ABSTRACT

Background: Cardiac remodeling (CR) refers to the molecular, interstitial, and cellular alterations in the shape, size, mass, and function of the heart following an injury that may be physiological or pathological such as due to increased workload after exercise or myocardial infarction (MI), aortic stenosis, myocarditis, hypertension, or valvular regurgitation. Initially an adaptive response to preserve cardiac function, CR can become maladaptive through reduced SERCA2a activity, and increased oxidative stress, fibrosis, inflammation, and apoptosis eventually leading to cardiac dysfunction. Semaglutide is a GLP-1 receptor agonist mainly used in managing type-2 diabetes and aiding in weight loss. It has also shown potential in reducing cardiac hypertrophy and improving cardiac health which will be explored in this review.

Aims: To explore the effects of semaglutide on cardiac remodeling, mainly its impact on cardiac hypertrophy, inflammation, fibrosis, oxidative stress, and apoptosis in mice models.

Methods: The literature search was conducted by making use of databases such as PubMed, Google Scholar, Springer Link, Cochrane, Nature, JACC, and Science Direct deploying keywords that included ‘semaglutide’, ‘cardiac remodeling’, ‘heart failure’, ‘HFpEF’, and ‘cardiac hypertrophy’. Studies on male and female mice discussing the effects of semaglutide on hypertrophy, oxidative stress, inflammatory markers, and cardiac remodeling were included. Those lacking a proper control group, with subjects other than mice and focusing effects of semaglutide for other conditions were excluded. Data were extracted using the PICO framework.

Results: Semaglutide consistently reduced body weight, fat mass, tissue-specific inflammation, apoptosis, and oxidative stress in mice. It substantially mitigates cardiac hypertrophy by reducing heart weight, and left ventricular mass, and improved cellular architecture leading to better cardiac output. Inflammatory markers critical in the pathogenesis of CR such as TNF-α, IL-6, atrial natriuretic peptide along with others are also markedly reduced on treatment with semaglutide. It also significantly attenuates fibrosis on both molecular and histologic levels by decreasing collagen deposition and reducing markers of fibrosis such as collage 1a1 and collagen 3a1. Moreover, it reduces oxidative stress by lowering levels of NOX2 and malondialdehyde, key indicators of oxidative burst. Upregulation of antioxidant pathways along with a rise in antioxidant enzymes such as superoxide dismutase (SOD) and catalase is seen. Furthermore, administration of semaglutide also mitigates apoptosis by significantly reducing BAX and slightly decreasing caspase-3, two of the important apoptosis-related proteins.

Conclusion: Results demonstrate the significant potential of semaglutide for managing cardiac remodeling (CR), particularly in obese patients. It showed considerable cardioprotective effects through the regulation of hypertrophy, oxidative stress, inflammation, apoptosis, fibrosis, and lipid metabolism. These benefits are suggestive of its viability as a promising therapeutic agent for cardiac disorders. However, more clinical trials especially on humans might be required to validate these findings and determine the right dosing.

Background: Adopting healthy nutritional behavior in patients with Heart Failure (HF) can play a crucial role in controlling symptoms of the disease. To develop effective interventions, it is recommended to recognize significant determinants of nutritional behavior based on theoretical frameworks in behavioral sciences and utilize valid instruments. The aim of this study was to develop and validate measurement tools for assessing the determinants of nutritional behavior among patients with HF based on the Theory of Planned Behavior (TPB) variables.

Methods: In this psychometrics study, a preliminary instrument based on the TPB with five subscales was created. Additionally, an instrument for measuring the nutritional behavior of HF patients was developed. The face validity and content validity of the instruments were assessed using both quantitative and qualitative methods. The factor structure of the instrument for assessing TPB variables was examined through Exploratory Factor Analysis (EFA) using a sample of 330 patients with HF. Furthermore, the reliability of the instruments was evaluated.

