluation of adult patients with PDA and is an important tool that provides diagnostic and hemodynamic assessment for the initial evaluation and routine follow-up after PDA closure. In this review, we present a simplified approach of basic echocardiographic assessment of various types of PDA presentations in adults.

BACKGROUND Patients with end-stage renal disease (ESRD) have a cardiovascular mortality about 15-30 times the general population and this is reduced by about 70% with renal transplant. Dobutamine stress echocardiography (DSE) is commonly performed for preoperative cardiac evaluation before renal transplantation. Hypertensive response during DSE occurs in about 1%-5% of DSE studies. However, it seems to be more frequent in patients with ESRD. But its frequency and clinical implications are not known. METHODS AND RESULTS Of the 249-consecutive adult ESRD patients undergoing DSE for pre-kidney transplant cardiac risk assessment at our dedicated clinic, 53 (21%) had a hypertensive response. Half of the patients with a hypertensive response had stress-induced segmental wall motion abnormalities, of whom only half had angiographically significant coronary artery disease by quantitative coronary angiography. The hypertensive response was not a predictor of survival. Stress-induced segmental wall motion abnormalities predicted poor survival in those with a normotensive response, but not in those with a hypertensive response. The main and independent predictor of a hypertensive response was higher baseline systolic blood pressure (P

Recent advances in surgical techniques and perioperative care for patients with single ventricle physiology have led to a remarkable improvement in long-term survival, such that now the majority of patients with single ventricle physiology are living to adulthood after Fontan palliation. The management of adult patients with Fontan physiology is one of the most challenging clinical dilemmas encountered in contemporary cardiology. The complex and heterogeneous anatomical and physiological abnormalities seen in Fontan patients mandate that any clinical evaluation, either for routine follow-up or preoperative evaluation prior to any transcatheter or surgical intervention, incorporates detailed information from a careful and thorough echocardiographic examination, These examinations, however, can be complex and confusing, even for experienced echocardiographers. Ideally, the interpretation of these studies is informed by an understanding of the basic anatomical lesions and of the potential long-term complications encountered in adult single ventricle patients. In this review, we present a practical and clinically oriented approach to the echocardiographic evaluation of adult patients with single ventricle physiology post-Fontan.

Ventricular septal defects (VSDs) are the most common forms of acyanotic congenital heart disease accounting for 37% of congenital heart disease in children. A VSD is defined by parts of the ventricular septum involved. There are four major types of VSDs: perimembranous, muscular, outlet, and inlet VSDs. Echocardiography is the most important clinical tool to help diagnose and characterize a VSD. Although most VSDs are clinically nonsignificant or close on their own, echocardiography with Doppler and color flow mapping can be used to provide accurate anatomic and hemodynamic evaluation of VSDs in order to determine if surgical or transcatheter-based intervention is needed. Hence, understanding how to use echocardiography to characterize VSDs is of crucial importance when caring for patients with adult congenital heart disease.

Amyloidosis refers to a group of disorders characterized by deposition of autologous fibrillary proteins into the interstitium, leading to multiple-organ dysfunction [(1)][1]. Depending upon the type, it can involve the skin, blood vessels, liver, kidney, nerves, heart, and other organs. The

