<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>
Pulmonary agenesis is a rare malformation associated with congenital heart disease and may lead to a life-threatening condition and death without pre-planned surgical and medical support.
We report an unusual case of unilateral pulmonary agenesis in combination with total anomalous pulmonary venous connection, complete vascular ring, retroaortic, retroesophageal innominate vein, secondary atrial septal defect, which was prenatally identified by fetal ultrasound and magnetic resonance imaging, later confirmed by postnatal computed tomography.
</abstract>

A case report of prenatal diagnostics and surgical correction of pulmonary agenesis associated with total anomalous pulmonary venous connection and vascular ring

<abstract>
<title style='display:none'>Abstract</title>
Atrial standstill is a rare arrhythmogenic condition characterized by the absence of electrical and mechanical activity in the atria. The therapeutic options for these patients described in the current literature, in which no reversible cause is detected, are permanent cardiac pacing, anticoagulant, and heart failure treatment when the latter exists. We present a case of a young male with no personal or family history of cardiovascular disease, diagnosed with atrial standstill after multiple syncopal episodes, in whom, because of the high expected ventricular pacing percentage, we opted for conduction system pacing with left bundle branch area pacing.
</abstract>

Atrial standstill in a young patient treated with left bundle branch area pacing

<abstract>
<title style='display:none'>Abstract</title>
<sec>
<title style='display:none'>Introduction</title>
The feasibility of the conduction system pacing combined with atrioventricular node ablation was demonstrated in patients with atrial fibrillation in whom rate control can’t be achieved with medication and heart failure.
</sec>
<sec>
<title style='display:none'>Clinical case</title>
We present a case of an 82-year-old man with a personal history of permanent atrial fibrillation, admitted with symptoms of heart failure. The resting electrocardiogram showed a very fast ventricular response, and the echocardiography showed a depressed left ventricular function, raising the suspicion of a tachycardia-mediated cardiomyopathy. Since the patient was on maximum doses of atrioventricular nodal-blocking drugs, we opted for a physiological pacing and atrioventricular node ablation strategy. First, the His bundle capture was achieved at low pacing thresholds, and ablation of the atrioventricular node was attempted. Unfortunately, after several failed attempts, an acute increase in the His bundle capture threshold was noted, suggesting inadvertent tissue ablation beneath the pacing lead. In this scenario, we removed the lead from the His bundle area and achieved optimal left bundle branch area pacing. With the lead in this position, atrioventricular node ablation was performed during the first attempt. At the six-month follow-up, there was no recovery of atrioventricular node conduction. Device interrogation revealed stable pacing and sensing parameters, and there was a significant improvement in clinical status and left ventricular function.
</sec>
<sec>
<title style='display:none'>Conclusions</title>
Mastering both His bundle pacing and left bundle branch area pacing offers the potential to overcome intraprocedural challenges, giving alternative strategies to achieve physiological pacing. These approaches can be used interchangeably based on the evolving dynamics of the procedure and the patient’s specific needs.
</sec>
</abstract>

Complementary use of conduction system pacing techniques for the “pace and ablate” strategy in permanent atrial fibrillation - a case report

<abstract>
<title style='display:none'>Abstract</title>
<sec>
<title style='display:none'>Objective</title>
Chronic heart failure (CHF) is a clinical syndrome that encompasses individuals who either have received a definitive diagnosis of heart failure or display a gradual escalation of symptoms as time elapses. Echocardiography, particularly evaluating left ventricular function, is crucial for diagnosis and prognosis. However, 24-hour Holter monitoring, focusing on heart rate variability (HRV), provides insights into autonomic dynamics and vulnerability. Recent HRV parameters offer nuanced information, enhancing risk stratification and guiding personalized interventions in CHF. The interplay between echocardiography and HRV enables a comprehensive approach, refining the management of CHF by considering both cardiac structure and autonomic regulation.
</sec>
<sec>
<title style='display:none'>Methods</title>
This prospective study at “St. Spiridon” County Hospital involved 80 patients with left ventricular ejection fraction (LVEF) &lt; 50%. The diagnosis was according to standard clinical echocardiography, laboratory panel, and Holter ECG monitoring.
</sec>
<sec>
<title style='display:none'>Results</title>
Unexpectedly, no statistically significant relationship was found between commonly used HRV parameters and echocardiographic parameters. Further analyses showed statistically significant associations between non-traditional HRV parameters and E/A ratio, E/E’, and S’ lateral and septal. Additionally, modifications in HRV parameters were correlated with mitral valve deceleration time, left atrial volume index, estimated pulmonary artery systolic pressure, and cardiac output.
</sec>
<sec>
<title style='display:none'>Conclusions</title>
Less commonly used Holter ECG parameters, such as acceleration capacity, deceleration capacity, and triangular index, demonstrated significant diagnostic efficacy, especially when conventional HRV parameters were normal. This highlights the importance of incorporating non-traditional HRV parameters in CHF patient risk stratification, urging further exploration through comprehensive multicenter studies for long-term prognostic implications.
</sec>
</abstract>

