<abstract>
<title style='display:none'>Abstract</title>
Acute decompensated heart failure (ADHF) is a worldwide health problem, with poor prognosis and significant morbidity and mortality. Fluid overload is the primary reason for hospitalization in ADHF. The efficacy of diuretic monotherapy is suboptimal, with a substantial proportion of patients being discharged with residual congestion that portends a poor outcome. Accordingly, the loop diuretic monotherapy from the DOSE trial achieved a successful decongestion in less than 20% of patients. Although the concept of sequential nephron blockade has regained interest following the publication of several randomized clinical trials (RCTs), the optimal approach to combination diuretic therapy is still an area of uncertainty. The selection of an adequate approach remains difficult as comparisons between different trials cannot be made due to different diuretic doses used, timing of sequential blockade, differences in study cohorts or in definitions used to define decongestion. Moreover, a direct comparison of different combination therapies in large trials is lacking. Nonetheless, the approach to the combination diuretic therapy should rather take into account the patient phenotype, the suspected nephron segment responsible for diuretic resistance, and the anticipated electrolyte and acid–base disturbances in order to select diuretic agents with divergent effects. Herein, we review the molecular mechanisms of action of diuretic agents, highlight the most recent trials evaluating combined diuretic therapy in ADHF and identify clinical scenarios, apart from diuretic resistance, for optimal association of diuretics to counteract their anticipated adverse effects.
</abstract>

A practical approach to sequential nephron blockade in acute decompensated heart failure

<abstract>
<title style='display:none'>Abstract</title>
<sec>
<title style='display:none'>Introduction</title>
Methicillin-resistant <italic>Staphylococcus aureus</italic> (MRSA) is a leading pathogen responsible for bacteremia and valvular endocarditis. In patients with Coronavirus Disease 2019 (COVID-19), MRSA co-infection represents a challenging scenario, with increased morbidity and mortality.
</sec>
<sec>
<title style='display:none'>Case presentation</title>
We present a case of possible valvular endocarditis in a patient with acute COVID-19 and MRSA bacteremia. A 75-year-old woman presented with severe symptomatic aortic stenosis and moderate mitral stenosis. During hospitalization, she developed COVID-19 pneumonia with acute respiratory failure, and temporal and frontal intraparenchymal cerebral hemorrhage. Blood cultures were positive for MRSA, and the patient was started on a specific antibiotics regimen. The patient subsequently developed multi-organ failure and was transferred to the intensive care unit. Repeated computed tomography of the brain was consistent with a new occipitotemporal cortical hypodensity. Transthoracic echocardiography (TTE) showed a small (4 x 4 mm) mass attached to the aortic valve, but with TTE features inconclusive for infective endocarditis. The patient was scheduled for transesophageal echocardiography, but she suffered cardiac arrest, with no response to resuscitation maneuvers.
</sec>
<sec>
<title style='display:none'>Conclusions</title>
This case reveals the diagnostic and therapeutic challenges raised by MRSA and COVID-19 coinfection in a patient with preexisting valvular heart disease.
</sec>
</abstract>

Follow the heart: A tale of possible infective endocarditis in a patient co-infected with Methicillin-resistant <italic>Staphylococcus aureus</italic> and Severe Acute Respiratory Syndrome Coronavirus 2

