Epicardial adipose tissue and nonvalvular atrial fibrillation

Background Several studies revealed the relationship between epicardial fat tissue (EF) and development of atrial fibrillation (AF). Though pathophysiological mechanisms are not clear enough, the anatomy and location EF as a part of visceral adiposity tissue could lead to proinflammatory and fibrotic changes in atrial myocardium. Purpose To evaluate the paracrine effects of EF and detect the association of tissue Doppler imaging (TDI) parameters, EF thickness by cardiac magnetic resonance tomography (CMR) and biochemical markers of fibrosis and inflammation in patients with nonvalvular AF without concomitant coronary artery disease. Methods Thirty-nine patients with idiopathic paroxysmal AF, normal or slightly enlarged left atria (LA) (mean LA diameter 4,5±0,6cm) were included. The mean age was 50,8±13,9 y.o., 19 (49%) were men. The absence of coronary lesions was confirmed by angiography in all cases. Besides standard ECG and ECHO, all patients underwent TDI and CMR with late gadolinium enhancement. EP thickness at anterior left ventricular (LV) wall was estimated by CMR. The myocardial fibrotic and proinflammatory biomarkers levels - matrix metalloproteinases (MMP-2, MMP-9), tissue inhibitor of matrix metalloproteinase-1 (TIMP-1) were estimated. Kendall rank correlation coefficient was used. If the |τ| >Tcr, the correlation ranked as statistically significant. Results The epicardial fat thickness was associated with TIMP-1 plasma level (τ=0,71; Tcr=0,18) and MMP-9 (τ=0,65; Tcr=0,16). Among clinical factors weight was slightly associated with fat thickness (τ=0,33; Tcr=0,26). Besides, we found correlation of MMP-9, TIMP-1 with E/e' by TDI (τ=0,65; Tcr=0,16 and τ=0,56; Tcr=0,21, relatively); and with maximal systolic strain of lateral LV wall (τ=−0,37; Tcr=0,18 and τ=−0,44; Tcr=0,16, relatively) and interventricular septum (τ=−0,36; Tcr=0,18 and τ=−0,44; Tcr=0,16, relatively). Conclusion The epicardial fat thickness by CMR is significantly associated with myocardial fibrosis markers (MMP-9, TIMP-1) in patients with AF without structural heart disease. The increasing levels of MMP-9 and TIMP-1 are associated with LV local contractility disturbances by TDI in patients with AF. This association demonstrates the paracrine effect of EF, which could lead to atrial remodeling and formation AF substrate even in patients without valvular and ischemic heart disease and with normal or slightly enlarged LA FUNDunding Acknowledgement Type of funding sources: None.

Predicting the need of aortic valve surgery in patients with chronic aortic regurgitation: a comparison between cardiovascular magnetic resonance imaging and transthoracic echocardiography

To compare the ability of cardiac magnetic resonance tomography (CMR) and transthoracic echocardiography (TTE) to predict the need for valve surgery in patients with chronic aortic regurgitation on a mid-term basis. 66 individuals underwent assessment of aortic regurgitation (AR) both in CMR and TTE between August 2012 and April 2017. The follow-up rate was 76% with a median of 5.1 years. Cox proportional hazards method was used to assess the association of the time-to-aortic-valve-surgery, including valve replacement and reconstruction, and imaging parameters. A direct comparison of most predictive CMR and echocardiographic parameters was performed by using nested-factor-models. Sixteen patients (32%) were treated with aortic valve surgery during follow-up. Aortic valve insufficiency parameters, both of echocardiography and CMR, showed good discriminative and predictive power regarding the need of valve surgery. Within all examined parameters AR gradation derived by CMR correlated best with outcome [χ2 = 27.1; HR 12.2 (95% CI: 4.56, 36.8); (p < 0.0001)]. In direct comparison of both modalities, CMR assessment provided additive prognostic power beyond echocardiographic assessment of AR but not vice versa (improvement of χ2 from 21.4 to 28.4; p = 0.008). Nested model analysis demonstrated an overall better correlation with outcome by using both modalities compared with using echo alone with the best improvement in the moderate to severe AR range with an echo grade II out of III and a regurgitation fraction of 32% in CMR. This study corroborates the capability of CMR in direct quantification of AR and its role for guiding further treatment decisions particularly in patients with moderate AR in echocardiography.

Late diagnosed DiGeorge syndrome in a 44-year-old female: a rare cause for recurrent syncopes in adulthood—a case report

Background DiGeorge syndrome, also known as ‘CATCH 22’, is the most common deletion in humans and is one of the velocardiofacial syndromes. It is characterized by a specific facial phenotype, and structural and functional abnormalities in the cardiac and endocrine systems. One form of endocrine system dysfunction is hypocalcaemia, which causes arrhythmic events and can result in a transient loss of consciousness. We present a case highlighting the late diagnosis of DiGeorge syndrome in a patient with recurrent episodes of syncope due to suspected arrhythmic events secondary to hypocalcaemia. Case summary A 44-year-old woman was referred for further investigation of recurrent syncope episodes and documented transient QT-prolongation with hypocalcaemia. Previous detailed cardiological examination, including invasive procedures such as coronary angiography and cardiac magnetic resonance tomography, was unremarkable. Slight characteristic facial dysmorphia and transient hypocalcaemia were strongly suggestive of DiGeorge syndrome. The diagnosis was confirmed by genetic testing. Calcium substitution was initiated and no recurrent episodes of syncope or arrhythmic events were reported during 12 months of follow-up. Discussion Clinical presentation and time of manifestation of the DiGeorge syndrome varies widely depending on the mutation expression extent. An atypical disease course may delay the diagnosis and appropriate management of affected patients. In this case, confirmation of the diagnosis allowed the initiation of appropriate treatment, reducing the risk for further events. Given that syncope and arrhythmia can be the first and only manifestation of late-onset DiGeorge syndrome, specialists in adult cardiology need to be aware of this presentation.

CARDIOVASCULAR COMPLICATIONS IN COVID-19: CASE REPORT AND CONCISE REVIEW

Cardiovascular system is one of the most vulnerable during COVID-19. The main mechanisms of cardiac injury are: direct myocardial damage, mediated by viral binding to angiotensin-converting-ensyme-2, cardiac microvascular damage and thrombosis, caused by hypercoagulability. Cardiovascular complications such as acute and chronic myocardial injury, myocarditis, myocardial infarction, pulmonary embolism, stress-cardiomyopathy, arterial and venous thrombosis and arrhythmic disorders are common among COVID-19 patients. Myocardial injury in COVID-19 could have different mechanisms and may occur at early and late stages of the COVID-19 disease, resulting in myocardial dysfunction and heart failure. Echocardiography is a first-line noninvasive imaging method to assess the cardiac injury during COVID 19 while cardiac magnetic resonance imaging is the best to identify myocardial oedema, inflammation and fibrosis. In this article we presented the analysis of experience of cardiologists in different countries concerning diagnostics ant treatment of COVID-19 related cardiovascular pathology and case reports from our own experience concerning cardiovascular complications of COVID-19. Laboratory diagnostics (troponin and brain-natriuretic peptide) and noninvasive imaging methods (echocardiography and cardiac magnetic resonance tomography) are essential to confirm the diagnosis of cardiac injury in COVID-19 and to evaluate the effect of the treatment. Long-term follow-up studies are needed to understand better the COVID-19 related cardiac pathology.