Intracardiac echocardiography (ICE) has evolved from an adjunct procedure to a major imaging component of contemporary electrophysiology (EP) and is transforming the assessment of complex ablation and device cases. This growth corresponds to an inflection point for EP practice in response to converging pressures: an interest in improving safety and efficiency in EP procedures, an ever-increasing trend toward minimal or zero fluoroscopy procedures, and a commensurate development of catheter technology and image integration. ICE specifically meets all of these demands by providing high-resolution intracardiac images through conscious sedation techniques and decreasing ionizing radiation exposure.

Background: Systemic sclerosis (SSc) is an autoimmune connective tissue disorder that leads to fibrosis of the skin and internal organs. Fragmented QRS (fQRS) is an important electrocardiographic (ECG) finding related to myocardial fibrosis. This study aimed to evaluate the effect of fQRS on ejection fraction (EF) and other echocardiographic parameters in individuals diagnosed with SSc.
Methods: This was a retrospective cohort study consisting of 52 patients with fQRS as the case group and 60 patients without fQRS as the control group. The characteristics and echocardiographic parameters of the patients from a minimum of a 3-year interval were recorded. All data were compared between the two groups using SPSS software, version 20.0 (IBM Corp).
Results: There were no significant differences in demographics, paraclinical results, and echocardiographic parameters, including average EF, pulmonary hypertension, and tricuspid regurgitation velocity, between cases and controls at the beginning and end of the follow-up.
Conclusion: Based on our results, fQRS had no significant effect on EF and other echocardiographic parameters over at least a 3-year interval in SSc patients. However, additional research with longer follow-up periods and larger sample sizes is needed to characterize the association fully.

Background: Heart failure (HF) and chronic kidney disease (CKD) frequently coexist and contribute to poor clinical outcomes, particularly in patients with diabetes mellitus. The modifying effect of diabetes on the association between renal markers and left ventricular ejection fraction (LVEF) remains poorly understood.
Objective: We sought to investigate whether diabetes modifies the relationship between renal biomarkers and LVEF in hospitalized patients with HF.
Methods: We conducted a cross-sectional analysis involving 112 patients diagnosed with HF who were admitted to a tertiary care hospital. Data were extracted from electronic medical records, including demographic characteristics, comorbidities, laboratory values, and echocardiographic assessments. The primary outcome was LVEF, as determined by transthoracic echocardiography. Renal function was evaluated using serum urea, creatinine, hemoglobin, and the estimated glomerular filtration rate (eGFR). To examine whether the association between these renal markers and LVEF differed based on diabetes status, we fitted multivariable linear regression models including interaction terms between diabetes and each renal marker. All models were adjusted for age, sex, and HF subtype (HFpEF, HFmrEF, or HFrEF).
Results: In multivariable models, both urea and creatinine remained significantly associated with LVEF (P=0.007 and P=0.005, respectively). Hemoglobin and eGFR did not show significant main effects in both unadjusted and adjusted models. In the moderation analysis, a significant interaction was found between diabetes and urea (P=0.022). Among patients with diabetes, an increase in urea was associated with a significant reduction in LVEF (P=0.022), whereas the association was attenuated in patients without diabetes. Similarly, the interaction between creatinine and diabetes was significant (β=−13.12; P=0.003). In contrast, the interaction between diabetes and eGFR approached significance (β=0.11; P=0.076). No significant interaction was found for hemoglobin and diabetes (β=−0.70; P=0.67).
Conclusion: Diabetes modifies the relationship between renal function and systolic performance in patients with HF. The stronger associations of urea and creatinine with reduced LVEF in individuals with diabetes highlight the importance of tailored risk assessment in the context of cardiorenal-metabolic disease.