<abstract>
<title style='display:none'>Abstract</title>
<sec><title style='display:none'>Introduction</title>There is an increasing interest in the past decade for more physiological pacing strategies due to detrimental long-term right ventricular pacing. His bundle pacing is the most physiological one, but it has some drawbacks, mainly an increased pacing threshold. Left bundle branch area pacing (LBBAP) emerged in the recent years as the next step in conduction system pacing. We present our initial experience and learning curve with this latter procedure.</sec>
<sec><title style='display:none'>Material and methods</title>During January 2019 and February 2021, 20 patients with pacing indications that failed initial permanent His bundle pacing underwent successful LBBAP.</sec>
<sec><title style='display:none'>Results</title>The mean age was 65.9 ± 12.7 years. The indications for cardiac pacing were AV block in 14 patients (70%) and cardiac resynchronization therapy in 6 patients (30%). At baseline, normal QRS complex was noted in 9 patients, a left bundle branch block pattern in 10 patients and a right bundle branch block in one patient. A total of 18 dual-chamber and one single chamber pacemakers were implanted and a cardiac resynchronization therapy defibrillator (CRT-D) device. The acute pacing threshold was 0.56±0.2 V at 0.4ms, the sensing threshold was 10.3±3.9 mV and the impedance was 684.9±112.2 Ω. The overall QRS duration decreased after LBBAP from 128.5 ± 27ms to 103.6 ± 17.4ms (p= 0.001). In patients with baseline wide QRS complex there was a highly significant decrease from 148.2 ± 11.6 ms to 104.7 ± 19.4 ms (p&lt;0.001). The fluoroscopy time, including the time spent for His bundle location, was 13.8 ± 8.5 minutes. The pacing thresholds remained constant after three-months (0.6 ± 0.2 V vs. 0.56 ± 0.2 V at 0.4 ms). We had two intraprocedural septal perforations without any consequences and three micro dislodgements at follow-up with pure left septal capture.</sec>
<sec><title style='display:none'>Conclusion</title>Left bundle branch area pacing is a feasible physiological pacing technique with a high success rate and the potential to overcome the limits of permanent His bundle pacing. It can be successfully performed virtually in all types of pacing indications, including cardiac resynchronization therapy as provides a rapid and synchronous activation of the left ventricle.</sec>
</abstract>

Learning Curve for Left Bundle Branch Area Pacing – the Experience of a Romanian Academic Center

<abstract>
<title style='display:none'>Abstract</title>
<sec>
<title style='display:none'>Objectives</title>
Myxomas are the most common primary tumors of the adult heart and should be considered in the differential diagnosis of intracavitary cardiac masses, along with thrombi and vegetations.
</sec>
<sec>
<title style='display:none'>Methods</title>
We report a case of a 64-year-old obese, hypertensive woman, who presented with dyspnea on moderate exertion as well as fatigue. The patient was admitted to our hospital after the discovery on transthoracic echocardiography of an intracardiac mass, which was highly suggestive for a left atrial myxoma.
</sec>
<sec>
<title style='display:none'>Results</title>
On admission, the patient presents no abnormalities on physical exam, with blood tests showing only slight deviations in the lipid profile. The ECG presents a normal sinus rhythm of 80/min with two premature ventricular contractions and a premature atrial contraction. Transthoracic echocardiography revealed the presence of a well-defined, pediculated, left atrial mass attached to the interatrial septum, measuring 25/17 mm, with no apparent interference in mitral valve motion. We supplemented our investigations with the use of transesophageal echocardiography which further defined the dimensions and location of the tumor, while also showing the presence of an atrial septal aneurysm associated to two small atrial septal defects measuring 6 mm and 7 mm respectively, with a left to right shunt. Cardiac CT examination confirmed the benign aspect of the mass and offered important anatomical elements, useful in preoperative planning. The patient was, therefore, admitted to our Cardiovascular Surgery department, where a successful surgical resection of the tumor was performed, without any local or systemic complications. The differential diagnosis of this mass included intracavitary thrombi, vegetations, as well as other histological subtypes of benign or malignant tumors, while the presence of an atrial septal defect, which represents a possible source of paradoxical emboli, provided an additional challenge.
</sec>
<sec>
<title style='display:none'>Conclusions</title>
This complicated case stands out due to its particular echocardiographic appearance and emphasizes the importance of a comprehensive evaluation in both the differential diagnosis and preoperative assessment.
</sec>
</abstract>

Cardiac masses and the role of imaging in their diagnostic

In Memoriam — Professor Carmen Ginghină (1948–2022)

