Archives of Cardiovascular Diseases最新文献_第10页

Cardiac amyloidosis and heart failure phenotypes: A prognostic study of systolic function markers 心脏淀粉样变性和心力衰竭表型：收缩功能标志物的预后研究

IF 2.2 3区医学 Q2 CARDIAC & CARDIOVASCULAR SYSTEMS

Archives of Cardiovascular Diseases

Pub Date : 2026-01-01 DOI: 10.1016/j.acvd.2025.10.086

A. Zaroui , S. Belaid , M. Kharoubi , S. Oghina , S. Odouard , E. Teiger , T. Damy

Introduction

Cardiac amyloidosis (CA), including light chain (AL), hereditary transthyretin (ATTRv), and wild-type transthyretin (ATTRwt), leads to heart failure (HF). Cardiologists use the ESC guidelines to classify patients with HF tailoring HF treatment accordingly. CA is commonly associated with HFpEF, with a smaller proportion presenting with HFmrEF and HFrEF.

Objective

This study aimed to assess the distribution of HF types in CA and their relationship with other left ventricular (LV) systolic function parameters such as global longitudinal strain (GLS) and cardiac index (CI) across amyloidosis subtypes.

Method

We retrospectively included symptomatic AL, ATTRv, and ATTRwt CA patients from our French referral center. LVEF was classified per ESC guidelines and compared to GLS and CI. Survival was assessed using Kaplan-Meier analyses and Cox regression. A decision tree incorporating LVEF, GLS, and CI was used to stratify patients into prognostic groups.

Results

Among 2244 patients, 557 AL, 392 ATTRv, 1137A TTRwt. Of these, 61.4% presented with HFpEF, 19.0% with HFmrEF, and 19.6% with HFrEF. In AL, 13.6%, 18%, and 68.4% were classified as HFrEF, HFmrEF, and HFpEF, respectively. In ATTRv, 28.3%, 15.3%, and 56.4% were HFrEF, HFmrEF, and HFpEF, respectively. In ATTRwt, 20.2%, 21.2%, and 58.6% were HFrEF, HFmrEF, and HFpEF, respectively. LVEF correlated moderately with GLS (r = 0.673), with stronger correlations in ATTRv (r = 0.776) compared to AL (r = 0.650) and ATTRwt (r = 0.644). LVEF correlated weakly with CI (r = 0.392). Median survival was 7 months [3–31] for AL, 28 months [12–54] for ATTRv, and 23 months [10–38] for ATTRwt. Survival differed by HF type: 30 months [18–41] for HFrEF, 40 months [20–42] for HFmrEF, and 51% survival at 48 months for HFpEF. A CI ≤ 1.96 L/min/m² was associated with a median survival of 29 months [17–37], with better outcomes in higher CI quartiles. A decision tree identified four prognostic groups, with hazard ratios for 4-year mortality ranging from 1.63 (LVEF ≥ 50%, GLS ≤ 11%) to 3.68 (LVEF ≤ 49%, CI ≤ 1.96 L/min/m²), reaching 12.34 in AL amyloidosis for the most severe group.

Conclusion

In CA, about 40% of patients present with reduced LVEF. Cardiologists should be aware that CA is not exclusively associated with HFpEF and that patients with reduced LVEF have worse prognosis. LV systolic function, assessed via LVEF, GLS, and CI, is a critical predictor of survival in CA, with distinct patterns across AL, ATTRv, and ATTRwt subtypes.

心脏淀粉样变性（CA），包括轻链（AL）、遗传性甲状腺转素（ATTRv）和野生型甲状腺转素（ATTRwt），可导致心力衰竭（HF）。心脏病专家使用ESC指南对心衰患者进行分类，相应地调整心衰治疗。CA通常与HFpEF相关，以HFmrEF和HFrEF为表现的比例较小。目的探讨不同淀粉样变性亚型CA中HF类型的分布及其与其他左心室收缩功能参数（如全局纵应变（GLS）和心脏指数（CI））的关系。方法回顾性研究来自法国转诊中心的有症状的AL、ATTRv和attrt CA患者。根据ESC指南对LVEF进行分类，并与GLS和CI进行比较。生存率采用Kaplan-Meier分析和Cox回归进行评估。采用结合LVEF、GLS和CI的决策树将患者分为预后组。结果2244例患者中，AL 557例，ATTRv 392例，TTRwt 1137A。其中，61.4%为HFpEF， 19.0%为HFmrEF， 19.6%为HFrEF。AL中，HFrEF、HFmrEF和HFpEF分别占13.6%、18%和68.4%。在ATTRv中，HFrEF、HFmrEF和HFpEF分别占28.3%、15.3%和56.4%。在ATTRwt中，HFrEF、HFmrEF和HFpEF分别占20.2%、21.2%和58.6%。LVEF与GLS有中度相关性（r = 0.673），与AL （r = 0.650）和ATTRwt （r = 0.644）相比，ATTRv的相关性更强（r = 0.776）。LVEF与CI呈弱相关（r = 0.392）。AL的中位生存期为7个月[3-31]，ATTRv为28个月[12-54]，attrt为23个月[10-38]。不同HF类型的生存期不同：HFrEF为30个月[18-41]，HFmrEF为40个月[20-42]，HFpEF为48个月时51%的生存期。CI≤1.96 L/min/m2与中位生存期为29个月相关[17-37]，CI越高，预后越好。决策树确定了4个预后组，4年死亡率的风险比从1.63 （LVEF≥50%,GLS≤11%）到3.68 (LVEF≤49%,CI≤1.96 L/min/m2)，最严重组AL淀粉样变性达到12.34。结论在CA中，约40%的患者表现为LVEF降低。心脏病专家应该意识到CA并不仅仅与HFpEF相关，LVEF降低的患者预后更差。通过LVEF、GLS和CI评估的左室收缩功能是CA患者生存的关键预测因子，在AL、ATTRv和ATTRwt亚型中具有不同的模式。

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引用次数: 0

Effect of telemonitoring implementation on heart failure hospitalization profiles: A real-world analysis 远程监护实施对心力衰竭住院概况的影响：现实世界的分析

IF 2.2 3区医学 Q2 CARDIAC & CARDIOVASCULAR SYSTEMS

Archives of Cardiovascular Diseases

Pub Date : 2026-01-01 DOI: 10.1016/j.acvd.2025.10.090

P. Lemiere , J. Quilici , A.-S. Canu , L. Querion , E. Saunier , A. Vaudron

Introduction

Heart failure (HF) remains a leading cause of hospitalization and mortality worldwide. Remote monitoring programs (RMP) are increasingly implemented to optimize care, yet their real-world impact on hospitalized patient characteristics remains underexplored.