Background: Cardiovascular complications account for a substantial proportion of perioperative complications. This study aimed to evaluate whether preoperative high-dose atorvastatin reduces postoperative changes in serum high-sensitivity cardiac troponin (hs-cTn) concentrations in patients at elevated cardiac risk undergoing noncardiac surgery.
Methods: In this triple-blind, parallel-group, randomized controlled trial, adults with a Revised Cardiac Risk Index (RCRI) of 1 or greater scheduled for noncardiac surgery were randomized (1:1) to receive atorvastatin 80 mg 24 hours preoperatively or placebo. The primary outcome was the change in serum hs-cTn concentrations 24 hours after surgery. Secondary outcomes included the incidence of major adverse cardiovascular events (MACE) within 7 days after surgery, as well as cardiovascular death, myocardial infarction, stroke, heart failure, arrhythmia, or transient ischemic attack.
Results: A total of 112 patients with similar baseline characteristics were randomized and completed a 7-day follow-up. Postoperative hs-cTn levels increased significantly in the placebo group (P<0.001) but decreased in the statin group (P<0.001), with a significant between-group difference favoring statin therapy (P<0.001). Subgroup analyses by anesthesia type and prior statin use showed consistent findings. MACE occurred in three patients (5.4%) in the statin group and two patients (3.6%) in the placebo group (P=1.00).
Conclusion: Preoperative high-dose atorvastatin significantly reduced postoperative hs-cTn levels, indicating a biochemical cardioprotective effect, but it did not translate into a reduction of short-term clinical cardiovascular events. Larger multicenter trials with longer follow-up are required to determine whether troponin reduction translates into improved clinical outcomes.

Background: Percutaneous coronary intervention (PCI) is a cornerstone in the management of obstructive coronary artery disease. The Gensini score quantitatively assesses the severity and complexity of coronary lesions. The residual Gensini score (rGensini), measured after PCI, may offer superior prognostic information compared with the baseline score. This study aimed to investigate the association between rGensini and cardiac mortality.
Methods: In this study, all consecutive patients who registered for follow-up at the Afshar Hospital Health Promotion Center within 30 days after PCI were included. The primary outcome was cardiac mortality. Baseline characteristics, comorbidities (diabetes, hypertension, dyslipidemia, and prior cardiac history), smoking status, family history, coronary dominance pattern, and coronary calcification were recorded. Patients were stratified into four risk categories based on rGensini: zero-risk (0), low-risk (>0 to ≤11), moderate-risk (>11 to ≤37), and high-risk (>37). Survival analysis was performed using the Kaplan-Meier method, and independent predictors of cardiac mortality were identified using Cox proportional hazards regression.
Results: The study included 141 patients (85 men and 56 women) with a mean age of 60.67 years. The mean Gensini score decreased from 31.22 at baseline to 18.20 after PCI. Over a median follow-up time of 9 months, 10 cardiac deaths occurred. Kaplan-Meier curves demonstrated a significant gradation in survival probability across the strata. Multivariable Cox regression analysis identified rGensini category, age, coronary calcification, diabetes, and hypertension as independent predictors of cardiac mortality.
Conclusion: This hypothesis-generating study suggests that the rGensini score is a promising and independent predictor of cardiac mortality after PCI.

Background: Myocardial infarction with nonobstructive coronary arteries (MINOCA) is a heterogeneous clinical entity characterized by evidence of myocardial infarction (MI) in the absence of obstructive coronary artery disease (CAD) on angiography. This study aimed to explore and visualize the global research trends and hotspots of MINOCA using bibliometric approaches.
Methods: The search was performed on October 1, 2025, using the keyword “MINOCA” and its synonyms. Data were obtained from the Scopus, Web of Science, and PubMed databases and analyzed using RStudio (version 4.5.0), employing the Bibliometrix package (via Biblioshiny) alongside VOSviewer (version 1.6.20) for bibliometric visualization.
Results: A total of 1,562 publications related to MINOCA were identified, showing a marked increase in output over the past decade. The mean number of citations per article was 19.21, with the highest citation count occurring in 2018. International Journal of Cardiology published the most articles, while F. Crea was the most contributing author. The United States, Italy, and China emerged as leading contributors. High-impact articles primarily focused on the pathophysiology, diagnostic algorithms, and prognosis of MINOCA. Keyword analysis revealed evolving research hotspots, including pathophysiology, imaging diagnostics, prognosis, therapy, and sex differences, indicating a growing focus on precision diagnostics and patient-tailored management strategies in MINOCA research.
Conclusion: The research landscape of MINOCA has expanded substantially, with growing attention to its underlying mechanisms and diagnostic challenges. Future studies should prioritize the development of standardized diagnostic criteria and the implementation of tailored therapeutic approaches. This bibliometric analysis provides a valuable framework for clinicians and researchers to navigate the evolving field of MINOCA.

