European Heart Journal Supplements最新文献

Transcatheter aortic valve implantation (TAVI) has transformed the treatment of severe aortic stenosis, becoming a preferred option for patients at high and moderate surgical risk and for individuals over 75 years of age. The NOTION study represents the first randomized clinical trial to reach a 10-year follow-up in patients at low surgical risk, comparing TAVI with surgical valve replacement (SAVR). The results show comparable clinical outcomes between TAVI and SAVR in terms of all-cause mortality, stroke, and myocardial infarction. TAVI demonstrated a better haemodynamic profile and a lower incidence of structural valve deterioration (SVD), but showed higher rates of pacemaker requirement and paravalvular leakage compared with surgical replacement. The trial highlights the excellent durability of transcatheter bioprostheses, although new-generation devices and advanced techniques could further reduce adverse events. The study confirms the increasing role of TAVI even in younger patients, but further long-term data will be needed to evaluate its full potential.

Arrhythmogenic cardiomyopathy (ACM) is a cardiac disorder characterized by structural alterations of the myocardium, which predisposes individuals to ventricular arrhythmias and increases the risk of sudden cardiac death. Initially described as arrhythmogenic right ventricular cardiomyopathy, the involvement of the left ventricle (LV) has been subsequently recognized, leading to the classification of various phenotypes under LV non-dilated cardiomyopathy. The clinical spectrum of ACM ranges from life-threatening ventricular arrhythmias to overt heart failure, sometimes presenting with acute myocarditis-like episodes and extracardiac symptoms, further contributing to the disease's heterogeneity. Diagnosis relies on imaging modalities, such as echocardiogram and cardiac magnetic resonance imaging, to detect areas of fibro-fatty replacement and/or non-ischemic ventricular scarring, integrated with genetic analysis. The 2023 European Society of Cardiology guidelines on Cardiomyopathies underscore the importance of a comprehensive diagnostic approach, combining imaging and genetics for arrhythmic risk stratification and comprehensive patient management. Growing evidence on genotype-phenotype correlation, along with the validation of specific predictive scores, is improving ACM clinical management and promoting personalized treatment tailored to individual and familial characteristics.

Electrocardiogram may play a crucial role in the diagnostic workup of different cardiomyopathies. Electrocardiogram abnormalities in impulse generation and transmission may be an early marker of these insidious pathologies. Some findings are suggestive of definite disorders, and other findings are less sensitive and/or specific, but may orient towards a specific diagnosis in a patient with a peculiar phenotype. Electrocardiogram findings not only could help to early recognize affected patients but may also have an important prognostic role in evaluating disease evolution over time and identifying patients at higher risk of sudden cardiac death. Electrocardiogram reading and the careful interpretation of its features remain a cornerstone for orienting the diagnosis towards specific forms and provide useful tools for risk stratification.

Tricuspid edge-to-edge repair (T-TEER) has emerged as a promising treatment option for severe functional tricuspid regurgitation (TR) in patients unsuitable for surgery. Recent findings from randomized clinical trials consistently demonstrated a reduction in TR severity and significant symptomatic improvement with T-TEER, particularly in terms of quality of life and functional status. However, no significant differences in mortality or hospitalizations were observed compared to guideline-directed medical therapy. In this complex scenario, careful patient selection and a comprehensive evaluation of the tricuspid valve remain critical for optimizing outcomes. Patients with preserved right ventricular (RV) function, absence of pulmonary hypertension (PH), and no significant organ dysfunction are more likely to benefit from T-TEER. Conversely, in patients with severe RV dysfunction, lack of contractile reserve, pre-capillary or severe combined post-capillary PH, end-stage organ failure, and significant impairment in daily activities and self-care, the procedure may be futile. Patients in the grey zone should be evaluated by a dedicated heart team, with a tailored decision-making approach.

Cardiac amyloidosis (CA) affects the myocardium, vessels, valves, and epi-pericardium. Guidelines and expert consensus documents provide recommendations for the diagnostic work-up, which has the dual purpose of confirming the presence of amyloid deposits and characterizing the amyloidogenic protein. Amyloid typing is essential for treatments targeting the different types of amyloidosis, mainly transthyretin (ATTR, the most common type) and light chain, and less commonly reactive-serum amyloid-A, and beta2-microglobulin. Endomyocardial biopsy (EMB), still considered the gold standard for diagnosing and typing amyloid, is primarily reserved for cases where non-invasive tools do not provide a definitive diagnosis. Interestingly, while EMB was expected to decline, its numbers have increased globally over the past decade. This trend was driven by the greater awareness of CA, the novel epidemiology of CA with exponentially increased ATTRwt, the limitations of non-invasive methods in diagnosing early-stage ATTR CA, and the need to diagnose and type CAs that are not identified through alternative tools. Looking ahead, it is anticipated that EMB will continue to play a crucial role in diagnosing CA. This review explores the current diagnostic role of EMB, and potential applications in early CA, in differential diagnoses, in detecting and typing rare CA, as well as in incidental findings.