Objective

This study aimed to assess changes in the clinical profiles and outcomes of patients hospitalized for acute heart failure (AHF) before and after the implementation of a RMP in a rural cardiology department.

Method

We conducted a retrospective, single-center, study focusing HF-related hospitalizations (HFRH) in two periods: 2018–2019 with standard care; and 2023–2024 post RMP implementation, combining non-invasive remote weight monitoring, therapeutic education, and early home-based intervention by a mobile HF team. Data were extracted using ICD-10 codes.

Results

Among 4092 admissions, we selected 1364 HFRH (610 in 2018–2019 vs. 754 in 2023–2024), patients in the post RMP period showed higher severity (High GHM levels 51.5% vs. 45.6%, P = 0.031; mean IGS2 score: 37.7 vs. 35.1, P < 0.0001), longer hospital stays (mean 9.5 vs. 8.9 days, P < 0.001), more emergency admissions (66.6% vs. 39.4%, P < 0.0001), non-significant increased mortality (6.1% vs 3.9%, P 0.07). However, rehospitalizations decreased (13.4% vs. 18.1%, P = 0.03), and discharges to home increased (61.0% vs. 49.3%, P < 0.0001) (Fig. 1).

Conclusion

The implementation of the RMP improved post-discharge outcomes and was associated with a shift toward hospitalization of more severe heart failure patients, likely reflecting earlier outpatient management of milder cases. These findings support telemonitoring as an effective tool in real-world heart failure management and underscore its role in the ongoing digital transformation of care pathways.

心力衰竭（HF）仍然是世界范围内住院和死亡的主要原因。远程监控程序（RMP）越来越多地用于优化护理，但它们对住院患者特征的实际影响仍未得到充分探讨。目的：本研究旨在评估农村心内科实施RMP前后急性心力衰竭（AHF）住院患者的临床概况和预后的变化。方法：我们进行了一项回顾性、单中心研究，重点研究了2018-2019年标准治疗的hf相关住院（HFRH）；以及2023-2024年实施RMP后，结合无创远程体重监测、治疗性教育和HF移动团队的早期家庭干预。使用ICD-10编码提取数据。结果在4092例入院患者中，我们选择了1364例HFRH（2018-2019年为610例，2023-2024年为754例），RMP后患者表现出更高的严重程度（高GHM水平为51.5%对45.6%,P = 0.031；平均IGS2评分：37.7对35.1,P < 0.0001），更长的住院时间（平均9.5对8.9天，P < 0.001），更多的急诊入院（66.6%对39.4%,P < 0.0001），死亡率无显著增加（6.1%对3.9%,P = 0.07）。然而，再住院率下降（13.4%比18.1%,P = 0.03），出院率增加（61.0%比49.3%,P < 0.0001）（图1）。RMP的实施改善了出院后的预后，并与更严重心力衰竭患者住院的转变有关，这可能反映了较轻病例的早期门诊管理。这些发现支持远程监测作为现实世界心力衰竭管理的有效工具，并强调其在正在进行的护理途径数字化转型中的作用。

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引用次数: 0

Variability in ACT response to standard UFH bolus during PCI: A prospective study on determinants of subtherapeutic anticoagulation PCI期间ACT对标准UFH丸反应的变异性：亚治疗抗凝决定因素的前瞻性研究

IF 2.2 3区医学 Q2 CARDIAC & CARDIOVASCULAR SYSTEMS

Archives of Cardiovascular Diseases

Pub Date : 2026-01-01 DOI: 10.1016/j.acvd.2025.10.006

M.C. Vu , A. Trimaille , A. Granier , A. Carmona , A. Elidrissi , M. Kibler , L. Jesel , P. Olhmann , L. Sattler , O. Morel

Introduction

Unfractionated heparin (UFH) remains the standard anticoagulant during percutaneous coronary intervention (PCI), with guidelines recommending a target activated clotting time (ACT) ≥ 250 seconds. However, despite receiving a standardized bolus dose, many patients fail to achieve this target.

Objective

To evaluate the effectiveness of standard UFH bolus dosing in achieving target ACT and to identify patient-related factors associated with suboptimal anticoagulant response.

Method

This single-center, prospective, observational study included 171 adult patients undergoing PCI between October 2024 and April 2025. All patients received a 100-IU/kg intravenous UFH bolus immediately prior to PCI. ACT was measured 5 minutes post-administration, additional 50 IU/kg boluses were given as needed to achieve the target ACT ≥ 250 seconds. The primary endpoint was the percentage of patients achieving this target. The secondary endpoint was the identification of factors associated with suboptimal anticoagulation.

Results

Among 171 patients (mean age, 68 ± 12 years; 26.3% women), the target ACT was achieved in 35.7% (n = 61), while 64.3% (n = 110) did not (Table 1). Active smoking was independently associated with failure to reach the target ACT (adjusted OR, 6.06; 95% CI, 1.41 to 43.8; P = 0.032) (Fig. 1). Despite similar initial UFH dosing and timing to ACT measurement, smokers had significantly lower ACT values (P < 0.001) and required higher cumulative UFH dose during PCI (P = 0.043) (Fig. 2). Propensity score matching confirmed this independent association (P = 0.004) (Fig. 3).

Conclusion

Nearly two-thirds of patients failed to achieve the recommended target ACT following a standard UFH bolus during PCI, in which active smoking was independently associated with a more than sixfold reduction in the likelihood of reaching therapeutic anticoagulation.

