Edo Y. Birati

Background: ST-elevation myocardial infarction (STEMI) remains a major cause of global mortality. While troponin is the gold-standard biomarker for myocardial injury, a subset of patients presents with troponin levels below the clinical “rule-in” threshold upon hospital admission. The long-term prognostic significance of these initial “low-troponin” presentations in a large-scale population remains insufficiently characterized. Methods: We conducted a retrospective multicenter cohort study using the “KINERET” database, analyzing 8,394 patients diagnosed with STEMI who underwent percutaneous coronary intervention (PCI) at four academic medical centers in Israel between 2016 and 2023. Patients were stratified into two groups based on ESC rule-in criteria for high-sensitivity cardiac troponin (hs-cTn) at admission: a High trop group (above rule-in cutoff) and a Low trop group (below rule-in cutoff). The primary outcome was all-cause mortality at 5 years. Results: Of the 8,394 patients (mean age 68.3±13.3 years; 76% male), 36.5% (n=3,064) presented with troponin levels below the rule-in cutoff. Patients in the High trop group were older and had a higher prevalence of comorbidities, including heart failure (46.7% vs. 28.7%) and chronic kidney disease (13.9% vs. 9%). The Low trop group demonstrated significantly higher survival rates at both 1 year (92.9% vs. 84.0%, p<0.001) and 5 years (85.7% vs. 75.0%, p<0.001). After adjusting for age, sex, and comorbidities in a multivariate Cox regression model, initially elevated troponin remained a robust independent predictor of 5-year mortality (HR 1.15, 95% CI 1.14-1.16, p75, female sex, and chronic kidney disease. Conclusions: STEMI patients presenting with initial troponin levels below the diagnostic rule-in threshold have a significantly better short- and long-term prognosis compared to those with early troponin elevation. Moreover, admission troponin levels serve as a powerful predictor of 5-year mortality and may be used as an independent prognostic factor following STEMI.

Background: Left ventricular (LV) summit is an important origin for ventricular arrhythmias (VAs). However, the complex electroanatomic structure of LV summit and the surrounding anatomic sites makes ablation of this arrhythmia challenging. Aim: In this paper, we review the main strategies to mapping and ablation of LV summit VAs and summarize our experience in this challenging ablation. Methods: To summarize our experience, we included all consecutive patients with outflow VAs referred to our institute for ablation between 2019 and 2024 who were eventually diagnosed with LV summit origin based on electroanatomical mapping and ablation result using stepwise and sequential ablation approach. Results: A total of 38 patients were found to have VAs from LV summit origin. Overall five patients had history of at least one failed ablation. V1 transition was seen in 15 patients, V2 transition in 12 patients, and V3 transition in 11 patients. Four patients had R wave pattern break in lead V2. Ablation was performed from the earliest activation or from one of the adjacent sites using stepwise and sequential approach. Acute suppression of VAs occurred in 35 patients without complications, except one case of pseudoaneurysm of femoral artery. Conclusions: Stepwise and sequential ablation approach can suppress VAs originating from LV summit in most patients.

Heart failure (HF), a prevalent global health issue characterized by the heart’s impaired ability to pump or fill blood, affects millions worldwide and continues to pose significant challenges despite advancements in treatment. This review delves into the critical and increasingly recognized role of inflammation in the development and progression of this complex syndrome. While the incidence of HF has seen a decline in some regions due to improved cardiac care, its overall prevalence is rising, particularly among younger adults and those with heart failure with a preserved ejection fraction (HFpEF). Given the persistently high rates of hospitalization and mortality associated with HF, understanding the underlying mechanisms, including the contribution of inflammation, is crucial for identifying novel therapeutic strategies. Inflammation in heart failure is a multifaceted process involving the activation of the immune system, both innate and adaptive, and encompasses various mechanisms such as the release of pro-inflammatory mediators, endothelial dysfunction, and neurohormonal activation. Myocardial damage triggers the innate immune response, while humoral immunity and chronic systemic inflammation, often linked to cardiovascular risk factors and autoimmune diseases, also play significant roles. Notably, heart failure and inflammation have a reciprocal relationship, with HF itself contributing to inflammatory processes within the cardiac tissue and systemically. Understanding these intricate pathways, including the involvement of specific immune cells and molecular mediators, is essential for comprehending the pathogenesis of heart failure and exploring potential therapeutic interventions. The review further examines various inflammatory biomarkers that have been implicated in heart failure, such as cytokines (including TNF-α and IL-1) and C-reactive protein (CRP). While these markers often correlate with the severity and prognosis of HF, clinical trials targeting specific inflammatory mediators have largely yielded disappointing results, highlighting the complexity of the inflammatory response in this context. The exploration of these biomarkers and the challenges encountered in translating anti-inflammatory strategies into effective treatments underscore the need for continued research to unravel the precise role of inflammation across different HF subtypes and to develop more targeted and effective anti-inflammatory therapies.