Results: In the stages of face validity and content validity assessment, 13 items were removed from the TBP instrument, and 14 items were modified in the two instruments. The EFA revealed that the 12 items of the TPB variables could be classified into 4 subscales, namely behavioral intention, attitude, and perceived behavioral control. The results of the EFA indicated that the Kaiser-Meyer-Olkin and Bartlett’s test of sphericity of the instrument were acceptable. These factors accounted for 87.03% of the variance. The TPB instrument subscales demonstrated acceptable levels of reliability, as indicated by Cronbach's alpha. Both instruments had acceptable levels of intraclass correlation coefficient.

Conclusions: The results showed that the developed instruments were two valid and reliable tools for assessing the determinants of adopting nutritional behavior among patients with HF, utilizing TPB variables. These instruments can be used in conducting needs assessments and developing education intervention efforts for patients with HF.

Background and objectives: Atrial Fibrillation (AF) is the most prevalent persistent arrhythmia with a great burden on people’s health and society. Due to associations between psychological factors and AF in previous studies, this study was conducted to investigate the association between perceived stress and arrhythmia.

Methods: In this case-control study, participants were recruited from the outpatient clinic of Rajaie Cardiovascular, Medical and Research Center in Tehran, Iran, between May 2021 and September 2021 based on eligible criteria. Data were collected through face-to-face interviews by trained research nurses using the appropriate checklists. The stress level of participants was evaluated using the Perceived Stress Scale (PSS). Data were analyzed by Chi-square, independent T-test, and logistic regression model in SPSS 16.

Results: One hundred fifty-five cases with arrhythmia and 144 controls were recruited for this study. The mean score of the perceived stress was 30.6 in cases and 25.07 in controls (P< 0.001). Stress-related symptoms including palpitation and chest discomfort were more common in patients with arrhythmia than healthy controls (P = 0.015 and P< 0.001 respectively). The risk of arrhythmia was independently associated with sex, diabetes mellitus, dyslipidemia, hypothyroidism, cardiomyopathy, concentration difficulty, chest discomfort, and stress score in the multivariate logistic regression model.

Interpretation and conclusions: The results of this study demonstrate that AF arrhythmia is strongly associated with psychological stress and higher perceived stress scores. Interventions targeting reducing stress in those who are at high risk of developing AF are beneficial.

Background: Heart failure is still a global health challenge that requires a deeper understanding of factors affecting mortality and quality of life. Considering that few studies have investigated the relationship between albumin serum level and the outcome of patients with chronic heart failure, especially their quality of life, we decided to conduct this study.

Methods: In this prospective study on hospitalized patients with chronic ischemic and non-ischemic heart failure, demographic information and laboratory findings, and ejection fraction (EF) were evaluated. EF less than 40% were included in the study as heart failure. Serum albumin level was measured. Patients completed the Minnesota Heart Failure Quality of Life Questionnaire (MLHFQ) in the same hospitalization. After discharge, the patients were followed up for 6 months.

Results: A total of 102 people were included in this study. 59.8% of the patients had a history of chronic heart failure. There was a weak but significant inverse relationship between serum albumin level and MLHFQ index (r=-0.263, p=0.018). Also, there was no significant difference between serum albumin level and MLHFQ index in dead and alive people (p=0.816 and p=0.12 respectively).

Conclusion: Our results show that lower serum albumin levels are weakly but significantly associated with reduced quality of life in heart failure patients, as indicated by the MLHFQ scores. However, no significant relationship was observed between serum albumin levels and mortality within the 6-month follow-up. These findings suggest that while hypoalbuminemia may impact patient quality of life, its role in short-term mortality is less clear.

Introduction: The echocardiographic planimetry is the primary and most available modality for diagnosing Rheumatic mitral stenosis (MS). However, this approach is significantly reliant on the examination technique. The echocardiographic evaluation of MS should also include RV function evaluation for its prognostic role. In this study, we hypothesized that the assessment of RV function using speckle tracking echocardiography (STE) might also have a diagnostic role in determining the severity of MS.

Methods and materials: This cross-sectional study included 47 patients with a definite diagnosis of rheumatic MS. The echocardiographic data were recorded and evaluated offline by an expert cardiologist. The right ventricular global longitudinal strain (RVGLS), right ventricular free wall longitudinal strain (RVFWLS), mitral valve area (MVA) using 2-D planimetry, and other conventional parameters of MS severity were measured. The Statistical Package for Social Science (SPSS) version 26 and Python 3.10.6 were used to analyze and visualize the collected data.

