Shmuel Banai

Background: Significant tricuspid regurgitation (TR) leads to right ventricular dysfunction and associated comorbidities. As the receiving chamber for regurgitant volume, the right atrium undergoes significant mechanical remodeling. This study investigated whether right atrial reservoir strain (RArS), a key marker of atrial mechanics, serves as a prognostic indicator for mortality in patients with moderate‐to‐severe TR. Methods: Clinical, laboratory, and echocardiographic data from 289 consecutive patients with TR (grade ≥+3) were analyzed. RArS was evaluated by 2‐dimensional speckle‐tracking echocardiography using semiautomated software (TOMTEC; Philips). The cohort was divided into 2 groups by RArS above or below the median value. Results: A total of 239 patients (mean age 82 years, 55% women) were included in the final study. Median RArS was 11.7%. Compared with patients with higher RArS, patients with RArS below median had a higher rate of atrial fibrillation and worse right ventricular function. Lower RArS was also associated with wider inferior vena cava diameter, abnormal cholestatic liver enzymes, and a higher rate of diuretic use. During a median follow‐up period of 26 months (interquartile range, 8–31), 99 (41%) patients died. Patients with RArS P P =0.04). Conclusions: Impaired RArS assessed by echocardiography is independently associated with all‐cause mortality in patients with moderate–severe TR. Serial measurement of RArS can potentially aid in optimizing timing for intervention in patients with TR.

Background: Coronary microvascular dysfunction (CMD) is increasingly recognized as a contributor to angina and adverse cardiovascular outcomes in patients without obstructive coronary artery disease (CAD). Emerging evidence suggests a pathophysiologic relationship between CMD and atrial fibrillation (AF), potentially mediated by endothelial dysfunction, atrial ischemia, and systemic inflammation. However, few studies have evaluated this association using invasive assessment of coronary microvascular function.Methods: We performed a single-center retrospective analysis of prospectively collected data from consecutive patients undergoing clinically indicated invasive assessment of coronary microvascular function between November 2019 and January 2025. Coronary physiological assessment included fractional flow reserve (FFR), coronary flow reserve (CFR), index of microvascular resistance (IMR), and resistive reserve ratio (RRR). CMD was defined as at least one abnormal parameter: CFR 25, or RRR <3.5.Results: Among 422 patients with non-obstructive CAD who underwent invasive coronary physiological evaluation (median age 69 years; 55% female), CMD was present in 219 (52%). Patients with CMD were older and had a higher prevalence of AF compared with those without CMD (13% vs. 6%, p=0.019). In multivariable analysis, AF (adjusted odds ratio [aOR] 2.99, 95% confidence interval [CI] 1.09–4.33, p=0.029), older age, and ischemic heart disease were independently associated with CMD. Among CMD patients, those with AF had higher left ventricular filling pressures, reduced right ventricular systolic function, and larger left atrial volume index.Conclusions: AF is significantly associated with CMD independent of age and other clinical characteristics. Larger prospective studies are needed to further clarify this relationship

Background: Diabetes and cancer exhibit a high likelihood of co‐occurrence. Diabetes serves as a risk factor for various forms of cancer and is associated with a poorer prognosis. SGLT2 (sodium‐glucose cotransporter 2) inhibitors (SGLT2i) are effective antidiabetic therapies associated with reduced all‐cause mortality in the general population; however, data among the population with cancer are scarce. We aimed to assess the safety and efficacy of SGLT2i therapy among patients with diabetes and cancer. Methods: A large retrospective, single‐center study including 849 patients diagnosed with diabetes and active cancer. Patients were divided into 2 groups: 169 patients treated with SGLT2i before cancer diagnosis and 680 patients SGLT2i naive. The primary end point was all‐cause mortality. The secondary end point was the composite of cardiovascular outcomes, including heart failure, acute coronary syndrome, and arrhythmias. Results: After a median follow‐up of 48 months (interquartile range, 27–72), all‐cause mortality was significantly lower in the SGLT2i group (67% versus 53%, P =0.001). Multivariable Cox regression identified SGLT2i as an independent predictor of reduced all‐cause mortality (hazard ratio, 0.676 [95% CI, 0.532–0.860], P =0.001). Cardiovascular outcomes were higher in the SGLT2i group (28% versus 16%, P =0.001), driven by increased heart failure events (14% versus 7%, P =0.008). After propensity score matching, SGLT2i remained a significant predictor of reduced mortality ( P =0.016), with no significant differences in cardiovascular outcome ( P =0.067). Conclusions: SGLT2i was associated with lower all‐cause mortality in patients diagnosed with diabetes and cancer. Randomized clinical trials are needed to confirm these findings and explore the underlying mechanism.