<abstract>
<title style='display:none'>Abstract</title>
We set out to assess whether the preoperative prediction of patient-prosthesis mismatch by an algorithm popularised by Pibarot et al. is accurate compared to PPMM defined as AVA &lt;0.85 cm2/m2 (‘any PPMM’) or as AVA &lt;0.65cm2/m2 (‘severe’ PPMM).
We studied 37 patients (16 female), with mean age 72.3 +/− 8.4 years, who had unplanned SAVR during 2019. By echo, 17 (19.7%) patients had severe PPMM (mean AVA (SD) = 0.55 (0.04) cm2). For the 0.85cm2/m2 cut-off, 14/37 patients (37%) had PPMM (mean AVA (SD) 0.70 (0.15) cm2. By the Pibarot algorithm, 21 (56.7%) patients were predicted to have any PPMM and 10 (27%) severe PPMM.
The preoperative algorithm for the avoidance of patient prosthetic mismatch does not accurately identify patients who have postoperative PPMM as defined by echocardiography. Further refinements of the algorithm seem necessary before it can be used widely in clinical practice.
</abstract>

Patient Prosthesis Mismatch in SAVR: How Avoidable is It in the ‘Real World’?

<abstract>
<title style='display:none'>Abstract</title>
Congenitally corrected transposition of the great arteries (ccTGA) is a rare congenital anomaly defined by double discordance – atrioventricular and ventricular-arterial. ccTGA frequently has associated lesions, which influence long-term survival.
The management of patients with ccTGA regarding the closure of defects and pacing strategies is often very challenging. Moreover, tricuspid valve regurgitation and its impact on the systemic right ventricle requires close monitoring and potentially timely interventions. In this paper, we present and discuss the management challenges raised by a patient with situs inversus totalis, dextrocardia, ccTGA, Ebstein anomaly of the tricuspid valve, atrial septal defect, and complete atrioventricular block.
</abstract>

Complex Congenital Heart Lesion - Should We Operate or Not?

<abstract>
<title style='display:none'>Abstract</title>
Personalized/precision cardiology is a great hope of our times. In daily practice, we apply personalized, but not precise, cardiology: we take individual patient histories and perform individual clinical examinations, but we treat using general rule, general evidence-based guidelines… We do hope, in the near future, to take individual examination and treat using individual rules.
Genuine, meaningful precision cardiology will rely heavily on genetics and artificial intelligence, but lifestyle, individual risk factors, patient and family compliance to treatment, and genetic makeup can influence diagnostic accuracy and treatment effects and should not be neglected. Extensive data exists regarding applications of artificial intelligence in the practice of precision cardiology, but we lack the systems that would translate its potential into clinical outcomes for real patients.
</abstract>

Personalized Cardiology

<abstract>
<title style='display:none'>Abstract</title>
<sec>
<title style='display:none'>Introduction</title>
Cardiac interventions in the setting of a ST-elevation myocardial infarction (STEMI) often require complex decision-making, especially when confronted with coronary bifurcation lesions. Although provisional stenting is the first choice regarding revascularization, bailout or upfront two stents may be required.
</sec>
<sec>
<title style='display:none'>Case presentation</title>
We present the case of a 53-year-old male patient with a history of arterial hypertension and type 2 diabetes who presented to our emergency department with an ST-elevation myocardial infarction associated with inferior and posterior wall involvement. The patient’s coronary angiogram revealed a thrombotic occlusion in the second segment of the right coronary artery. A dual stenting technique was employed using simultaneous kissing stents to address this complex coronary bifurcation lesion. Six months follow up with coronary angiography and optical coherence tomography demonstrated functional neo carina with no malapposition and successful endothelialization of two stents.
</sec>
<sec>
<title style='display:none'>Conclusions</title>
In our case, the simultaneous kissing stents approach was deemed appropriate due to the presence of a thrombotic bifurcation lesion involving both the posterior descending artery and retro posterior branch, while minimizing the risk of side branch compromise.
</sec>
</abstract>

