Cardiovascular care

Real-world experience of transoesophageal echocardiography for detection of clinically significant persistent foramen ovale (2026)

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Type of publication:

Journal article

Author(s):

Wilmshurst, Peter; *Pearson, Matthew; Walsh, Kevin; Morrison, W Lindsay.

Citation:

Diving & Hyperbaric Medicine. 56(2):148-153, 2026 Jun 30.

Abstract:

Introduction: Transoesophageal echocardiography (TOE) is claimed to be the investigation of choice for detecting a persistent foramen ovale (PFO) with almost 100% diagnostic accuracy. If true, TOE would detect all large/clinically significant PFOs.
Methods: Retrospective analysis to determine the sensitivity of TOE for detection of clinically significant PFOs. Patients were from a consecutive series of 150 patients who had transcatheter closure of a PFO following events attributed to paradoxical embolism (decompression sickness or stroke). In each patient, transthoracic echocardiogram with bubble contrast showed a clinically significant atrial right-to-left shunt. The data reported are from the sub-group of the 150 patients with a clinically significant PFO who also had a TOE performed in other hospitals.
Results: Twenty seven of 150 consecutive patients had a total of 31 TOEs performed at 22 United Kingdom regional cardiac centres. TOE failed to detect a PFO in 17 of the 27 patients. Four patients had a TOE on two separate occasions and in each case both of the TOEs failed to show a PFO. TOE gave a false negative test in 21 of 31 investigations (sensitivity 32%). The mean PFO diameter was 9.4 mm (median 9 mm, range 5-16 mm) in the 21 patients in whom balloon sizing was performed and 9.8 mm (median 10 mm, range 5-16 mm) in the 13 patients in whom balloon sizing was performed and a TOE failed to show a PFO.
Conclusions: These finding demonstrate that the precision of TOE for detecting a PFO in real world clinical practice is considerably lower than generally believed.Introduction: Liver transplantation has re-emerged as a potential therapeutic option for patients with unresectable colorectal liver metastases after failure of standard treatments. This systematic review and meta-analysis evaluated survival outcomes, recurrence patterns, and prognostic factors associated with this approach. Materials and Methods: A systematic review was conducted according to PRISMA 2020 guidelines and registered in PROSPERO. Electronic databases were searched for studies published between November 2015 and November 2025, that assessed liver transplantation in the context of unresectable colorectal liver metastases. Random-effect meta-analyses were conducted to estimate the pooled overall survival, disease-free survival and recurrence rates. Heterogeneity was assessed using I2 statistics.
Results: Twenty-three studies involving patients with unresectable liver-only colorectal metastases were included. Pooled overall survival after liver transplantation was 96.6% at 1 year (95% CI 93.9-99.4; I2 = 44.3%), 73.4% at 3 years (95% CI 62.9-83.9; I2 = 95.4%), and 49.4% at 5 years (95% CI 35.4-63.3; I2 = 90.5%). Ten-year overall survival was approximately 27%. The pooled recurrence rate was 63.5% (95% CI 52.5-76.8), and the type of recurrence was mainly extrahepatic, most commonly pulmonary. Disease-free survival was 64.1% (95% CI 47.5-80.7) with substantial heterogeneity (I2 = 95.6%). Biological risk factors, including carcinoembryonic antigen levels, metabolic tumor volume, and composite risk scores, consistently influenced survival outcomes.
Conclusions: In highly selected patients with unresectable colorectal liver metastases, liver transplantation is associated with favorable long-term survival despite frequent recurrence. Outcomes appear to be primarily driven by tumor biology rather than tumor burden, supporting the cautious use within specialized centers under structured selection protocols.

DOI: 10.28920/dhm56.2.148-153

Relationship between social deprivation, CEAP score and time to varicose vein surgery: A single-centre retrospective analysis (2026)

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Type of publication:

Journal article

Author(s):

*Crossdale, Martin; *Damaraju, Sandeep; *Smith, Benjamin; *Alawattegama, Lakna Harindi; *Bhanderi, Shivam; *Jones, Steven.