在经皮冠状动脉介入治疗（PCI）期间，未分级肝素（UFH）仍然是标准的抗凝剂，指南建议靶活化凝血时间(ACT)≥250秒。然而，尽管接受了标准的丸剂剂量，许多患者未能达到这一目标。目的评价标准UFH大剂量在实现ACT目标中的有效性，并确定与抗凝反应次优相关的患者相关因素。方法这项单中心、前瞻性、观察性研究纳入了171例2024年10月至2025年4月期间接受PCI治疗的成年患者。所有患者在PCI前立即接受100 iu /kg静脉注射UFH。给药后5分钟测量ACT，根据需要额外给予50 IU/kg，以达到ACT≥250秒的目标。主要终点是达到这一目标的患者百分比。次要终点是确定与次优抗凝相关的因素。结果171例患者（平均年龄68±12岁，女性26.3%）中，35.7% （n = 61）的患者达到了ACT目标，64.3% （n = 110）的患者未达到ACT目标（表1）。主动吸烟与未能达到目标ACT独立相关（调整后OR为6.06；95% CI为1.41 ~ 43.8;P = 0.032）（图1）。尽管初始UFH剂量和时间与ACT测量相似，但吸烟者的ACT值明显较低（P < 0.001），并且在PCI期间需要更高的累积UFH剂量（P = 0.043）（图2）。倾向评分匹配证实了这种独立关联（P = 0.004）（图3）。结论：近三分之二的患者在PCI期间接受标准UFH后未能达到推荐的目标ACT，其中主动吸烟与达到治疗性抗凝治疗的可能性降低6倍以上独立相关。

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引用次数: 0

Impact of daily coronary CT angiography implementation on invasive coronary angiography in chronic coronary syndrome: A single-center experience 慢性冠脉综合征患者每日冠脉CT血管造影对侵入性冠脉造影的影响：单中心研究

IF 2.2 3区医学 Q2 CARDIAC & CARDIOVASCULAR SYSTEMS

Archives of Cardiovascular Diseases

Pub Date : 2026-01-01 DOI: 10.1016/j.acvd.2025.10.007

C. Thuaire, F. Bahri, A. Benjemaa, C.A.B. Samb, R. Hakim, G. Rangé, F. Albert

Introduction

Coronary computed tomography angiography (CCTA) has become a first-line imaging modality for the diagnosis of coronary atherosclerosis in patients with chronic coronary syndrome (CCS). It is primarily considered a means to reduce unnecessary invasive procedures, particularly normal or non-significant coronary angiographies.

Objective

To evaluate the impact of the implementation of a daily CCTA activity on the rate and diagnostic yield of invasive coronary angiographies performed for CCS at Chartres Hospital.

Method

In February 2024, daily CCTA was introduced at Chartres Hospital using a Canon Aquilion One® wide-detector CT scanner (16 cm coverage). Each scan was systematically coupled with a cardiology consultation at the time of result delivery, including treatment prescription and patient orientation based on CAD-RADS classification. A total of 2490 CCTAs were performed over the year, representing a 2.9-fold increase in imaging activity compared to previous years.

Using data from the France PCI registry, we assessed the impact of this implementation on coronary angiographies performed for stable angina and/or silent ischemia by comparing the rates of normal angiograms, lesions < 50%, and lesions > 50% from February 2024 to April 2025 against the mean of the three previous years (February 2021 to January 2024).

Results

Although total annual coronary angiography volume did not significantly increase (adjusted total for 2024–2025: 846 patients vs. 701 in previous years; P = 0.13), we observed a significant rise in the number of angiographies with lesions < 50% (248 vs. 181; P = 0.029), but more importantly a highly significant increase in angiographies showing lesions > 50%: monovessel (245 vs. 155; P = 0.0017), bivessel (197 vs. 113; P = 0.0009), and trivessel disease (169 vs. 119; P = 0.045).

Conclusion

Compared to the average of the three previous years, daily CCTA implementation did not significantly change the overall volume of coronary angiography in CCS patients in our center, nor did it significantly reduce the rate of normal angiograms. However, it was associated with a moderate but significant increase in < 50% lesions, and most importantly a marked and highly significant increase in angiographies with > 50% stenosis.

Daily CCTA combined with structured cardiology consultation improves patient selection and substantially enhances the diagnostic yield of invasive coronary angiography.

冠状动脉ct血管造影（CCTA）已成为慢性冠状动脉综合征（CCS）患者冠状动脉粥样硬化诊断的一线成像方式。它主要被认为是一种减少不必要的侵入性手术的手段，特别是正常或不重要的冠状动脉造影。目的评价每日CCTA活动对Chartres医院有创冠状动脉造影诊断率和诊断率的影响。方法2024年2月，Chartres医院开始使用Canon Aquilion One®宽探测器CT扫描仪（16 cm覆盖范围）进行每日CCTA。每次扫描在结果发布时系统地与心脏病学咨询相结合，包括基于CAD-RADS分类的治疗处方和患者定位。全年共进行了2490次ccta，与前几年相比，成像活动增加了2.9倍。使用来自法国PCI登记处的数据，我们通过比较2024年2月至2025年4月正常血管造影、病变<； 50%和病变>； 50%与前三年（2021年2月至2024年1月）的平均值，评估了该实施对稳定性心绞痛和/或无症状缺血进行冠状动脉造影的影响。ResultsAlthough年度冠状动脉造影总量没有显著增加(2024 - 2025年调整后的总:846名患者和701名在前几年;P = 0.13),我们观察到显著上升的数量与病变血管摄影& lt; 50% (248 vs 181; P = 0.029),但更重要的是一个高度显著增加血管造影显示病变在50%:monovessel (245 vs 155; P = 0.0017), bivessel (197 vs 113; P = 0.0009),和trivessel疾病(169 vs 119; P = 0.045)。结论与前三年的平均值相比，每日CCTA的实施并没有显著改变我中心CCS患者冠状动脉造影总容积，也没有显著降低正常血管造影率。然而，它与中度但显著增加50%病变相关，最重要的是，血管造影显示50%狭窄的显著且高度显著增加。每日CCTA结合结构化的心脏病学会诊，改善了患者的选择，大大提高了有创冠状动脉造影的诊断率。

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引用次数: 0

ExtraCorporeal life support versus IMPELLA® pump as Bridge to Left ventricular Assist Device (ECI-BLAD trial) 体外生命支持与IMPELLA®泵作为左心室辅助装置的桥梁（ECI-BLAD试验）

IF 2.2 3区医学 Q2 CARDIAC & CARDIOVASCULAR SYSTEMS

Archives of Cardiovascular Diseases

Pub Date : 2026-01-01 DOI: 10.1016/j.acvd.2025.10.072

O. Simon , A. Quessard , N. Labaste , P.-G. Guinot , N. Nesseler , A. Beurton , P. Gaudard , A. Ouattara

Introduction

Among patients treated by temporary mechanical circulatory support (tMCS) for refractory cardiogenic shock, some of them suffer from persistent cardiac dysfunction incompatible with a successful weaning. In eligible patients, the heart transplantation is still the gold standard therapy. However, due to the shortage of grafts and/or contraindications, some patients will not be transplanted. In these patients, for whom the Left ventricular Assist Device (LVAD) represents an alternative therapy, the best approach of tMCS as a bridge to durable LVAD remains to be clarified.