BACKGROUND: The underlying mechanisms responsible for the clinical benefits following coronary sinus narrowing and pressure elevation remain unclear. The present study aims to investigate whether coronary sinus narrowing improves the indexes of coronary microcirculatory function. METHODS: Patients with refractory angina who had a clinical indication for reducer implantation underwent invasive physiological assessments before and 4 months after the procedure. The primary outcome was the change in the values of the index of microcirculatory resistance. Secondary end points included changes in coronary flow reserve and the resistive resistance ratio values. Angina status was assessed with the Canadian Cardiology Society class and the Seattle Angina Questionnaire. RESULTS: Twenty-four patients with a history of obstructive coronary artery disease and prior coronary revascularization (surgical and percutaneous) treated with reducer implantation were enrolled, and 21 of them (87%) underwent repeated invasive coronary physiological assessment after 4 months. The index of microcirculatory resistance values decreased from 33.35±19.88 at baseline to 15.42±11.36 at 4-month follow-up ( P P =0.016). Coronary flow reserve increased from 2.46±1.52 to 4.20±2.52 (mean difference, 1.73 [95% CI, 0.51–2.96]). Similar findings were observed for resistive resistance ratio values. Overall, 16 patients (76.1%) had an improvement of 1 Canadian Cardiology Society class. Seattle Angina Questionnaire summary score increase of around 3 points (3.01 [95% CI, 1.39–4.61]). CONCLUSIONS: Coronary sinus reduction implantation is associated with a significant improvement in the parameters of coronary microcirculatory function. These findings provide insights into the improvement of angina symptoms and may have implications for the treatment of coronary microvascular dysfunction. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT05174572.

Aim: We used a combined stress echocardiography and cardiopulmonary exercise test (CPET) to explore effort intolerance in peripheral arterial disease (PAD) patients. Methods: Twenty-three patients who had both PAD and coronary artery disease (CAD) were compared with twenty-four sex- and age-matched CAD patients and fifteen normal controls using a symptom-limited ramp bicycle CPET on a tilting dedicated ergometer. Echocardiographic images were obtained concurrently with gas exchange measurements along predefined stages of exercise. Oxygen extraction was calculated using the Fick equation at each activity level. Results: Along the stages of exercise (unloaded; anaerobic threshold; peak), in PAD + CAD patients compared with CAD or controls, diastolic function worsened (p = 0.051 and p = 0.013, respectively), and oxygen consumption (p < 0.001 and p < 0.001, respectively) and oxygen pulse (p = 0.0024 and p = 0.0027, respectively) were reduced. Notably, oxygen pulse was blunted due to an insufficient increase in both stroke volume (p = 0.025 and p = 0.028, respectively) and peripheral oxygen extraction (p = 0.031 and p = 0.038, respectively). Chronotropic incompetence was more prevalent in PAD patients and persisted after correction for beta-blocker use (62% vs. 42% and 11%, respectively). Conclusions: In PAD patients, exercise limitation is associated with diastolic dysfunction, chronotropic incompetence and peripheral factors.