Citation:

Phlebology. 2683555261444161, 2026 Apr 17.

Abstract:

Introduction: Inequalities in access to planned venous surgery are not well understood. We aimed to explore the relationships between disease severity, socioeconomic deprivation, procedure performed, and waiting times. Methods We analysed retrospectively collected data from 302 patients undergoing varicose vein surgery at a single NHS Trust in Shropshire, England between 1st January 2024 to 31st December 2024. Spearman's correlation, chi-squared testing, and Kruskal-Wallis tests were used to examine associations between CEAP score, Index of Multiple Deprivation (IMD) decile, procedure performed, referral-to-treatment time and time on the waiting list. Results The median age was 54 years (IQR 26), with equal male and female representation. The most common CEAP score was C2, median IMD decile was 6 (IQR 4), and median time on the surgical waiting list was 215 days (IQR 278). There was no statistically significant association between IMD and either wait time or CEAP score, in either England or Wales. CEAP score did not correlate with waiting list time (Spearman's rho = -0.031, p = 0.59). CEAP score was not associated with procedure performed (chi2 = 20.0, df = 35, p = 0.98). Similarly, no association was seen between IMD and procedure in England, Wales, Shropshire, or Telford & Wrekin. Conclusion In this cohort, socioeconomic deprivation was not associated with disease severity, procedure selection, or delays to intervention, although the under-representation of the most deprived deciles may limit the strength of this conclusion. The lack of correlation between CEAP score and waiting time may suggest there are other factors limiting clinical prioritisation.

DOI: 10.1177/02683555261444161

Continuous Infusion and Sequential Nephron Blockade Versus Bolus Furosemide in Acute Heart Failure: A Systematic Review (2026)

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Type of publication:

Systematic review

Author(s):

Ahmed Mohamed, Leena Awad Alkareem; *Abozaid, Khalid; Mohammed Ahmed Hassan, Hala Fakhri; Ali, Yasir; Hussein Abdalla, Nibras Elfatih; Ibrahim, Mohamed Samir Yasin; Ahmed Mohammed, Weam Mohammed; Babikir Omer, Ahmed Mohammed; Awad, Alaa.

Citation:

Cureus. 18(6):e111063, 2026 Jun.

Abstract:

Acute heart failure (AHF) is a leading cause of hospitalization worldwide, with congestion as its central pathophysiologic feature. Loop diuretics, particularly furosemide, remain the cornerstone of decongestive therapy, yet the optimal administration strategy, continuous infusion versus bolus dosing, remains debated. Furthermore, sequential nephron blockade through the addition of distal tubule-acting diuretics or sodium-glucose cotransporter-2 (SGLT2) inhibitors has emerged as a strategy to overcome diuretic resistance. This systematic review had two primary objectives: first, to compare continuous infusion versus bolus dosing of furosemide; second, to evaluate the efficacy and safety of adjunctive sequential nephron blockade (SGLT2 inhibitors, thiazides, and acetazolamide) added to loop diuretics within the context of the ongoing debate over optimal decongestion in AHF. A systematic literature search was conducted in PubMed, Scopus, Web of Science, the Cochrane Library, and ClinicalTrials.gov for studies published between 2021 and 2025. Eligible studies included randomized controlled trials (RCTs) and prospective observational studies evaluating either continuous furosemide infusion versus bolus furosemide or adjunctive sequential nephron blockade (added to loop diuretics) versus placebo, usual care, or, in one case, an active diuretic comparator. The Cochrane Risk of Bias 2 (RoB 2) tool was used for RCTs, and the Risk of Bias in Non-randomized Studies of Interventions (ROBINS-I) tool was used for the nonrandomized study. A narrative synthesis was performed because of substantial clinical and methodological heterogeneity. Ten studies (nine RCTs and one prospective observational study) comprising 2,972 patients were included. Continuous furosemide infusion consistently improved surrogate measures of decongestion (urine output and weight loss) compared with bolus dosing. However, these benefits did not reliably translate into improved symptoms or shorter hospital stays, and one large study reported increased renal injury and adverse events, highlighting a potential efficacy-safety trade-off. Sequential nephron blockade with SGLT2 inhibitors enhanced diuresis with favorable renal and electrolyte safety profiles and a nonsignificant trend toward lower mortality (the studies were not powered for mortality). Thiazide-based strategies achieved potent diuresis but significantly increased the risks of acute kidney injury and electrolyte disturbances without a mortality benefit. Acetazolamide improved decongestion safely but did not reduce mortality or readmissions. No single decongestive strategy is universally superior. However, direct comparisons across strategies are limited by substantial heterogeneity in study design, patient populations (e.g., renal function and congestion severity), and outcome definitions. Continuous furosemide infusion offers enhanced diuresis but inconsistent clinical benefits and potential renal harm. Based largely on surrogate outcomes from heterogeneous studies not designed to detect differences in mortality or readmissions, definitive clinical recommendations remain limited. SGLT2 inhibitors represent a promising but not yet proven adjunct in AHF, pending larger, adequately powered trials. Thiazide-based sequential blockade should be reserved for refractory cases with close monitoring. Treatment should be individualized based on baseline renal function, congestion severity, and electrolyte status.