Heartbeat Chronicles: Decoding the Interplay of Echocardiography and Heart Rate Variability in Chronic Heart Failure Patients – Unraveling the Mysteries with Traditional and Advanced 24-Hour Holter ECG Parameters

<abstract>
<title style='display:none'>Abstract</title>
Cardiac resynchronization therapy (CRT) has become part of the standard of care for symptomatic patients with heart failure, reduced ejection fraction (HRrEF), and wide QRS, despite optimal medical therapy. Device technology, operator experience, and post-implant optimization on follow-up have significantly improved CRT response during the last decade. In parallel, conduction system pacing (CSP) has emerged as a new and potentially better tool for maintaining physiological ventricular activation in patients with antibradycardia pacing, as well as an alternative for dyssynchrony correction in HFrEF patients. The current review focuses on cardiac dyssynchrony pathophysiology and correction methods, clinical evidence on CRT and CSP as therapies for cardiac dyssynchrony, and the role of each according to clinical evidence and current guidelines for HFrEF treatment.
</abstract>

How to treat cardiac dyssynchrony in heart failure with reduced ejection fraction

<abstract>
<title style='display:none'>Abstract</title>
<sec>
<title style='display:none'>Introduction</title>
Delta wave morphology during sinus rhythm on 12 lead ECG usually allows for a relatively precise prediction of the anatomic location of an accessory pathway (AP) provided that the rhythm is fully pre-excited. However, the pre-excitation pattern during sinus rhythm usually offers little information about sudden cardiac death (SCD) risk in adult patients with asymptomatic Wolf-Parkinson-White (WPW).
</sec>
<sec>
<title style='display:none'>Case Presentation</title>
A 42-year-old policeman was referred for an asymptomatic WPW pattern with an unusual delta wave. Initial mapping showed that atrio-ventricular (A-V) fusion on the lateral mitral annulus and radiofrequency (RF) ablation induced a shift in the pre-excitation pattern. Re-mapping identified A-V fusion on the left postero-septal area. Another RF application eliminated pre-excitation. Re-mapping identified A-V fusion on the postero-septal aspect of the mitral annulus and another RF application almost instantaneously induced an A-V split and loss of pre-excitation. Post-ablation testing proved normal anterograde A-V conduction without pre-excitation and no ventriculo-atrial conduction. Serial ECGs proved the persistent loss of pre-excitation at one-month of follow-up.
</sec>
<sec>
<title style='display:none'>Conclusion</title>
This case highlights the diagnostic challenges associated with atypical pre-excitation patterns and the importance of a thorough evaluation in asymptomatic individuals. Patients with atypical pre-excitation may harbor multiple accessory pathways (MAPs) and should be carefully assessed to mitigate the risk of SCD.
</sec>
</abstract>

Atypical Pre-excitation Pattern in Asymptomatic Wolff-Parkinson-White—A Hallmark for High Risk?

<abstract>
<title style='display:none'>Abstract</title>
Tachycardiomyopathy, characterized by ventricular systolic dysfunction resulting from persistent tachycardia, poses a significant challenge in cardiovascular disease management. This article presents the case of a 31-year-old male patient with dilated cardiomyopathy and recurrent persistent atrial fibrillation, admitted due to heart failure decompensation. Ischemic and inflammatory etiologies for heart failure were ruled out in prior assessments. Despite multiple antiarrhythmic drugs and attempted electrical cardioversion, sinus rhythm was not maintained. Echocardiography confirmed a decline in the already reduced ejection fraction. Atrial fibrillation cryoablation was performed, and procedural specifics are detailed. Subsequent follow-up visits revealed a noteworthy improvement in exercise tolerance and ventricular function. This case underscores the importance of considering tachycardiomyopathy in the differential diagnosis of new-onset or worsening heart failure and highlights the potential for symptom resolution and ventricular function recovery with atrial fibrillation ablation.
</abstract>

<italic>Reshaping Prognosis</italic>: Atrial fibrillation ablation in a case of severe tachycardiomyopathy in a young patient

<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

Guidelines for Authors

Preparation of Manuscript

Manuscript Submission Checklist

Guidelines for Reviewers