Results: Our analysis showed both RVGLS (R=-0.598, p <0.05) and RVFWLS (R=-0.620, p <0.05) were significantly correlated with MVA. The mean RVGLS in the severe and progressive MS patients were -14.44 ± 4.36 and -18.12 ± 3.25 (p=0.017). The mean RVFWLS values also demonstrated a significant difference between these two groups (-16.3 ± 4.7 vs -20.8 ± 3.2, p=0.005). The area under the curve (AUC) for RVGLS and RVFWLS in detecting severe MS was 0.75 (95% Confidence Interval: 0.64 - 0.86) and 0.78 (95% Confidence Interval: 0.66 - 0.90), respectively.

Conclusion: RVGLS and RVFWLS significantly correlate with MVA and may serve as a tool to assess the severity of rheumatic mitral stenosis in daily clinical practice. RVGLS and RVFWLS have high sensitivity for ruling out severe MS and assessing the severity of MS during routine echocardiographic evaluation.

Background: Infective endocarditis (IE) uncommonly happens right-sided. Furthermore, Streptococcus agalactiae rarely causes IE, in which only 2-9% of bacteremia cases manifest as endocarditis. 

Case presentation: A 30-year-old Lebanese woman came to the emergency room (ER) with a high-grade fever and chills. Blood tests were drawn, urine analysis showed leukocytes in urine, and treatment for urinary tract infection was started accordingly. The patient was hospitalized three days later and transferred to the intensive care unit (ICU); severe right-sided cardiomegaly, flailed tricuspid leaflets with ruptured chordae, and large coaptation deflect were discovered during echocardiography. She was diagnosed with Streptococcus agalactiae right-sided infective endocarditis and underwent tricuspid valvular replacement. Unfortunately, the patient died after suffering from acute decompensated heart failure. 

Conclusion: This is an unusual S. agalactiae right-sided infective endocarditis case found in Lebanon, in which definitive treatment for IE caused by this agent is still limited.

Background: Pregnancy in pulmonary hypertensive female patients is strongly contraindicated because of the high mortality rate according to physiological changes, especially in peri- and postpartum periods, and in case of occurrence, termination at an early stage is recommended. Therefore, our experience with continued pregnancies in patients with pulmonary hypertension are scarce.

Case presentation: This case report presents a young woman diagnosed with multiple bilateral pulmonary hydatid cysts and right ventricular hydatid cyst, who underwent surgical and pharmacologic treatments, but developed pulmonary hypertension due to pulmonary artery obstruction eight years after. According to the unsuitable condition of the patient for surgery, she was a candidate for medical therapy, including Tadalafil, Bosentan, and Eplerenone. After 3 years, despite the advice to avoid pregnancy, the patient got pregnant and at 37 weeks underwent a successful emergent cesarean section due to maternal dyspnea and tachycardia.

Conclusions: We believe that prompt treatment and regular follow-ups in a tertiary care center with a multidisciplinary approach would be crucial in the management of pulmonary hypertensive patients who get pregnant.

Infective endocarditis (IE) is an under-recognized cause of fever that is often missed in preliminary evaluation. This may stem from a lack of vigilance towards IE and using empirical antibiotic therapy to treat fever. As a result, patients often present with complications of IE that warrant surgical intervention. We hereby discuss a case of IE that remained undiagnosed for 2 years, receiving short courses of oral antibiotic therapy for recurrent fever, ultimately developing heart failure due to valve perforation.

Gallbladder and biliary tract diseases may manifest as cardiac symptoms, ischemic ECG changes, and arrhythmias. Although rare, bradyarrhythmia cases induced by cardiobiliary reflex have been linked to acute cholecystitis. This case emphasizes the cardiobiliary reflex as a possible cause of bradyarrhythmia in patients with gallbladder and biliary tract diseases . 

Background: In-stent restenosis (ISR) following percutaneous coronary intervention (PCI) is an unwanted complication in some patients. The etiology is multifactorial, and identifying these factors may help improve long-term outcomes after PCI.

