Advancements in 3D Transoesophageal Echocardiography (TOE) and Computed Tomography (CT) for Stroke Prevention in Left Atrial Appendage Occlusion Interventions.

Left atrial appendage occlusion (LAAO) has emerged as a highly effective alternative to oral anticoagulation for stroke prevention in patients with non-valvular atrial fibrillation. Precise pre-procedural planning and meticulous post-procedural follow-up are essential for achieving successful LAAO outcomes. This review explores the latest advancements in three-dimensional (3D) transoesophageal echocardiography (TOE) and computed tomography (CT) imaging modalities, which have considerably improved the planning, intra-procedural guidance, and follow-up processes for LAAO interventions.

Smartphone-Based Remote Monitoring in Heart Failure With Reduced Ejection Fraction: Retrospective Cohort Study of Secondary Care Use and Costs.

Background: Despite effective therapies, the economic burden of heart failure with reduced ejection fraction (HFrEF) is driven by frequent hospitalizations. Treatment optimization and admission avoidance rely on frequent symptom reviews and monitoring of vital signs. Remote monitoring (RM) aims to prevent admissions by facilitating early intervention, but the impact of noninvasive, smartphone-based RM of vital signs on secondary health care use and costs in the months after a new diagnosis of HFrEF is unknown.

Restricted Use of Echocardiography in Suspected Endocarditis during COVID-19 Lockdown: A Multidisciplinary Team Approach.

Background: Infective endocarditis (IE) is challenging to manage in the COVID-19 lockdown period, in part given its reliance on echocardiography for diagnosis and management and the associated virus transmission risks to patients and healthcare workers. This study assesses utilisation of the endocarditis team (ET) in limiting routine echocardiography, especially transoesophageal echocardiography (TOE), in patients with suspected IE, and explores the effect on clinical outcomes.

Methods: All patients discussed at the ET meeting at Imperial College Healthcare NHS Trust during the first lockdown in the UK (23 March to 8 July 2020) were prospectively included and analysed in this observational study.

New horizons in cardiogeriatrics: geriatricians and heart failure care-the custard in the tart, not the icing on the cake.

Heart failure (HF) can be considered a disease of older people. It is a leading cause of hospitalisation and is associated with high rates of morbidity and mortality in the over-65s. In 2012, an editorial in this journal detailed the latest HF research and guidelines, calling for greater integration of geriatricians in HF care.

COVID-19 and its impact on the cardiovascular system.

Objectives: The clinical impact of SARS-CoV-2 has varied across countries with varying cardiovascular manifestations. We review the cardiac presentations, in-hospital outcomes and development of cardiovascular complications in the initial cohort of SARS-CoV-2 positive patients at Imperial College Healthcare National Health Service Trust, UK.

Methods: We retrospectively analysed 498 COVID-19 positive adult admissions to our institute from 7 March to 7 April 2020.

Urinary drug metabolite testing in chronic heart failure patients indicates high levels of adherence with life-prolonging therapies.

Aims: Despite medical therapy for heart failure (HF) having proven benefits of improving quality of life and survival, many patients remain under-treated. This may be due to a combination of under-prescription by medical professionals and poor adherence from patients. In HF, as with many other chronic diseases, adherence to medication can deteriorate over time particularly when symptoms are well controlled.

Adapting the role of handheld echocardiography during the COVID-19 pandemic: A practical guide.

The COVID-19 pandemic has altered our approach to inpatient echocardiography delivery. There is now a greater focus to address key clinical questions likely to make an immediate impact in management, particularly during the period of widespread infection. Handheld echocardiography (HHE) can be used as a first-line assessment tool, limiting scanning time and exposure to high viral load.

The effect of concomitant COVID-19 infection on outcomes in patients hospitalized with heart failure.

Aims: Patients with cardiovascular disease appear particularly susceptible to severe COVID-19 disease, but the impact of COVID-19 infection on patients with heart failure (HF) is not known. This study aimed to quantify the impact of COVID-19 infection on mortality in hospitalized patients known to have HF.

Methods And Results: We undertook a retrospective analysis of all patients admitted with a pre-existing diagnosis of HF between 1 March and 6 May 2020 to our unit.

Artificial Intelligence, Data Sensors and Interconnectivity: Future Opportunities for Heart Failure.

A higher proportion of patients with heart failure have benefitted from a wide and expanding variety of sensor-enabled implantable devices than any other patient group. These patients can now also take advantage of the ever-increasing availability and affordability of consumer electronics. Wearable, on- and near-body sensor technologies, much like implantable devices, generate massive amounts of data.

Improving haemodynamic optimization of cardiac resynchronization therapy for heart failure.

Objective: Optimization of cardiac resynchronization therapy using non-invasive haemodynamic parameters produces reliable optima when performed at high atrial paced heart rates. Here we investigate whether this is a result of increased heart rate or atrial pacing itself.

Approach: Forty-three patients with cardiac resynchronization therapy underwent haemodynamic optimization of atrioventricular (AV) delay using non-invasive beat-to-beat systolic blood pressure in three states: rest (atrial-sensing, 66  ±  11 bpm), slow atrial pacing (73  ±  12 bpm), and fast atrial pacing (94  ±  10 bpm).

Distinct impacts of heart rate and right atrial-pacing on left atrial mechanical activation and optimal AV delay in CRT.

Background: Controversy exists regarding how atrial activation mode and heart rate affect optimal atrioventricular (AV) delay in cardiac resynchronization therapy. We studied these questions using high-reproducibility hemodynamic and echocardiographic measurements.