DOI: 10.7759/cureus.111063

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Point-of-care echocardiography training pathways: a global perspective and the need for standardisation (2026)

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Type of publication:

Journal article

Author(s):

Abbawy, Marcus, Holden, Finlay, Fisher, Tom, Nasa, Prashant, Manjunathasawamy, Akshay Hiryur, Renukappa, Suresh, Suresh, Subashini, Kumar, Nanda, Ingram, Tom, Hothi, Sandeep, Cotton, James M, *Maharaj, Aruna, Chacko, Cyril, Veenith, Tonny

Citation:

Open Heart. 13(1), 2026 May 26.

Abstract:

Point-of-care ultrasound echocardiography has become an indispensable tool for rapid clinical assessment in emergency medicine. This review article examines the heterogeneity in training pathways globally, outlining the advantages and presenting the challenges to standardisation, documentation practices and quality assurance. By reviewing current curricula, training methods and international models, we aim to identify the positive elements and propose a framework for an ideal national training programme, including the potential role of an examination and higher education institutions.

DOI: 10.1136/openhrt-2026-004057

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Understanding the Nuanced Concept of Hemodynamic Incoherence and Its Underlying Physiology (2026)

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Type of publication:

Journal article

Author(s):

Rola P.; *Miller A.; Haycock K.; Spiegel R.; Rikhraj K.; Kattan E.; Hernandez G.

Citation:

Journal of Clinical Medicine. 15(15) (no pagination), 2026. Article Number: 5811. Date of Publication: 01 Aug 2026. [epub ahead of print]

Abstract:

Hemodynamic incoherence is commonly defined as a dissociation between normalization of macrocirculatory variables and persistent impairment of tissue perfusion. However, this phenomenon is not physiologically homogeneous. We propose a conceptual distinction between two forms of macro-microcirculatory incoherence. Type 1 incoherence represents primary microcirculatory dysfunction, in which intrinsic alterations in microvascular regulation and flow distribution lead to heterogeneous capillary perfusion despite apparently adequate upstream hemodynamics, as observed in sepsis. In contrast, Type 2 incoherence reflects secondary impairment of microcirculatory flow resulting from hemodynamic constraints elsewhere in the circulation, including excessive vasoconstriction, limited cardiac forward flow, or venous congestion. In this setting, impaired perfusion arises from ineffective transmission of flow across the system rather than primary microvascular failure. The four-interface model of the circulation provides a unifying physiological framework to interpret these mechanisms as failures of energy transfer across sequential hemodynamic domains. Recognizing these distinct forms of incoherence may improve not only physiologic interpretation of shock and help avoid conflating fundamentally different mechanisms under a single conceptual entity, but also be key in individualizing therapeutic interventions to the proper phenotypes of tissue malperfusion