“SKS is not dead” - A Case Report Of Dual Stenting Technique in the Management of a Complex Coronary Bifurcation Lesion During ST Elevation Myocardial Infarction

<abstract>
<title style='display:none'>Abstract</title>
A sinus of Valsalva aneurysm is a rare cardiac anomaly characterized by an abnormal dilatation of the aortic root. This occurs due to a weakened elastic lamina at the junction of the aortic media and the annulus fibrosus. The aneurysm can be congenital or acquired and comprises up to 3.5% of all congenital cardiac defects. Due to the aneurysm’s physiologic function and location, it can present significant clinical consequences in both the rupture and unruptured state. We present the case of a middle-aged male with no significant medical history who was found to have a massive unruptured sinus of Valsalva aneurysm. He was treated surgically with no postoperative complications.
</abstract>

Massive sinus of Valsalva aneurysm with an associated bicuspid aortic valve: A rare clinical image

<abstract>
<title style='display:none'>Abstract</title>
Bifurcation lesions are the cause of 20% of all percutaneous coronary interventions, representing a complex category associated with lower procedure success rates and higher restenosis rates. However, the optimal approach to bifurcation needs further research. This paper aims to determine the optimal method for implementing a two-stent strategy in bifurcation cases. It desires to identify the characteristics that can guide our approach and the outcomes that can be expected. This paper also highlights relevant trials that support the findings.
In nontrue bifurcation cases (Medina 1-1-0, 1-0-0, 0-1-0, 0-0-1), a one stent strategy, eventually with the provisional approach, is preferable. When treating a left main or non-left main bifurcation in a Medina classification of 1-1-1, 1-0-1, or 0-1-1 without meeting at least one major and two minor criteria and of DEFINITION II Classification (simple true bifurcation), the layered provisional approach is the appropriate strategy.
In cases of left main or non-left main complex true bifurcation (Medina 1-1-1, 1-0-1, 0-1-1) meeting the Definition II Classification criteria, a two-stent strategy could be a suitable option in cases where the SB is more than 2.5 mm and has a lesion length of more than 16 mm.
</abstract>

A Perspective on a Two-stent Approach in Bifurcation Cases

<abstract>
<title style='display:none'>Abstract</title>
<sec>
<title style='display:none'>Objective</title>
Multidetector computed tomography is considered a reliable, non-invasive modality for diagnosing myocardial bridging. The prevalence of myocardial bridges varies greatly based on the technique used to identify the anomaly. We aimed to evaluate the frequency and morphological features of myocardial bridging in patients who underwent ECG-gated 640 slice Multidetector computed tomography coronary angiography at Shahid Gangalal National Heart Centre.
</sec>
<sec>
<title style='display:none'>Methods</title>
A retrospective cross-selectional study was conducted at Shahid Gangalal National Heart Centre. From 1 January 2021 to 30 June 2021, 1068 consecutive patients were enrolled, and the frequency and morphological features of myocardial bridging among those patients were evaluated.
</sec>
<sec>
<title style='display:none'>Results</title>
Among the 1068 patients examined, 141 had one or multiple Myocardial bridging (13.2%). Out of 141 patients, 94.3% of bridging was superficial, while only 5.7% was deep. 97.9% of myocardial bridging was located in the left anterior descending artery, and 86.2% was present in the mid-segment of the left anterior descending artery.
</sec>
<sec>
<title style='display:none'>Conclusion</title>
Multidetector computed tomography is an effective noninvasive method for the diagnosis of myocardial bridging. The frequency of myocardial bridging in our study was 13.2%.
</sec>
</abstract>

Morphological features of myocardial bridging in patients who underwent CT coronary angiography in the National Heart Centre of Nepal