Objective

We tested the hypothesis that the use of IMPELLA® as bridge to LVAD should improve early postoperative outcomes by offering the opportunité of active rehabilitation under tMCS.

Method

The ECI-BLAD trial was a multicentre retrospective study including adults, supported with IMPELLA® or ECLS as a bridge to LVAD between January 2012 and December 2020 in 5 French cardiac intensive care units. The IMPELLA® group included patients assisted by an IMPELLA® alone at least five days prior the implantation of the LVAD while the ECLS group included patients treated by a ECLS with or without IMPELLA®. The primary endpoint was the proportion of patients alive with a John Hopkins Highest Level of Mobility score = 8, discharged from the critical care unit and not perfused at 30 days after LVAD implantation. Secondary endpoints included rehabilitation under tMCS (tracheal extubation, mobilization to chair, walking and cyclo-ergometer), 6-month survival rate after the LVAD implantation. This study was approved by our ethics committee and registered on Clinical trials (NCT04480151).

Results

From 388 consecutive patients implanted by LVAD, 92 patients treated as bridge to LVAD have been included in our study (ECLS group n = 42/IMPELLA group n = 50). Most of patients of IMPELLA group (72%) were implanted through an axillary approach. Early mobilization on tMCS was more frequently achieved in IMPELLA group (seating 50% vs 2%, P < 0.001 and walking 18% vs 0%, P < 0.01). A larger proportion of patients in IMPELLA group reached the primary endpoint (52% vs 26%, P = 0.018). The 6-month survival rate after LVAD implantation was significantly better in IMPELLA group (Fig. 1).

Conclusion

Implantation of IMPELLA through axillary approach as bridge to LVAD by allowing active and early rehabilitation might be associated with better outcomes.

在接受临时机械循环支持（tMCS）治疗难治性心源性休克的患者中，一些患者患有持续性心功能障碍，与成功脱机不相容。在符合条件的患者中，心脏移植仍然是金标准治疗。然而，由于移植物短缺和/或禁忌症，一些患者不会进行移植。在这些患者中，左心室辅助装置（LVAD）是一种替代疗法，tMCS作为持久左心室辅助装置的桥梁的最佳方法仍有待明确。目的：通过提供tMCS下主动康复的机会，我们验证了使用IMPELLA®作为LVAD桥应改善早期术后预后的假设。ECI-BLAD试验是一项多中心回顾性研究，包括成人，在2012年1月至2020年12月期间，在5个法国心脏重症监护病房中使用IMPELLA®或ECLS作为LVAD的桥梁。IMPELLA®组包括在LVAD植入前至少5天单独使用IMPELLA®辅助的患者，而ECLS组包括使用或不使用IMPELLA®的ECLS治疗的患者。主要终点是在LVAD植入后30天，John Hopkins最高活动水平评分= 8、从重症监护病房出院且未进行灌注的存活患者比例。次要终点包括tMCS下的康复（气管拔管，椅子活动，步行和循环计劳器），LVAD植入后6个月的生存率。本研究经伦理委员会批准，注册临床试验（NCT04480151）。结果在连续388例LVAD植入患者中，92例作为LVAD桥接患者纳入我们的研究（ECLS组42例/IMPELLA组50例）。IMPELLA组大部分患者（72%）采用腋窝入路植入术。IMPELLA组在tMCS上的早期活动更频繁（坐下50%对2%，P < 0.001，步行18%对0%，P < 0.01）。IMPELLA组达到主要终点的患者比例较大（52% vs 26%, P = 0.018）。IMPELLA组LVAD植入后6个月生存率明显优于IMPELLA组（图1）。结论经腋窝入路植入IMPELLA作为LVAD的桥梁，早期主动康复治疗效果较好。

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引用次数: 0

Correlation between perivascular retinal ischemic lesions (RIPL) and the severity of coronary lesions in patients with acute coronary syndrome 急性冠脉综合征患者血管周围视网膜缺血性病变（RIPL）与冠脉病变严重程度的相关性

IF 2.2 3区医学 Q2 CARDIAC & CARDIOVASCULAR SYSTEMS

Archives of Cardiovascular Diseases

Pub Date : 2026-01-01 DOI: 10.1016/j.acvd.2025.10.013

A. Hassimi, Y. Outifa, A. Ech-Chenbouli, B. El Boussaadani, Z. Raissouni

Introduction

Perivascular retinal ischemic lesions (RIPL) may represent an ophthalmological marker of the severity of coronary artery disease.

Objective

Evaluate the correlation between the presence of RIPL and the severity of coronary lesions detected by coronary angiography in patients with acute coronary syndrome (ACS).

Method

This study included 200 patients who had presented with acute coronary syndrome (ACS) and significant coronary lesions (≥50% stenosis). All patients underwent a systematic ophthalmological evaluation to screen for perivascular retinal ischemic lesions (RIPL). To minimize bias related to diabetic retinopathy, diabetic patients were excluded from the study. The mean age of the patients was 61.4 years (±12.3), with a sex distribution of 41.1% male and 57.9% female. The most prevalent cardiovascular risk factors included hypertension (49.6%) and smoking (34.9%). The mean SYNTAX score was 14.3 (±5.0), reflecting varying degrees of coronary lesion complexity. Regarding the extent of coronary involvement, 16.4% of patients had single-vessel disease, 11.6% had two-vessel disease, and 9.6% had three-vessel disease. The most commonly affected arteries were the left anterior descending artery (75.7%), the circumflex artery (52.0%), and the right coronary artery (50.9%). In terms of treatment approach, 41.2% of patients underwent percutaneous coronary intervention (PCI) with stenting, while 14.6% required coronary artery bypass grafting (CABG) due to the complexity of their coronary disease.