Funding Acknowledgements: Type of funding sources: None. Background: Among Patients with myocardial infarction hospitalized patients, deterioration of renal function resulting in acute kidney injury (AKI) is an important complication, associated with increased length of hospital stay, morbidity and mortality. Given large variation in care for AKI patients and poor outcomes of AKI, the interest in implementing care bundles for AKI is growing. Several reports suggested that compliance with AKI bundles among hospitalized patients resulted in better kidney and patient outcomes non, however, included acute cardiac patients. Purpose: We investigated the effect of AKI care bundle (AKI-CB ) utilization on the incidence and renal outcomes of AKI in a large cohort of myocardial infarction patients treated percutaneous coronary intervention (PCI). Methods: We Included ST elevation myocardial infarction (STEMI) patients admitted to the cardiac intensive care unit following PCI between January 2008- December 2020. From January 2016 AKI- CB was implemented in our cardiac intensive care unit. AKI-CB consisted of simple standardized investigations and interventions, reminding clinicians of the importance of early AKI detection, management, via strict monitoring of serum creatinine and urine analysis, planning investigations and treatment and guidance about seeking nephrologist advice. .Patients' records were evaluated for the occurrence of AKI, its severity, AKI recovery, length of hospital stay and long term mortality before and after the implementation of AKI-CB. Results: 2646 patients were included (1945 patients in the years 2008-2015 and 705 patients in the years 2016-2020). Overall, 232 AKI episodes occurred within the study period (232/2646, 8.7%). Implementation of care bundles resulted in a decrease in the occurrence of AKI from 190/1945 ( 10%) to 42/705 (6%); P1 (20% vs. 25% ; p=0.07), higher AKI recovery ( 62% vs. 45% , p=0.001) and reduction in the length of hospital stay ( 5.2± 6 days vs. 5.9 ± 5 days ; p=0.02). Over a median follow up period of 48 month, mortality was significantly lower following implementation of AKI-CB ( 3.7% vs. 5.8%,p=0.002,figure 1). Using a multivariable regression model, the use of care bundles resulted in a 45% decrease in the relative risk for AKI (HR 0.55, 95% CI 0.37-0.82, p=0.003; figure 2). Conclusion: Among STEMI patients, compliance with AKI-CB was independently associated with a decrease in AKI occurrence and better renal outcomes following an AKI event. Further interventions are required to improve utilization of the AKI-CB.

Funding Acknowledgements: Type of funding sources: None. Background: Positive fluid balance has been associated with adverse outcomes in patients admitted to intensive care units (ICU). Urine output (UO) is used both to assess deterioration of renal function as well as for management of fluid balance in patients admitted to the general ICU. In the cardiac ICU, patients admitted for acute decompensated heart failure (ADHF) are at high risk for type I cardio-renal syndrome and increased morbidity and mortality. Studies have shown that poor fluid management in these patients contributes to worse outcomes in this patient population (1). Aim: To investigate the possible effect of real-time monitoring of UO trends on the individualized pharmacologic management, fluid balance, and clinical outcomes of patients admitted to the cardiac ICU with ADHF. Methods: We performed a case series of 35 patients admitted to the cardiac ICU from July 2021 and January 2022 with ADHF. Their standard Foley catheter was connected to an electronic monitoring system (Clarity-RMS sensor kit) that continuously monitors UO in real-time. Its technology is described elsewhere (2). The UO monitoring system displays UO trends on the consoles that are updated in real-time. UO trends were utilized to detect dynamic changes in urine output and guide an individualized approach for the pharmacologic management of each patient, based on blood pressure, hourly UO and total fluid balance. Daily and accumulated fluid balance was registered at up to 72 hours following admission. Patient outcomes included incidence of acute kidney injury (AKI), as defined by the KDIGO criteria for changes in serum creatinine (SCr), and 30-day mortality. The case series group was than compared to a historical group of 35 matched controlled patients admitted between 2018-2019. Patients were matched according to cause of admission, age and glomerular filtration rate. Results: Mean age was 71 ± 11 years and 49 (70%) were men. Patients in the electronic urinary monitoring cohort demonstrated significantly more negative daily and cumulative fluid balance as compared to the historical cohort, (P<0.001 for all, Figure 1). Incidence of AKI and AKI combined with 30-day mortality was significantly lower in the electronic UO monitoring cohort (23% vs. 57%, p<0.001, and 34% vs. 63%, p<0.001, respectively). These changes were more prominent in the subgroup of patients with chronic kidney disease (CKD) (Figure 2). Conclusion: We demonstrated that real time monitoring of UO trends may be used for goal-directed care for the prevention of fluid overload and adverse outcomes in patients with ADHF. Further studies on larger populations are required to validate the potential utility of UO trending in the management of critically ill patients with ADHF.