<abstract>
<title style='display:none'>Abstract</title>
Well documented shortcomings of current heart valve substitutes – biological and mechanical prostheses make them imperfect choices for patients diagnosed with heart valve disease, in need for a cardiac valve replacement. Regenerative Medicine and Tissue Engineering represent the research grounds of the next generation of valvular prostheses – Tissue Engineering Heart Valves (TEHV). Mimicking the structure and function of the native valves, TEHVs are three dimensional structures obtained in laboratories encompassing scaffolds (natural and synthetic), cells (stem cells and differentiated cells) and bioreactors. The literature stipulates two major heart valve regeneration paradigms, differing in the manner of autologous cells repopulation of the scaffolds; <italic>in vitro</italic>, or <italic>in vivo</italic>, respectively. During the past two decades, multidisciplinary both <italic>in vitro</italic> and <italic>in vitro</italic> research work was performed and published. <italic>In vivo</italic> experience comprises preclinical tests in experimental animal model and cautious limited clinical translation in patients. Despite initial encouraging results, translation of their usage in large clinical scenarios represents the most important challenge that needs to be overcome. This review purpose is to outline the most remarkable preclinical and clinical results of TEHV evaluation along with the lessons learnt from all this experience.
</abstract>

Tissue Engineering Heart Valves – a Review of More than Two Decades into Preclinical and Clinical Testing for Obtaining the Next Generation of Heart Valve Substitutes

<abstract>
<title style='display:none'>Abstract</title>
The Coronavirus disease 2019 (COVID-19) pandemic, caused by the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV2), exhibits a wide spectrum of manifestations, from asymptomatic presentations to acute respiratory failure, myocardial injury, arterial or venous thrombosis, multiorgan failure, and death. Although COVID-19 mainly disrupts the respiratory syndrome, it has been shown to have detrimental impact on cardiac morphology and function, resulting in a broad range of cardiovascular complications and poor outcome, increasing morbidity and mortality of these patients. This review will summarize the knowledge on characterization of myocardial injury in COVID 19, by using cardiac biomarkers, electrocardiographic, and cardiac multi-modality imaging findings for an early and accurate diagnosis, proper management, correct treatment, and follow-up of COVID-19 patients.
</abstract>

Multimodality diagnosis of cardiac involvement in COVID-19 patients

<abstract>
<title style='display:none'>Abstract</title>
Pediatric multisystem inflammatory syndrome (PMIS) appears to be a relatively rare complication of COVID-19 in children, occurring in less than 1% of children with confirmed SARS-CoV-2 infection. This condition can appear several weeks after the acute SARS-CoV-2 infection and is assumed to be a delayed immune response to coronavirus disease 2019 which can lead to a severe cardiovascular involvement.
In this retrospective study, our main purpose was to summarize the clinical data from three types of onsets in patients diagnosed with PMIS and report the experience to the known data in the literature. We put the emphasis on the course of management considering the three different presenting faces of the PMIS in children. All patients received IV immunoglobulin and antiplatelet treatment, 66% (2 of 3) necessitated inotropic support, corticosteroid therapy (metilprednisolon), anticoagulation, 33% (1 of 3) received Anakinra (antagonist of the interleukin 1 receptor). All of them received cardiac remodeling treatment with Lisinopril and Bisoprolol (associated or not with Spironolactone and Furosemide). Evolution was good with discharge in approximately 2 weeks from admission, without symptoms, and with cardiac improvement at echocardiography.
PMIS is an alarming situation that necessitate multidisciplinary approach and a complex management. The cardiac evaluation is crucial in risk evaluation and guidance for a correct approach of the disease.
</abstract>

„Carol Davila” University of Medicine and Pharmacy

Cardiac Implication in Pediatric Multisystemic Inflammatory Syndrome – Three Case Reports and Review of the Literature

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Romanian Journal of Cardiology

Revista Română de Cardiologie

The Romanian Journal of Cardiology (RJC) is the official journal of the Romanian Society of Cardiology (Societatea Romana de Cardiologie) and is published quarterly. ...

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The Romanian Journal of Cardiology (RJC) is the official journal of the Romanian Society of Cardiology (Societatea Romana de...

Romanian Journal of Cardiology

Revista Română de Cardiologie

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