Results

The results were satisfactory, highlighting an association between the presence of RIPL and the severity of coronary lesions. The presence of RIPL was significantly associated with multivessel disease (≥2 vessels) and bifurcation lesions. Furthermore, patients who underwent coronary artery bypass grafting or complex percutaneous intervention had an increased frequency of RIPL.

Conclusion

These findings suggest that the presence of RIPL could serve as a non-invasive ophthalmological marker to identify patients at high risk of developing ACS (STEMI, NSTEMI). A multidisciplinary approach integrating ophthalmology into cardiovascular risk assessment could improve coronary risk stratification. Long-term follow-up of patients with RIPL is necessary to confirm their prognostic value and refine their role in early diagnostic strategies.

血管周围视网膜缺血性病变（RIPL）可能是冠状动脉疾病严重程度的眼科标志。目的探讨急性冠脉综合征（ACS）患者冠脉造影中RIPL的存在与冠脉病变严重程度的相关性。方法本研究纳入200例以急性冠脉综合征（ACS）为临床表现，冠脉病变明显（冠脉狭窄≥50%）的患者。所有患者都进行了系统的眼科评估，以筛查血管周围视网膜缺血性病变（RIPL）。为了减少与糖尿病视网膜病变相关的偏倚，糖尿病患者被排除在研究之外。患者平均年龄61.4岁（±12.3岁），性别分布为男性41.1%，女性57.9%。最常见的心血管危险因素包括高血压（49.6%）和吸烟（34.9%）。SYNTAX平均评分为14.3（±5.0）分，反映冠脉病变复杂程度不同。在冠脉受累程度方面，16.4%的患者为单支血管病变，11.6%为双支血管病变，9.6%为三支血管病变。最常见的病变动脉为左前降支（75.7%）、旋支（52.0%）和右冠状动脉（50.9%）。在治疗方式上，41.2%的患者接受了经皮冠状动脉介入治疗（PCI）并支架植入术，14.6%的患者由于其冠状动脉疾病的复杂性需要冠状动脉旁路移植术（CABG）。结果结果令人满意，强调了RIPL的存在与冠状动脉病变严重程度之间的关联。RIPL的存在与多血管疾病（≥2条血管）和分叉病变显著相关。此外，接受冠状动脉旁路移植术或复杂经皮介入治疗的患者发生RIPL的频率增加。结论RIPL的存在可作为识别ACS （STEMI， NSTEMI）高危患者的非侵入性眼科标志物。将眼科纳入心血管风险评估的多学科方法可以改善冠状动脉风险分层。对RIPL患者进行长期随访是必要的，以确认其预后价值并完善其在早期诊断策略中的作用。

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引用次数: 0

Catecholaminergic strom and cardiac failure in children: Insights from severe scorpion envenomation cases 儿茶酚胺能性风暴和儿童心力衰竭：来自严重蝎子中毒病例的见解

IF 2.2 3区医学 Q2 CARDIAC & CARDIOVASCULAR SYSTEMS

Archives of Cardiovascular Diseases

Pub Date : 2026-01-01 DOI: 10.1016/j.acvd.2025.10.094

D.-D. Batouche , D. Boumendil , D. Batouche , Z.Z. Addou , H. Saddok , A. Bouguerra , F. Bounoua , F. Latreche , N.-F. Benatta , R. Okbani

Introduction

Scorpion envenomation is a common pediatric emergency in endemic regions. In its severe form, it may trigger a catecholaminergic storm leading to acute fulminant myocarditis. This cardiac involvement is a major prognostic factor but potentially reversible with intensive care management.

Objective

To describe the clinical, therapeutic, and prognostic features of severe scorpion envenomation (SE) in children, with a focus on cardiac involvement related to catecholaminergic myocarditis.

Method

We conducted prospective descriptive study involving 10 children admitted to pediatric intensive care for stage III scorpion envenomation between 2016 and 2024. Clinical, biological, echocardiographic, and outcome data were analyzed from medical records.

Results

The cohort included 8 boys and 2 girls, aged between 4 and 15 years. The average delay between the sting and admission was 8.5 ± 1.2 hours.

All patients presented with respiratory distress: tachypnea, severe hypoxemia (average SpO₂: 70%), and crackles on auscultation. Neurological signs included agitation (7 cases), stage II coma (2 cases), fasciculations (7 cases), and myoclonus (4 cases). Hemodynamically, all children exhibited cardiovascular collapse with a mean heart rate of 132 bpm. Chest imaging revealed fluffy pulmonary opacities consistent with acute pulmonary edema. Echocardiography showed marked left ventricular depression with global hypokinesia, apical ballooning, and significantly reduced ejection fraction (average 12%). Biological findings included elevated CPK and troponin levels, hyperglycemia in 2 cases, and acute kidney injury classified as stage R of the pediatric RIFLE score in 2 patients.

All children required mechanical ventilation, vasopressor support, cautious fluid resuscitation guided by echocardiographic preload assessment, and diuretics in 2 cases. Clinical outcomes were favorable in 9 patients, with one fatal case.

Conclusion

Catecholaminergic myocarditis represents the cornerstone of clinical severity in pediatric severe scorpion envenomation. Although dramatic, it is potentially reversible with appropriate and timely intensive care management.

蝎子中毒是流行地区常见的儿科急症。在其严重的形式，它可能引发儿茶酚胺能风暴导致急性暴发性心肌炎。这种心脏受累是一个主要的预后因素，但通过重症监护管理可能是可逆的。目的描述儿童严重蝎子中毒（SE）的临床、治疗和预后特点，重点关注儿茶酚胺能性心肌炎相关的心脏损害。方法采用前瞻性描述性研究，纳入2016 - 2024年间10例小儿重症监护III期蝎子中毒患儿。从医疗记录中分析临床、生物学、超声心动图和结局数据。结果该队列包括8名男孩和2名女孩，年龄在4 ~ 15岁之间。蜇伤至入院平均延迟8.5±1.2小时。所有患者均表现为呼吸窘迫：呼吸急促，严重低氧血症（平均SpO2: 70%），听诊时有杂音。神经学症状包括躁动（7例）、II期昏迷（2例）、束状震颤（7例）和肌阵挛（4例）。血流动力学方面，所有儿童均表现出心血管衰竭，平均心率为132次/分钟。胸部影像显示绒毛状肺混浊，符合急性肺水肿。超声心动图显示明显的左心室凹陷伴整体运动减退，心尖球囊化，射血分数明显降低（平均12%）。生物学结果包括CPK和肌钙蛋白水平升高，2例高血糖，2例急性肾损伤，小儿RIFLE评分为R期。所有患儿均需要机械通气、血管加压支持、超声心动图预负荷评估指导下的谨慎液体复苏，2例患儿需要利尿剂。9例患者临床结果良好，1例死亡。结论儿茶酚胺能性心肌炎是小儿重度蝎子中毒临床严重程度的基础。虽然严重，但通过适当和及时的重症监护管理，可能是可逆的。