Key Points Question What is the variability in left ventricular ejection fraction (LVEF) as measured by different cardiac imaging modalities? Findings In this multicenter diagnostic study of 2032 patients with coronary artery disease and LVEF of 35% or less with imaging interpreted by core laboratories, correlation of LVEF between modalities ranged from r = 0.493 (for biplane echocardiography and cardiovascular magnetic resonance) to r = 0.660 (for cardiovascular magnetic resonance and gated single-photon emission computed tomography). There was no systematic overestimation or underestimation of LVEF for any modality. Meaning There is substantial variability in LVEF assessment between modalities, which should be considered in trial design and clinical management., Importance Clinical decisions are frequently based on measurement of left ventricular ejection fraction (LVEF). Limited information exists regarding inconsistencies in LVEF measurements when determined by various imaging modalities and the potential impact of such variability. Objective To determine the intermodality variability of LVEF measured by echocardiography, gated single-photon emission computed tomography (SPECT), and cardiovascular magnetic resonance (CMR) in patients with left ventricular dysfunction. Design, Setting, and Participants International multicenter diagnostic study with LVEF imaging performed at 127 clinical sites in 26 countries from July 24, 2002, to May 5, 2007, and measured by core laboratories. Secondary study of clinical diagnostic measurements of LVEF in the Surgical Treatment for Ischemic Heart Failure (STICH), a randomized trial to identify the optimal treatment strategy for patients with LVEF of 35% or less and coronary artery disease. Data analysis was conducted from March 19, 2016, to May 29, 2018. Main Outcomes and Measures At baseline, most patients had an echocardiogram and subsets of patients underwent SPECT and/or CMR. Left ventricular ejection fraction was measured by a core laboratory for each modality independent of the results of other modalities, and measurements were compared among imaging methods using correlation, Bland-Altman plots, and coverage probability methods. Association of LVEF by each method and death was assessed. Results A total of 2032 patients (mean [SD] age, 60.9 [9.6] years; 1759 [86.6%] male) with baseline LVEF data were included. Correlation of LVEF between modalities was r = 0.601 (for biplane echocardiography and SPECT [n = 385]), r = 0.493 (for biplane echocardiography and CMR [n = 204]), and r = 0.660 (for CMR and SPECT [n = 134]). Bland-Altman plots showed only moderate agreement in LVEF measurements from all 3 core laboratories with no substantial overestimation or underestimation of LVEF by any modality. The percentage of observations that fell within a range of 5% ranged from 43% to 54% between different imaging modalities. Conclusions and Relevance In this international multicenter study of patients with coronary artery disease and reduced LVEF, there was substantial variation between modalities in LVEF determination by core laboratories. This variability should be considered in clinical management and trial design. Trial Registration Clinicaltrials.gov Identifier: NCT00023595, This multicenter diagnostic study determines the intermodality variability of left ventricular ejection fraction (LVEF) measured by echocardiography, gated single-photon emission computed tomography (SPECT), and cardiovascular magnetic resonance (CMR) in patients with coronary artery disease and left ventricular dysfunction.

Background: Female sex is conventionally considered a risk factor for coronary artery bypass grafting (CABG) and has been included as a poor prognostic factor in multiple cardiac operative risk evaluation scores. We aimed to investigate the association of sex and the long-term benefit of CABG in patients with ischemic left ventricular dysfunction enrolled in the prospective STICH trial (Surgical Treatment for Ischemic Heart Failure Study). Methods: The STICH trial randomized 1212 patients (148 [12%] women and 1064 [88%] men) with coronary artery disease and left ventricular ejection fraction ≤35% to CABG+medical therapy (MED) versus MED alone. Long-term (10-year) outcomes with each treatment were compared according to sex. Results: At baseline, women were older (63.4 versus 59.3 years; P =0.016) with higher body mass index (27.9 versus 26.7 kg/m 2 ; P =0.001). Women had more coronary artery disease risk factors (diabetes mellitus, 55.4% versus 37.2%; hypertension, 70.9% versus 58.6%; hyperlipidemia, 70.3% versus 58.9%) except for smoking (13.5% versus 21.8%) and had lower rates of prior CABG (0% versus 3.4%; all P P P =0.002) and cardiovascular mortality (34.3% versus 52.3%; adjusted hazard ratio, 0.65; 95% confidence interval, 0.48–0.89; P =0.006) were significantly lower in women compared with men. With randomization to CABG+MED versus MED treatment, there was no significant interaction between sex and treatment group in all-cause mortality, cardiovascular mortality, or the composite of all-cause mortality or cardiovascular hospitalization (all P >0.05). In addition, surgical deaths were not statistically different (1.5% versus 5.1%; P =0.187) between sexes among patients randomized to CABG per protocol as initial treatment. Conclusions: Sex is not associated with the effect of CABG+MED versus MED on all-cause mortality, cardiovascular mortality, the composite of death or cardiovascular hospitalization, or surgical deaths in patients with ischemic left ventricular dysfunction. Thus, sex should not influence treatment decisions about CABG in these patients. Clinical Trial Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT00023595.