Notes

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The aim of this study was to explore if right ventricular (RV) contractile function and its coupling to pulmonary circulation (PC) were associated with successful weaning from venoarterial-extracorporeal membrane oxygenation (VA-ECMO) at maintenance of pump flow.

Limited data are available on predictors of successful weaning from VA-ECMO. under full cardiac support of VA-ECMO.

A total of 79 patients with cardiogenic shock underwent transthoracic echocardiography to evaluate weaning from ECMO and were prospectively enrolled between 2016 and 2019. The noninvasively measured RV-PC coupling index was acquired by indexing tricuspid annular S' velocity, tricuspid annular plane systolic excursion (TAPSE), fractional area change (FAC), and RV free-wall longitudinal strain (FWLS) to right ventricular systolic pressure (RVSP).

Transthoracic echocardiography was performed at a median 3.0days (range 1 to 6days) after ECMO initiation at a median ECMO flow of 3.2 l/min (range 3.0 to 3.6 l/min). The RV-PC coupling matrix, tricuspid annular S'/RVSP, TAPSE/RVSP, and RV FWLS/RVSP exhibited satisfactory predictive performances for predicting successful weaning from ECMO. check details Using the best cutoff values derived from the area under the receiver-operator characteristic curve, tricuspid annular S'/RVSP demonstrated a significantly better predictive performance than conventional echocardiographic parameters (left ventricular ejection fraction >20%, left ventricular outflow tract time-velocity integral≥10cm, and mitral annular S'≥6cm/s).

Echocardiographic RV-PC coupling metrics exhibited a significantly better performance for predicting successful weaning from VA ECMO compared with conventional echocardiographic criteria at maintenance of pump flow.
Echocardiographic RV-PC coupling metrics exhibited a significantly better performance for predicting successful weaning from VA ECMO compared with conventional echocardiographic criteria at maintenance of pump flow.
The purpose of this study was to develop a risk prediction model for patients with nonobstructive CAD.

Among stable chest pain patients, most cardiovascular (CV) events occur in those with nonobstructive coronary artery disease (CAD). Thus, developing tailored risk prediction approaches in this group of patients, including CV risk factors and CAD characteristics, is needed.

In Prospective Multicenter Imaging Study for Evaluation of Chest Pain (PROMISE) computed tomographic angiography patients, a core laboratory assessed prevalence of CAD (nonobstructive 1% to 49% left main or 1% to 69% stenosis any coronary artery), degree of stenosis (minimal 1% to 29%; mild 30% to 49%; or moderate 50% to 69%), high-risk plaque (HRP) features (positive remodeling, low-attenuation plaque, and napkin-ring sign), segment involvement score (SIS), and coronary artery calcium (CAC). The primary end point was an adjudicated composite of unstable angina pectoris, nonfatal myocardial infarction, and death. Cox regression analyThis may be a first step to improve prevention in this cohort with the highest absolute risk for CV events.
Advanced coronary plaque features have incremental value over total plaque burden for the discrimination of clinical events in low-risk stable chest pain patients with nonobstructive CAD. This may be a first step to improve prevention in this cohort with the highest absolute risk for CV events.
This study sought to assess training volumes and its relationship to learning and identify potential new thresholds for determining expertise.

Competency-based medical education (CBME) is being rapidly adopted and therefore training programs will need to adapt and identify new and novel methods of defining, measuring, and assessing clinical skills.

Consecutive cardiac computed tomography (CT) studies were interpreted independently by trainees and expert readers, and their interpretations (Agatston score, coronary artery disease severity, and Coronary Artery Disease Reporting and Data System) were collected. Kappa agreements were measured between trainees and experts for every 50 consecutive cases. Agreements between trainees and experts were tracked and compared with the agreement between expert readers.

A total of 36 trainees interpreted 14,432 cardiac CT studies. Agreement between trainees and experts increased with CT case volumes, but trainees learned at different rates. Using a threshold for expertise, skill of measuring coronary calcification was achieved within 50 cases, but expertise for coronary CT angiography appeared to require a mean case volume of 750, comprising 400 abnormal cases.

Current volume-based training guidelines may be insufficient and higher case volumes may be required. We demonstrate that tracking cardiac CT learners is feasible and that CBME could be incorporated into CT training programs.
Current volume-based training guidelines may be insufficient and higher case volumes may be required. We demonstrate that tracking cardiac CT learners is feasible and that CBME could be incorporated into CT training programs.
This study sought to evaluate the long-term prognostic implications of coronary microvascular dysfunction (CMD) when assessed with both cardiovascular magnetic resonance (CMR) and index of microcirculatory resistance (IMR) in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI).

Post-ischemic CMD can be assessed using the pressure-wire based IMR and/or by the presence of microvascular obstruction (MVO) on CMR.

A total of 198 patients with STEMI underwent IMR and MVO assessment. Patients were classified as follows Group 1, no significant CMD (low IMR [≤40 U] and no MVO); Group 2, CMD with either high IMR (>40 U) or MVO; Group 3, CMD with both IMR >40 U and MVO. The primary endpoint was the composite of all-cause mortality, diagnosis of new heart failure, cardiac arrest, sustained ventricular tachycardia/fibrillation, and cardioverter defibrillator implantation.

CMD with both high IMR and MVO was present in 23.7% of the cases (Group 3) and CMD with either high IMR or MVO was observed in 40.9% of cases (Group 2). At a median follow-up of 40.1 months, the primary endpoint occurred in 34 (17%) cases. At 1 year of follow-up, Group 3 (hazard ratio [HR] 12.6; 95% confidence interval [CI] 1.6 to 100.6; p=0.017) but not Group 2 (HR 7.2; 95%CI 0.9 to 57.9; p=0.062) had worse clinical outcomes compared with those with no significant CMD in Group 1. However, in the long-term, patients in Group 2 (HR 4.2; 95%CI 1.4 to 12.5; p=0.009) and those in Group 3 (HR 5.2; 95%CI 1.7 to 16.2; p=0.004) showed similar adverse outcomes, mainly driven by the occurrence of heart failure.

Post-ischemic CMD predicts a more than 4-fold increase in long-term risk of adverse outcomes, mainlydriven by the occurrence of heart failure. Defining CMD by either invasive IMR >40 U or by CMR-assessed MVO showed similar risk of adverse outcomes.
40 U or by CMR-assessed MVO showed similar risk of adverse outcomes.
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