{"title":"Catecholaminergic strom and cardiac failure in children: Insights from severe scorpion envenomation cases","authors":"D.-D. Batouche , D. Boumendil , D. Batouche , Z.Z. Addou , H. Saddok , A. Bouguerra , F. Bounoua , F. Latreche , N.-F. Benatta , R. Okbani","doi":"10.1016/j.acvd.2025.10.094","DOIUrl":"10.1016/j.acvd.2025.10.094","url":null,"abstract":"<div><h3>Introduction</h3><div>Scorpion envenomation is a common pediatric emergency in endemic regions. In its severe form, it may trigger a catecholaminergic storm leading to acute fulminant myocarditis. This cardiac involvement is a major prognostic factor but potentially reversible with intensive care management.</div></div><div><h3>Objective</h3><div>To describe the clinical, therapeutic, and prognostic features of severe scorpion envenomation (SE) in children, with a focus on cardiac involvement related to catecholaminergic myocarditis.</div></div><div><h3>Method</h3><div>We conducted prospective descriptive study involving 10 children admitted to pediatric intensive care for stage III scorpion envenomation between 2016 and 2024. Clinical, biological, echocardiographic, and outcome data were analyzed from medical records.</div></div><div><h3>Results</h3><div>The cohort included 8 boys and 2 girls, aged between 4 and 15 years. The average delay between the sting and admission was 8.5±1.2hours.</div><div>All patients presented with respiratory distress: tachypnea, severe hypoxemia (average SpO<sub>2</sub>: 70%), and crackles on auscultation. Neurological signs included agitation (7 cases), stage II coma (2 cases), fasciculations (7 cases), and myoclonus (4 cases). Hemodynamically, all children exhibited cardiovascular collapse with a mean heart rate of 132 bpm. Chest imaging revealed fluffy pulmonary opacities consistent with acute pulmonary edema. Echocardiography showed marked left ventricular depression with global hypokinesia, apical ballooning, and significantly reduced ejection fraction (average 12%). Biological findings included elevated CPK and troponin levels, hyperglycemia in 2 cases, and acute kidney injury classified as stage R of the pediatric RIFLE score in 2 patients.</div><div>All children required mechanical ventilation, vasopressor support, cautious fluid resuscitation guided by echocardiographic preload assessment, and diuretics in 2 cases. Clinical outcomes were favorable in 9 patients, with one fatal case.</div></div><div><h3>Conclusion</h3><div>Catecholaminergic myocarditis represents the cornerstone of clinical severity in pediatric severe scorpion envenomation. Although dramatic, it is potentially reversible with appropriate and timely intensive care management.</div></div>","PeriodicalId":55472,"journal":{"name":"Archives of Cardiovascular Diseases","volume":"119 1","pages":"Page S53"},"PeriodicalIF":2.2,"publicationDate":"2026-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145904120","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

引用次数: 0

Improved heart failure after myocardial infarction: Myth or reality? 心肌梗死后心力衰竭的改善：神话还是现实？

IF 2.2 3区医学 Q2 CARDIAC & CARDIOVASCULAR SYSTEMS

Archives of Cardiovascular Diseases

Pub Date : 2026-01-01 DOI: 10.1016/j.acvd.2025.10.095

S. Abid, T. Ellouze, M. Jabeur, A. Bahloul, L. Abid

Introduction

With the advent of modern pharmacological therapies and advanced interventional strategies, there is growing interest in reassessing the heart's capacity for functional recovery. Understanding the interplay between myocardial damage, therapeutic intervention, and potential reversibility is essential for optimizing long-term outcomes in patients with ischemic heart failure.

Objective

To identify predictors of improving Left ventricular contractility after myocardial infarction.

Method

We conducted a retrospective study including all patients admitted to the Cardiology Department at Hedi Chaker University Hospital between April 1, 2022, and March 31, 2023, with a diagnosis of ST-elevation myocardial infarction (STEMI). Clinical, echocardiographic, and angiographic data were collected and analyzed. Left ventricular ejection fraction (LVEF) was assessed by experienced operators. Left ventricular dysfunction was defined as LVEF < 40%, and improvement was defined as LVEF > 40%. Revascularization indications followed international guidelines.

Results

A total of 342 patients with STEMI were included. The prevalence of LV dysfunction was 28.65%, with 98 patients having an initial LVEF < 40% on admission. Among them, only 25 patients (25.5%) underwent a follow-up echocardiography at 40 days post-STEMI, and 17 of those showed improved LVEF (> 40%). Multivariate analysis identified three independent predictors of improved LVEF: optimal heart failure treatment including the four recommended drug classes (P < 0.001; OR = 2.46), female sex (P = 0.001; OR = 4.61), and good adherence to therapy (P = 0.019; OR = 2.27). Smoking was less common among patients with improved LVEF but was not an independent predictor.

Conclusion

In our study, we evaluated the occurrence of improved ejection fraction in patients who developed heart failure following myocardial infarction. Female sex, adherence to therapy, and being discharged on optimal heart failure medication were associated with improved LVEF. These findings support the potential for recovery of systolic function under appropriate conditions.