Background: Left ventricular (LV) summit is important origin for ventricular arrhythmias (VAs). However, the complex electroanatomic structure of LV summit and the surrounding anatomic sites, makes ablation of this arrythmia challenging. Aim: In this paper, we review the main strategies to mapping and ablation of LV summit VAs and summarize our experience in this challenging ablation. Methods: to summarize our experience, we included All consecutive patients with outflow VAs referred to ablation in our institute between 2019 and 2024 who eventually diagnosed to have LV summit origin based on electroanatomical mapping and ablation result using stepwise and sequential ablation approach Results: A total of 38 patients were found to have VAs from LV summit origin. Overall 5 patients had history of at least 1 failed ablation. V1 transition was seen in 15 patients, V2 transition in 12 patients, V3 transition in 11 patients. Four patients had R wave pattern break in lead V2. Ablation was performed from the earliest activation and or from one of the adjacent sites using stepwise and sequential approach. Acute suppression of VAs occurred in 35 patients without complications except one case of pseudoaneurysm of femoral artery. Conclusion: stepwise and sequential ablation approach can suppress VAs originated from LV summit in most of patients.

Background: Epidemiological data are lacking on patients in the rural areas who are being admitted after out‐of‐hospital cardiac arrest (OHCA). We report here the first descriptive analysis study of patients who were hospitalized and treated after OHCA at an academic medical center in the Lower Galilee which located in the north part of Israel.Methods: This is a descriptive, retrospective analysis of all patients admitted after OHCA to Tzafon Medical Center between the years 2017 and 2023. The analysis consists of the epidemiological, social, and clinical data based on the electronic medical records.Results: A total of 62 patients were included in this analysis, 82% were men with a median age of 61.5 years old. Thirty‐four percent had history of ischemic heart disease (IHD) and 60% history of hypertension. Twenty‐seven (44%) patients died during their admission. In 49 (79%) patients the first rhythm on emergency medical service (EMS) arrival was a shockable rhythm and 30 (48%) patients had a ST‐elevation myocardial infarction (STEMI) on electrocardiogram (ECG). Patients who were admitted to the hospital after OHCA were more likely to be discharged alive if they had no history of IHD (n = 27; p = 0.037), hypertension, or hyperlipidemia. Moreover, the presence of first shockable rhythm on the first ECG that performed by EMS was associated with higher rates of survival (n = 33; p < 0.001).Conclusions: We present the first single‐center epidemiological analysis of patients admitted after OHCA at a rural area in Israel, with an in‐hospital survival rate of 56%. Patients without history of IHD, hypertension, hyperlipidemia, and acute kidney injury and those with first shockable rhythm were more likely to discharged alive.

Background and Objectives: Iodinated Contrast Media (ICM) is used daily in many imaging departments worldwide. The main risk associated with ICM is hypersensitivity. When a severe hypersensitivity reaction is not properly managed and treated swiftly, it may be fatal. Currently, there is no data to demonstrate how ICM sensitivity affects the prognosis of cardiac patients, especially those diagnosed with ST elevation myocardial infarction (STEMI), in whom urgent coronary angiography is indicated. This study aimed to identify and characterize this relationship. Materials and Methods: We included patients hospitalized with STEMI between 2016 and 2019 from the National Inpatient Sample. The population was compared based on ICM sensitivity status, sensitive vs. non-sensitive. The primary endpoint was in-hospital mortality, with additional endpoints: length of stay and in-hospital complications. Results: The study included 664,620 STEMI patients, of whom 4905 (0.7%) were diagnosed with ICM sensitivity. ICM-sensitive patients were older, more often white, females, and had more comorbidities and cardiovascular risk factors. Both groups show similarities in management but are slightly less probable to undergo PCI or CABG. Multivariable logistic regression models found that the ICM-sensitive population had similar odds of in-hospital mortality (OR: 1.02, 95% CI: 0.89–1.16) and MACCE (OR: 1.05, 95% CI: 0.95–1.16), and less major bleeding (OR: 0.73, 95% CI: 0.60–0.87). Conclusions: Our study found that ICM sensitivity status was not a significant factor for worse prognosis in patients hospitalized with STEMI.

Background: Annual heart transplant (HT) volumes have increased, as have post‐HT outpatient care needs. Data on HT‐related emergency department (ED) visits are limited. Methods and Results: A retrospective analysis of 177 450 HT patient ED visits from the 2009 to 2018 Nationwide Emergency Department Sample was conducted. HT recipients, primary diagnoses, and comorbidities associated with ED visits were identified via International Classification of Diseases, Ninth Revision ( ICD‐9 ) and International Classification of Diseases, Tenth Revision ( ICD‐10 ) codes. Multivariable logistic regression was used to predict outcomes of hospital admission and death. HT volumes and HT‐related ED visits increased from 2009 to 2018. Infection was the most common primary diagnosis (24%), and cardiac primary diagnoses represented 10% of encounters. Hospital admissions occurred in 48% of visits, but overall mortality was low (1.6%). Length of stay was 3.1 days (interquartile range, 1.6–5.9 days), and comorbidity burden was high: 42% had hypertension, 38% had diabetes, and 31% had ≥2 comorbidities. Those aged ≥65 years had significantly higher odds of admission (odds ratio [OR], 2.14 [95% CI, 1.97–2.33]) and death (OR, 2.06 [95% CI, 1.61–2.62]). Comorbidities increased odds of admission (OR, 1.62 [95% CI, 1.51–1.75]) but not death. Renal primary diagnosis had the highest risk of admission (OR, 4.1 [95% CI, 3.6–4.6]), but cardiac primary diagnosis had the highest odds of death (OR, 11.6 [95% CI, 9.1–14.8]). Conclusions: HT‐related ED visits increased from 2009 to 2018 with high admission rates but low in‐hospital mortality, suggesting an opportunity to improve prehospital care. Older patients and those with cardiac primary diagnoses had the highest risk of death. The observed contrast between predictors of admission and mortality signals a need for further study to improve risk stratification and outpatient care strategies.