DOI: 10.3390/jcm15155811

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Adherence to European Society of Cardiology (ESC) Guideline for Diagnosis of MINOCA (2025)

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Type of publication:

Service improvement case study

Author(s):

*Caryn Tsujean Lim, *ElshaimaaSeaoud, *Jignesh Kaklotar, *Yuseon Lee,Zoe Exon, *Sarah Wilson, *Qurratul Hussain, *Sarthak Sinha, *Tamara Murphy

Citation:

SaTH Improvement Hub, November 2025

SMART Aim:

Increase adherence to cardiac MRI (CMR) investigation in indicated MINOCA patients by 10% over 2 months, in line with ESC guidelines, at Princess Royal Hospital, Shrewsbury and Telford Hospital NHS Trust.

Link to PDF poster

Pulmonary Embolism and Myocardial Infarction With Non-obstructive Coronary Arteries in Immune Thrombocytopenia: Unmasking Underlying Antiphospholipid Syndrome (2026)

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Type of publication:

Journal article

Author(s):

*Shahzeb, Muhammad; Naeem, Faiqa Jabeen; *Naz, Kiran; *Irfan, Muhammad; *Ahmad, Nawaid; Rafiq, Nawal; Ul Haq, Ijaz.

Citation:

Cureus. 18(1):e100731, 2026 Jan.

Abstract:

This case report presents the clinical scenario of a 35-year-old male patient who experienced chest pain due to a combination of pulmonary embolism (PE) and myocardial infarction with non-obstructive coronary arteries (MINOCA), concurrently while undergoing treatment with avatrombopag for immune thrombocytopenia (ITP). His investigations included a CT pulmonary angiogram that confirmed a PE, a coronary angiography which was normal, a cardiac MRI which showed evidence of subendocardial infarct, and a CT coronary angiogram, which was normal. His unique presentation with these findings prompted further investigations, which revealed an undiagnosed antiphospholipid syndrome (APS) alongside a patent foramen ovale (PFO). Hence, the paradoxical thrombotic incidents were precipitated by this unique diagnosis. After establishing the diagnosis, our patient was commenced on warfarin, and his treatment protocol for ITP was changed to a different drug. He remains under haematology follow-up.

DOI: 10.7759/cureus.100731

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Chronic Infective Endocarditis Linked to Staphylococcus epidermidis Infection of a Pacemaker Lead: A Case Report (2025)

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Type of publication:

Journal article

Author(s):

*Abdalla, Osama S; *Idris, Ghada; *Ekanayake, Darshani; *Khallaf, Laila; *Adjepon, Charlotte.

Citation:

Cureus. 17(12):e99028, 2025 Dec.

Abstract:

The diagnosis and management of pacemaker-related infective endocarditis present significant challenges, with limited available data. Accurately attributing a systemic infection to pacemaker endocarditis can be difficult, particularly in identifying vegetations and obtaining positive blood cultures from patients who have undergone non-specific antibiotic therapy. Moreover, such infections may manifest long after pacemaker implantation. Herein, we present a male patient in his 70s, with a history of pacemaker placement, who was admitted with a three-month history of fever and chills, having already completed two courses of empirical antibiotics prior to admission. Upon hospital admission, he was treated for an infection of unknown origin with intravenous antibiotics. Initial laboratory evaluations indicated leucocytosis and elevated C-reactive protein levels; however, blood cultures and infectious serologies returned normal results. A CT scan of the abdomen and pelvis was deemed unremarkable, and transthoracic echocardiography (TTE) also yielded normal findings. The empirical antibiotic regimen was discontinued, leading to three sets of blood cultures being subsequently positive for coagulase-negative Staphylococcus epidermidis. A transoesophageal echocardiography (TOE) was performed, revealing vegetation on the pacemaker lead. The patient received a triple antibiotic therapy and underwent device removal; subsequent blood cultures were negative following a four-week antibiotic course. A new pacemaker was implanted, and the patient has since remained asymptomatic. This case illustrates that coagulase-negative Staphylococcus epidermidis can infect pacemaker leads even long after installation, potentially leading to an indolent course of infective endocarditis that is difficult to diagnose and manage. Consequently, clinicians should maintain a high index of suspicion for pacemaker infective endocarditis in patients presenting with prolonged fever.