随着现代药物治疗和先进介入策略的出现，人们对重新评估心脏功能恢复能力的兴趣越来越大。了解心肌损伤、治疗干预和潜在可逆性之间的相互作用对于优化缺血性心力衰竭患者的长期预后至关重要。目的探讨心肌梗死后左室收缩力改善的预测因素。方法回顾性研究，纳入2022年4月1日至2023年3月31日在Hedi Chaker大学附属医院心内科诊断为st段抬高型心肌梗死（STEMI）的所有患者。收集并分析临床、超声心动图和血管造影资料。由经验丰富的操作人员评估左室射血分数（LVEF）。左心室功能不全定义为LVEF <； 40%，改善定义为LVEF >； 40%。血运重建指征遵循国际指南。结果共纳入342例STEMI患者。左室功能障碍的患病率为28.65%，其中98例患者入院时初始LVEF为40%。其中，仅有25例（25.5%）患者在stemi后40天接受了随访超声心动图检查，其中17例患者LVEF改善（40%）。多变量分析确定了改善LVEF的三个独立预测因素：最佳心力衰竭治疗包括四种推荐的药物类别（P < 0.001; OR = 2.46），女性（P = 0.001; OR = 4.61），以及良好的治疗依从性（P = 0.019; OR = 2.27）。吸烟在LVEF改善的患者中较少见，但不是一个独立的预测因子。结论：在我们的研究中，我们评估了心肌梗死后心力衰竭患者射血分数改善的发生情况。女性、坚持治疗和出院时使用最佳心力衰竭药物与LVEF改善相关。这些发现支持在适当条件下收缩功能恢复的潜力。

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引用次数: 0

Artificial intelligence-enhanced cardiovascular magnetic resonance for cardiovascular risk prediction in asymptomatic CAD patients 人工智能增强心血管磁共振在无症状冠心病患者心血管风险预测中的应用

IF 2.2 3区医学 Q2 CARDIAC & CARDIOVASCULAR SYSTEMS

Archives of Cardiovascular Diseases

Pub Date : 2026-01-01 DOI: 10.1016/j.acvd.2025.10.100

S. Toupin , J. Amar , J. Garot , S. Duhamel , A. Myriam , T. Hovasse , A. Neylon , S. Champagne , T. Unterseeh , A. Unger , T. Goncalves , J. Florence , S. Houssany-Pissot , E. Gall , J.-G. Dillinger , V. Bousson , F. Sanguineti , P. Garot , T. Pezel

Introduction

Risk stratification in patients with known coronary artery disease (CAD) remains a clinical challenge, especially in asymptomatic individuals. While stress cardiac magnetic resonance imaging (MRI) has strong prognostic value, current models do not fully exploit the richness of available clinical and imaging data. Machine learning (ML) offers an opportunity to optimize prediction by capturing complex patterns in high-dimensional datasets.

Objective

To assess the performance of a supervised ML model combining clinical and stress cardiac MRI data for predicting 10-year major adverse cardiovascular events (MACE) in asymptomatic patients with obstructive CAD, compared to logistic regression models.

Method

A total of 966 asymptomatic patients with obstructive CAD who underwent vasodilator stress cardiac MRI between 2009 and 2011 in two centres were retrospectively included. The first centre (n = 742) provided a derivation cohort (n = 603) and an internal validation cohort (n = 139), while the second centre (n = 224) served as an external validation cohort. Feature selection was performed using LASSO, XGBoost, Random Forest (RF), and Boruta. A final RF model was trained using five selected variables and compared to a generalized logistic regression model (GLM) using AUROC and PRAUC metrics.

Results

Five key variables were selected: number of ischemic segments, number of late gadolinium enhancement (LGE) segments, left ventricular ejection fraction (LVEF), left ventricular end-diastolic diameter indexed, and age (Figure 1). Over the 10-year follow-up period, MACE occurred in 28% of patients in the derivation cohort, 30% in the internal validation cohort, and 24% in the external test cohort. The RF model demonstrated the best predictive performance in the derivation cohort (AUROC: 0.99, PRAUC: 0.98). Consistently, the AUROC was 0.98 versus 0.86 for the GLM, and PRAUC was 0.97 versus 0.78 (all p < 0.001) in the internal validation cohort. In the external validation cohort, the RF model achieved an AUROC of 0.92 versus 0.74 for the GLM, and a PRAUC of 0.84 versus 0.58 (all p < 0.001). SHAP analysis confirmed the interpretability of the model and the individual contribution of each variable (Figure 2).

Conclusion

A ML model combining stress cardiac MRI and clinical data significantly outperformed traditional methods in predicting MACE in asymptomatic patients with obstructive CAD.

已知冠状动脉疾病（CAD）患者的风险分层仍然是一个临床挑战，特别是在无症状个体中。虽然心脏磁共振成像（MRI）具有很强的预后价值，但目前的模型并没有充分利用现有临床和影像学数据的丰富性。机器学习（ML）提供了一个通过捕获高维数据集中的复杂模式来优化预测的机会。目的评价结合临床和心脏MRI应激数据的监督ML模型预测无症状阻塞性CAD患者10年主要不良心血管事件（MACE）的效果，并与logistic回归模型进行比较。方法回顾性分析2009 - 2011年两个中心966例无症状梗阻性CAD患者行血管扩张剂应激心脏MRI检查。第一个中心（n = 742）提供了一个衍生队列（n = 603）和一个内部验证队列（n = 139），而第二个中心（n = 224）作为一个外部验证队列。使用LASSO、XGBoost、Random Forest （RF）和Boruta进行特征选择。最终的RF模型使用五个选定的变量进行训练，并与使用AUROC和PRAUC指标的广义逻辑回归模型（GLM）进行比较。结果选择了5个关键变量：缺血节段数、晚期钆增强（LGE）节段数、左室射血分数（LVEF）、左室舒张末期内径指数和年龄（图1）。在10年的随访期间，衍生队列中有28%的患者发生了MACE，内部验证队列中有30%，外部测试队列中有24%。RF模型在衍生队列中表现出最好的预测性能（AUROC: 0.99, PRAUC: 0.98）。在内部验证队列中，GLM的AUROC为0.98比0.86，PRAUC为0.97比0.78（均p <； 0.001）。在外部验证队列中，RF模型的AUROC为0.92，而GLM模型为0.74，PRAUC为0.84，而GLM模型为0.58（均p <； 0.001）。SHAP分析证实了模型的可解释性和每个变量的个体贡献（图2）。结论结合应激性心脏MRI和临床资料的ML模型预测无症状阻塞性CAD患者MACE的效果明显优于传统方法。

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引用次数: 0

PSS Stress Scale: A novel indicator of endothelial dysfunction in coronary artery disease PSS应激量表：冠状动脉疾病内皮功能障碍的新指标

IF 2.2 3区医学 Q2 CARDIAC & CARDIOVASCULAR SYSTEMS

Archives of Cardiovascular Diseases

Pub Date : 2026-01-01 DOI: 10.1016/j.acvd.2025.10.025

Y. Ayadi, S. Charfeddine, A. Ghrab, A. Bahloul, R. Gargouri, Z. Triki, M. Jabeur, T. Ellouze, F. Triki, S. Mallek, L. Abid

Introduction

Endothelial dysfunction is an early marker of vascular injury in CAD. While traditional risk factors are known, psychological stress—measured by the Perceived Stress Scale (PSS)—may also impact vascular health, though its role in predicting endothelial dysfunction is not well studied.