Background: Congestive heart failure is a leading cause of morbidity and mortality worldwide. One of the signs of congestive heart failure is fluid overload including pulmonary edema, peripheral edema, and ascites. The cause of fluid overload remains incompletely understood, and management of these patients continues to be a challenge. The role of lymphatic circulation abnormalities in the cause and pathophysiology of fluid overload also remains unclear. Here we report on a study in a large animal model of right heart failure caused by severe tricuspid regurgitation comparing cardiovascular and lymphatic findings in a group of animals that did not develop ascites with a group of animals that developed ascites. Methods and Results: Thirteen Yorkshire pigs were included in this study divided into 2 groups. Group 1 included 6 animals that did not develop ascites, and Group 2 included 7 animals that had developed ascites. The groups were compared on hemodynamic parameters as well as comparison of the animal's lymphatic anatomy and function. There was no difference between the groups in degree of tricuspid regurgitation and central venous pressure, with inferior vena cava pressure measuring 11.6±1.6 versus 13.2±3.7 ( P =0.534) and superior vena cava pressure measuring 12.0±2.3 versus 13.7±3.2 ( P =0.366). There was also no difference between the groups in all measured hemodynamic parameters, including right ventricular pressure, pulmonary artery pressure, and left ventricular function. The weighted liver size in the ascites group was significantly larger than in the nonascites group (30.3±12.4 versus 63.3±14.0 mL/kg, respectively; P =0.001). The 2 groups also differed in the number of animals with regurgitant thoracic duct flow (Group 1: 1/6,17% versus Group 2: 6/7, 86%; P =0.029) and the minimal thoracic duct diameter (Group 1: 2.3±0.3 versus Group 2: 4.2±2.2; P =0.035). Conclusions: In animals with right heart failure caused by severe tricuspid regurgitation, fluid overload did not correlate with hemodynamic parameters but rather with changes in the lymphatic system, including regurgitant lymphatic flow, minimal thoracic duct diameter, and liver size. This study is consistent with lymphatic dysfunction and not cardiovascular function playing a significant role in the cause of fluid overload. Further studies are needed to confirm these findings.

Durable implantable left ventricular assist devices (LVADs) have been shown to improve survival and quality of life for patients with stage D heart failure. Even though LVADs remain underused overall, the number of patients with heart failure supported with LVADs is steadily increasing. Therefore, general cardiologists will increasingly encounter these patients. In this review, we provide an overview of the field of durable LVADs. We discuss which patients should be referred for consideration of advanced heart failure therapies. We summarize the basic principles of LVAD care, including medical and surgical considerations. We also discuss the common complications associated with LVAD therapy, including bleeding, infections, thrombotic issues, and neurologic events. Our goal is to provide a primer for the general cardiologist in the recognition of patients who could benefit from LVADs and in the principles of managing patients with LVAD. Our hope is to “demystify” LVADs for the general cardiologist.

Background: Mechanical circulatory support devices, such as the intra‐aortic balloon pump (IABP) and Impella, are often used in patients on veno‐arterial extracorporeal life support (VA‐ECLS) with cardiogenic shock despite limited supporting clinical trial data. Methods and Results: Hospitalizations for cardiogenic shock from 2016 to 2018 were identified from the National Inpatient Sample. Trends in the use of VA‐ECLS with and without an IABP or Impella were assessed semiannually. Multivariable logistic regression and general linear regression evaluated the association of Impella and IABP use with in‐hospital outcomes. Overall, 12 035 hospitalizations with cardiogenic shock and VA‐ECLS were identified, of which 3115 (26%) also received an IABP and 1880 (16%) an Impella. Use of an Impella with VA‐ECLS substantially increased from 10% to 18% over this period ( P P P <0.001 each). Most (57%) IABPs or Impellas were placed on the same day as VA‐ECLS. After adjustment, there were no differences in in‐hospital mortality or length of stay with the addition of an IABP or Impella compared with VA‐ECLS alone. Conclusions: From 2016 to 2018 in the United States, use of an Impella and IABP with VA‐ECLS significantly increased. More than half of Impellas and IABPs were placed on the same day as VA‐ECLS, and the use of a second mechanical circulatory support device did not impact in‐hospital mortality. Further studies are needed to decipher the optimal timing and patient selection for this growing practice.