Background: Myxedema crisis, which occurs due to hypothyroidism, is a rare and life-threatening condition that can lead to severe myocardial infarction and lethal arrhythmia, as presented in this case.
Case Presentation: A 63-year-old man presented with typical prolonged chest pain, palpitations leading to near syncope, severe fatigue, loss of appetite, dizziness, and somnolence 2 days before admission. The patient exhibited somnolence, hypotension, thin eyebrows, and pretibial pitting edema. Electrocardiography revealed sinus rhythm with a prolonged QT interval, inferolateral-anterior ischemia, and a troponin-T value five times above the upper limit of normal. Therefore, the working diagnosis included non–ST-elevation myocardial infarction Killip IV, severe biventricular heart failure, severe acute kidney injury, and severe acute liver injury. On the third day of treatment, the patient experienced two consecutive episodes of unstable ventricular tachycardia and one episode of return of spontaneous circulation cardiac arrest. Thyroid examination incidentally revealed severe hypothyroidism with severe hyperkalemia. After other causes were excluded, the diagnosis of myxedema crisis was assumed. Oral thyroid therapy, levothyroxine (100 µg once daily), was administered. Within 3 days of initiating all treatments, the patient experienced significant hemodynamic improvement, improved kidney function, and normalization of liver function, accompanied by the disappearance of dyspnea, chest pain, and edema, with a compos mentis status. The patient was discharged with stable hemodynamics without support on the tenth day of treatment and underwent a coronary computed tomography angiography at an outpatient facility, which showed near-normal coronary results. The patient has been on routine follow-up for almost 1 year with levothyroxine (50 µg once daily) and has recently demonstrated good left ventricular function (ejection fraction=50%) and good functional capacity on an exercise test.
Conclusion: Clinicians should consider hypothyroidism crisis in the differential diagnosis for myocardial infarction, heart failure, and lethal arrhythmia, and treatment should be initiated immediately.

Percutaneous Transvenous Mitral Commissurotomy (PTMC) remains the standard intervention for rheumatic mitral stenosis in suitable candidates. Conventional septal puncture and balloon entry can occasionally be challenging in cases with distorted left atrial anatomy or unfavorable interatrial septal orientation.In such situations ,the catheter is looped within the left atrium in a reverse configuration. This maneuver redirects the balloon tip toward the mitral orifice, enabling smoother passage across the valve without repeated manipulations or risk of atrial injury.The reverse loop technique provides improved control, reduces procedural time, and minimizes trauma to the atrial wall in anatomically difficult cases. Early procedural success and hemodynamic improvement are comparable to standard PTMC.

Background: The coronary slow flow phenomenon (CSFP) involves delayed coronary artery filling without obstruction and is associated with angina and myocardial ischemia. This meta-analysis assessed the link between CSFP and impaired left ventricular global longitudinal strain (LVGLS), a marker of subclinical myocardial dysfunction.
Methods: A systematic search (PubMed, Embase, Scopus up to January 2025) identified 18 observational studies comparing LVGLS and layer-specific strain in patients with CSFP vs controls with normal coronary flow.
Results: Patients with CSFP showed significantly reduced LVGLS vs controls (SMD, 1.22; 95% CI, 0.69 to 1.75). Layer-specific analysis revealed impairment across all myocardial layers, most pronounced in the endocardium (SMD, 0.79; 95% CI, 0.21 to 1.38). While left ventricular ejection fraction (LVEF) was preserved, LVGLS demonstrated moderate-to-high diagnostic accuracy for CSFP (AUC, 0.80; 95% CI, 0.66 to 0.95). Reduced LVGLS independently predicted CSFP (adjusted OR, 1.43; 95% CI, 1.19 to 1.46). Exercise stress effects on LVGLS were inconsistent.
Conclusion: CSFP is associated with impaired LVGLS, particularly in the endocardial layer, despite preserved LVEF. LVGLS may serve as a noninvasive marker for subclinical dysfunction in CSFP.