DOI: 10.7759/cureus.99028

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Autonomic Nervous System Dysregulation in Metabolic Syndrome: An Association With Hypertension and Cardiovascular Risk (2025)

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Type of publication:

Systematic Review

Author(s):

Soomra, Hoor; Mukhtar, Asad; *Asif, Fatima; Khalid, Ayesha; Noureen, Sadia; Qamar, Zeeshan; Haider, Usman.

Citation:

Cureus. 17(12):e98932, 2025 Dec.

Abstract:

Metabolic syndrome (MetS) is a cluster of cardiometabolic abnormalities, including abdominal obesity, insulin resistance, dyslipidemia, and elevated blood pressure, that increases the risk of type 2 diabetes and cardiovascular disease (CVD). Autonomic imbalance, characterized by increased sympathetic activity and reduced parasympathetic tone, is proposed to play an important role in the development of hypertension and adverse cardiovascular outcomes in individuals with MetS. This systematic review evaluates the association between autonomic nervous system (ANS) dysregulation and MetS. A systematic search was conducted in PubMed, Embase, Scopus, and Cochrane Library for studies published from January 2015 to September 2025. Eligible studies included human research that examined measures of autonomic function such as heart rate variability (HRV), baroreflex sensitivity, muscle sympathetic nerve activity, and plasma catecholamine levels at rest in individuals with MetS. Observational and interventional studies were included. Data were extracted and synthesized narratively. A total of 16 studies met the inclusion criteria. Most included studies reported reduced HRV, impaired baroreflex sensitivity, increased resting sympathetic nerve activity, and elevated plasma catecholamines in participants with MetS, suggesting a consistent association between ANS dysregulation and blood pressure elevation. However, causality could not be established due to the predominantly observational study designs. Current evidence indicates a significant association between autonomic dysfunction and MetS, particularly in relation to hypertension and increased cardiovascular risk. ANS biomarkers may support refined cardiometabolic risk stratification, although further prospective and mechanistic studies are needed to clarify causal pathways.

DOI: 10.7759/cureus.98932

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Vascular Eagle's syndrome: difficult diagnosis in patient with recurrent transient ischaemic attack (2026)

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Type of publication:

Journal article

Author(s):

Lyons, T; *Saunders, T; Littleton, E; Monksfield, P; Tiwari, A.

Citation:

Annals of the Royal College of Surgeons of England. 2026 Jan 12.

Abstract:

Eagle's syndrome describes the elongation of the styloid process. The condition has been recognised for over 90 years and causes a wide range of symptoms depending on the level of compression. Compression of the internal carotid artery by the styloid process is referred to in the literature as 'stylocarotid syndrome' or 'vascular Eagle's syndrome' (VES), presenting most commonly as arterial dissection and cerebrovascular events. We present the case of a 53-year-old patient who presented with multiple cerebrovascular events over a six-month period. Computed tomography angiography (CTA) suggested VES; however, magnetic resonance imaging (MRI) of the neck revealed no arterial wall abnormalities, including dissection. Despite the escalation of medical therapy, the patient continued to experience multiple transient ischaemic attacks. Following multidisciplinary team discussion and exclusion of other sources of emboli, a transcervical styloidectomy was performed freeing compression of the carotid artery, resulting in the complete resolution of symptoms. VES should be considered in patients with recurrent or unexplained cerebrovascular or cervical neurogenic symptoms even in the absence of arterial injury. We recommend early styloidectomy when there is a strong clinical suspicion of VES to achieve definitive symptom resolution.

DOI: 10.1308/rcsann.2025.0113

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