Objective

This study explores whether PSS stress scores are linked to endothelial function, assessing perceived stress as a potential early marker of vascular impairment in CAD patients.

Method

This observational study (Jan–Apr 2025) included Chronic Coronary Syndrome patients in follow-up. Stress was measured using the PSS, and endothelial function was evaluated via the Endothelium Quality Index (EQI).

Results

Among 51 CAD patients (mean age 57.86 years; 43 men, 8 women), the prevalence of hypertension, diabetes, and dyslipidemia was 66.6%, 60.78%, and 25.49%, respectively. Endothelial function, assessed by the Endothelial Quality Index (EQI), revealed severe dysfunction (EQI < 1) in 9 patients, moderate dysfunction (1 ≤ EQI < 2) in 21, and normal function (EQI ≥ 2) in 21. Poorly controlled hypertension and diabetes were present in 15% and 23% of patients, respectively. No significant association was found between endothelial dysfunction and traditional risk factors, but higher PSS scores were significantly correlated with worse endothelial function (P = 0.028, r = –0.38) (Fig. 1).

Conclusion

In chronic coronary syndrome patients, traditional risk factors were not significantly linked to endothelial dysfunction, likely due to well-controlled comorbidities. However, higher perceived stress levels were significantly associated with poorer endothelial function, suggesting that psychological stress could be an early marker of vascular impairment. Incorporating stress assessment into routine cardiovascular evaluations may improve early detection and prevention.

内皮功能障碍是冠心病血管损伤的早期标志。虽然传统的风险因素是已知的，但心理压力（通过感知压力量表（PSS）测量）也可能影响血管健康，尽管其在预测内皮功能障碍方面的作用尚未得到很好的研究。目的：本研究探讨PSS压力评分是否与内皮功能有关，评估感知压力作为CAD患者血管损伤的潜在早期标志物。方法观察性研究（2025年1 - 4月）纳入慢性冠状动脉综合征患者进行随访。采用PSS测定应激，内皮质量指数（EQI）评价内皮功能。结果51例冠心病患者（平均年龄57.86岁，男性43例，女性8例），高血压、糖尿病和血脂异常的患病率分别为66.6%、60.78%和25.49%。内皮质量指数（EQI）评价内皮功能，严重功能障碍（EQI < 1）者9例，中度功能障碍（1≤EQI < 2）者21例，功能正常（EQI≥2）者21例。控制不佳的高血压和糖尿病患者分别占15%和23%。内皮功能障碍与传统危险因素无显著相关性，但PSS评分越高，内皮功能越差（P = 0.028, r = -0.38）（图1）。结论在慢性冠状动脉综合征患者中，传统危险因素与内皮功能障碍无显著相关性，可能是由于合并症控制良好。然而，较高的感知压力水平与较差的内皮功能显著相关，这表明心理压力可能是血管损伤的早期标志。将压力评估纳入常规心血管评估可改善早期发现和预防。

{"title":"PSS Stress Scale: A novel indicator of endothelial dysfunction in coronary artery disease","authors":"Y. Ayadi, S. Charfeddine, A. Ghrab, A. Bahloul, R. Gargouri, Z. Triki, M. Jabeur, T. Ellouze, F. Triki, S. Mallek, L. Abid","doi":"10.1016/j.acvd.2025.10.025","DOIUrl":"10.1016/j.acvd.2025.10.025","url":null,"abstract":"<div><h3>Introduction</h3><div>Endothelial dysfunction is an early marker of vascular injury in CAD. While traditional risk factors are known, psychological stress—measured by the Perceived Stress Scale (PSS)—may also impact vascular health, though its role in predicting endothelial dysfunction is not well studied.</div></div><div><h3>Objective</h3><div>This study explores whether PSS stress scores are linked to endothelial function, assessing perceived stress as a potential early marker of vascular impairment in CAD patients.</div></div><div><h3>Method</h3><div>This observational study (Jan–Apr 2025) included Chronic Coronary Syndrome patients in follow-up. Stress was measured using the PSS, and endothelial function was evaluated via the Endothelium Quality Index (EQI).</div></div><div><h3>Results</h3><div>Among 51 CAD patients (mean age 57.86 years; 43 men, 8 women), the prevalence of hypertension, diabetes, and dyslipidemia was 66.6%, 60.78%, and 25.49%, respectively. Endothelial function, assessed by the Endothelial Quality Index (EQI), revealed severe dysfunction (EQI<1) in 9 patients, moderate dysfunction (1≤EQI<2) in 21, and normal function (EQI≥2) in 21. Poorly controlled hypertension and diabetes were present in 15% and 23% of patients, respectively. No significant association was found between endothelial dysfunction and traditional risk factors, but higher PSS scores were significantly correlated with worse endothelial function (<em>P</em>  =–0.38) (<span><span>Fig. 1</span></span>).</div></div><div><h3>Conclusion</h3><div>In chronic coronary syndrome patients, traditional risk factors were not significantly linked to endothelial dysfunction, likely due to well-controlled comorbidities. However, higher perceived stress levels were significantly associated with poorer endothelial function, suggesting that psychological stress could be an early marker of vascular impairment. Incorporating stress assessment into routine cardiovascular evaluations may improve early detection and prevention.</div></div>","PeriodicalId":55472,"journal":{"name":"Archives of Cardiovascular Diseases","volume":"119 1","pages":"Page S17"},"PeriodicalIF":2.2,"publicationDate":"2026-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145904170","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

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