Large vessel occlusion stroke is a significant cause of disability and mortality. Mechanical thrombectomy (MT) has greatly improved outcomes when performed within 6 h of symptom onset. However, many patients present beyond this window, which limits treatment options. Studies show that up to 70% of stroke patients in the USA and 30-40% in Europe arrive after 6 h. Advanced imaging techniques, such as computed tomography perfusion and magnetic resonance imaging, can aid in identifying salvageable tissue (penumbra) and guide late thrombectomy decisions. Trials like DAWN and DEFUSE-3 demonstrated considerable benefits of MT up to 24 h post-stroke in selected patients. Recent research, including the MR CLEAN-LATE, SELECT2, and ANGEL-ASPECT trials, suggests potential advantages for patients with large ischaemic cores (ASPECTS 3-5) without the need for advanced imaging. Despite these advancements, challenges persist, such as identifying optimal candidates, reducing haemorrhagic risks, and managing complications like no-reflow phenomena. Future research aims to enhance patient selection, optimize treatment strategies, and investigate new pharmacological approaches. Endovascular therapy continues to progress, providing new treatment options for late-presenting stroke patients.

Traditionally, structural heart interventions have been performed at heart valve centres with on-site heart surgery to maximize expertise and deal with complications requiring emergent cardiac surgery (ECS). However, at present, only transcatheter aortic-valve implantation (TAVI) must be performed at centres with on-site heart surgery according to current guidelines, while mitral transcatheter edge-to-edge repair, or left appendage atrial occlusion could be performed also in centres without on-site cardiac surgery. Today, ageing of the population and improved results of TAVI have increased the need for such procedures posing strong pressure to traditional heart valve centres, prolonging waiting times for TAVI and increasing access disparities. Fortunately, TAVI procedures have a very low rate of complications, including those necessitating ECS, and observational data suggest that TAVI can be safely performed in centres without on-site cardiac surgery. However, guideline recommendations need randomized clinical trials like the TRanscatheter Aortic-Valve Implantation with or without on-site Cardiac Surgery (TRACS) trial to be updated. The TRACS trial randomizes high-risk symptomatic aortic stenosis patients to treatment by the same operators either at centres with or without on-site cardiac surgery and compares 1-year follow-up. Key issues for structural interventions, in particular TAVI, at centres without on-site surgery are shared indications through heart team evaluation, consistent experiences and competences of non-surgical centres, and strong networking with the Hub centre. The increasing demand for structural heart interventions highlights the need for innovative care models and the careful introduction of a 'Hub-and-Spoke' approach for high-volume heart valve networks could be a study option.

Systemic arterial hypertension is one of the leading causes of mortality and morbidity worldwide. Despite therapeutic advancements, a significant proportion of hypertensive patients fail to achieve adequate blood pressure control. Renal denervation (RDN) is emerging as an innovative and minimally invasive procedure to treat hypertension by modulating the renal sympathetic nervous system. Recent clinical trials, including SYMPLICITY HTN-3, SPYRAL HTN-OFF MED, and RADIANCE-HTN SOLO, have shown variable results, influenced by patient selection and study design. The latest 2024 ESC guidelines on systemic arterial hypertension recommend RDN as a therapeutic option in selected cases, especially in patients with resistant hypertension not adequately controlled by pharmacological therapy. However, the response to this approach varies according to individual pathophysiology and the level of sympathetic activation. This article highlights how RDN, performed using ultrasound or radiofrequency technologies, may represent a breakthrough for difficult-to-treat patients, bridging current therapeutic gaps and reducing long-term cardiovascular risk. Finally, it emphasizes the importance of a multi-disciplinary assessment to maximize the benefits of the procedure.

Clinical guidelines (GLs) are crafted by professional medical societies with the primary goal of supporting healthcare providers in making informed decisions during routine clinical practice. These GLs serve as practical tools, offering evidence-based recommendations that help clinicians navigate complex scenarios in patient care. By synthesizing the latest scientific evidence and expert consensus, they provide a structured framework for diagnosing, managing, and preventing various medical conditions. This ensures that clinical decision-making is consistent, effective, and aligned with current best practices, ultimately promoting high-quality care and better patient outcomes in everyday healthcare settings. This paper aims to emphasize the importance of updating the European Society of Cardiology 2020 GLs, particularly in light of advances and evolving evidence in the management of atrial fibrillation (AF). It examines the key updates introduced in the 2024 GLs, with a specific focus on AF ablation, highlighting the changes and advancements that address gaps or enhance clinical practices. Additionally, the paper explores potential future directions for refining these GLs, considering emerging research, evolving technologies, and practical challenges in their implementation including new editing methods.

[This corrects the article DOI: 10.1093/eurheartjsupp/suae114.].