Case summary: We hereby describe two cases of recurrent ISR; case 1 describes the techniques of PCI used over 17 years to manage recurrent ISR of Left Main bifurcation disease, while case 2 highlights the role of coronary artery bypass grafting (CABG) as a treatment modality for recurrent ISR of the right coronary artery.

Discussion: Management of post-PCI recurrent ISR has witnessed multiple advancements over the past decade. Newer technologies like intravascular imaging, plaque or calcium modification techniques, and drug-eluting balloons enable effective management of recurrent ISR.  This article describes possible risk factors for recurrent ISR and discusses various treatment strategies for its management.

Background: A sinus venous atrial septal defect (SVASD) is a type of congenital heart defect that predominantly involves an opening between the Superior Vena Cava (SVC) and the Right Upper Pulmonary Vein (RUPV). Surgical closure of SVASD has been the standard treatment; however, the surgical closure of SVASD is far more complex than mere ASD secundum reconstruction, and complications are more likely. Transcatheter closure of SVASD is an emerging alternative for surgical repair.

Methods: We report five cases of successful transcatheter closure of SVASD and one case of failure that required surgical intervention. All patients underwent pre-procedure Computed Tomography Angiography (CTA) to determine the size and location of the defect and the optimal stent size and position. The SVC stenting was performed using balloon-expandable stents, followed by RUPV angioplasty if needed.

Results:  Final angiograms and pressure measurements in the SVC, RUPV, and Right Atrium (RA) confirmed the absence of residual shunt and pulmonary venous obstruction. One patient experienced stent migration to the pulmonary artery, which necessitated surgical retrieval and defect closure.

Conclusion: The balloon expansion test is not mandatory before stent implantation, as in the case of RUPV obstruction, its flow could be reestablished by ballooning and/or stent implantation within the RUPV with a mild residual shunt which might resolve spontaneously.

Technological refinements and advancements, introduction of newer tools, physician and patient preference for catheter-based techniques have led to an increasing number of endovascular interventions worldwide in the last two decades. Despite these advancements, operators face unforeseen hardware-related complications due to various factors.

Worldwide, cases of broken/dislodged fragment(s) of various hardware (e.g., catheters, guidewires, angioplasty balloons, and stents) have been reported increasingly. These broken fragments may cause life-threatening consequences. Hence, interventionists need to be aware as well as skilled with different retrieval techniques.

Here, we report two cases where successful percutaneous retrieval of broken, dislodged, and embolized angiographic catheters from the coronary and renal arteries were done using two different techniques.

Background: Congenital heart disease (CHD) is a leading cause of morbidity and mortality in children requiring surgery. Accurate mortality prediction post-surgery remains challenging due to the limitations of traditional risk stratification systems. Artificial intelligence (AI) has emerged as a promising tool for enhancing predictive accuracy in this field.

Objective: This systematic review and meta-analysis aimed to evaluate the efficacy of AI in predicting postoperative mortality in patients with CHD.

Methods: Following PRISMA guidelines and PROSPERO registration (CRD42024557722), five databases were systematically searched up to July 16, 2024. Eligible studies included retrospective, prospective, or cross-sectional designs evaluating AI-based models for predicting mortality after CHD surgery. Data were extracted, and study quality was assessed using the PROBAST tool. Pooled sensitivity, specificity, and area under the curve (AUC) were calculated.

Results: Six studies involving 42,536 patients and 11 AI models were included. The pooled AUC was 0.90 (95% CI: 0.88–0.93), with a pooled sensitivity of 0.43 (95% CI: 0.23–0.65) and specificity of 0.96 (95% CI: 0.92–0.98). Subgroup analysis revealed that XGBoost (AUC: 0.93) and Gradient Boosting Machine (AUC: 0.91) had the highest predictive performance. All studies demonstrated a low risk of bias.

Conclusion: XGBoost and GBM, shows high specificity and promising accuracy in predicting postoperative mortality in CHD patients, outperforming traditional scoring systems. Further multicenter, prospective studies are needed to enhance generalizability and clinical implementation.