Methods: Twenty patients were hemodynamically optimized using noninvasive beat-to-beat blood pressure at rest (62 ± 11 beats/min), during exercise (80 ± 6 beats/min), and at three atrially paced rates: 5, 25, and 45 beats/min above rest, denoted as A , A , and A , respectively.

Cardiac resynchronization therapy and AV optimization increase myocardial oxygen consumption, but increase cardiac function more than proportionally.

Background: The mechanoenergetic effects of atrioventricular delay optimization during biventricular pacing ("cardiac resynchronization therapy", CRT) are unknown.

Methods: Eleven patients with heart failure and left bundle branch block (LBBB) underwent invasive measurements of left ventricular (LV) developed pressure, aortic flow velocity-time-integral (VTI) and myocardial oxygen consumption (MVO2) at 4 pacing states: biventricular pacing (with VV 0 ms) at AVD 40 ms (AV-40), AVD 120 ms (AV-120, a common nominal AV delay), at their pre-identified individualised haemodynamic optimum (AV-Opt); and intrinsic conduction (LBBB).

Results: AV-120, relative to LBBB, increased LV developed pressure by a mean of 11(SEM 2)%, p=0.

Evidence-based recommendations for PISA measurements in mitral regurgitation: systematic review, clinical and in-vitro study.

Background: Guidelines for quantifying mitral regurgitation (MR) using "proximal isovelocity surface area" (PISA) instruct operators to measure the PISA radius from valve orifice to Doppler flow convergence "hemisphere". Using clinical data and a physically-constructed MR model we (A) analyse the actually-observed colour Doppler PISA shape and (B) test whether instructions to measure a "hemisphere" are helpful.

Methods And Results: In part A, the true shape of PISA shells was investigated using three separate approaches.

Multinational evaluation of the interpretability of the iterative method of optimisation of AV delay for CRT.

Background: AV delay optimisation of biventricular pacing devices (cardiac resynchronisation therapy, CRT) is performed in trials and recommended by current guidelines. The Doppler echocardiographic iterative method is the most commonly recommended. Yet whether it can be executed reliably has never been tested formally.

The limit of plausibility for predictors of response: application to biventricular pacing.

Objectives: We sought a method for any reader to quantify the limit, imposed by variability, to sustainably observable R(2) between any baseline predictor and response marker. We then apply this to echocardiographic measurements of mechanical dyssynchrony and response.

Background: Can mechanical dyssynchrony markers strongly predict ventricular remodeling by biventricular pacing (cardiac resynchronization therapy)?

Methods: First, we established the mathematical depression of observable R(2) arising from: 1) spontaneous variability of response markers; and 2) test-retest variability of dyssynchrony measurements.

Improvement in coronary blood flow velocity with acute biventricular pacing is predominantly due to an increase in a diastolic backward-travelling decompression (suction) wave.

Background: Normal coronary blood flow is principally determined by a backward-traveling decompression (suction) wave in diastole. Dyssynchronous chronic heart failure may attenuate suction, because regional relaxation and contraction overlap in timing. We hypothesized that biventricular pacing, by restoring left ventricular (LV) synchronization and improving LV relaxation, might increase this suction wave, improving coronary flow.

Fully automatable, reproducible, noninvasive simple plethysmographic optimization: proof of concept and potential for implantability.

Background: Hemodynamic optimization of cardiac resynchronization therapy (CRT) can be achieved reproducibly and--with bulky, nonimplantable equipment--noninvasively. We explored whether a simple photoplethysmogram signal might be used instead.

Method: Twenty patients (age 65 ± 12) with CRT underwent automatic atrioventricular (AV) delay optimization, using a multiple-transitions protocol, at two atrially paced heart rates: just above sinus rate ("slow ApVp," 77 ± 11 beats per minute [bpm]) and 100 bpm ("fast ApVp").

A systematic approach to designing reliable VV optimization methodology: assessment of internal validity of echocardiographic, electrocardiographic and haemodynamic optimization of cardiac resynchronization therapy.

Background: In atrial fibrillation (AF), VV optimization of biventricular pacemakers can be examined in isolation. We used this approach to evaluate internal validity of three VV optimization methods by three criteria.

Methods And Results: Twenty patients (16 men, age 75 ± 7) in AF were optimized, at two paced heart rates, by LVOT VTI (flow), non-invasive arterial pressure, and ECG (minimizing QRS duration).

A novel fully automated method for mitral regurgitant orifice area quantification.

Background: Effective regurgitant orifice area (EROA) in mitral regurgitation (MR) is difficult to quantify. Clinically it is measured using the proximal isovelocity surface area (PISA) method, which is intrinsically not automatable, because it requires the operator to manually identify the mitral valve orifice. We introduce a new fully automated algorithm, ("AQURO"), which calculates EROA directly from echocardiographic colour M-mode data, without requiring operator input.

Cardiac resynchronization therapy is certainly cardiac therapy, but how much resynchronization and how much atrioventricular delay optimization?

Cardiac resynchronization therapy has become a standard therapy for patients who are refractory to optimal medical therapy and fulfill the criteria of QRS >120 ms, ejection fraction <35% and NYHA class II, III or IV. Unless there is some other heretofore unrecognized effect of pacing, the benefits of atrio-biventricular pacing on hard outcomes observed in randomized trials can only be attributed to the physiological changes it induces such as increases in cardiac output and/or reduction in myocardial oxygen consumption leading to an improvement in cardiac function efficiency. The term "Cardiac Resynchronization Therapy" for biventricular pacing presupposes that restoration of synchrony (simultaneity of timing) between left and right ventricles and/or between walls of the left ventricle is the mechanism of benefit.