Frontiers in Cardiovascular Medicine最新文献

Introduction: Hemiarch replacement with proximal aortic replacement is seldom performed via upper hemisternotomy (UHS). We report our surgical technique and postoperative outcomes in 11 patients who underwent UHS for hemiarch and proximal aortic replacement, compared with 15 patients who underwent the procedure via full sternotomy (FS).

Methods: A UHS was performed at the right third or fourth intercostal space. Cardiopulmonary bypass (CPB) was established via the distal ascending aorta or right axillary artery and right common femoral vein. After aortic cross-clamping (ACC), the heart was arrested with single-dose antegrade crystalloid cardioplegia. After proximal aortic replacement, hypothermic circulatory arrest (HCA) between 20 and 24 °C was initiated with bilateral antegrade or retrograde cerebral perfusion, and hemiarch replacement performed.

Results: Between February and December 2010, 15 patients (median age 67 yr) underwent hemiarch repair with proximal aortic replacement using FS. From April 2015 to February 2019, 11 patients (median age 74 yr) underwent the same procedure via UHS. Median CPB, ACC, and HCA times were 192 min vs. 185 min (P = 0.72), 105 min vs. 157 min (P  = 0.03), and 5 min vs. 15 min (P = 0.95) for UHS and FS, respectively. There were no in-hospital deaths. Survival at 1 and 5 yr was 100% and 72.7% in the UHS group, and 100% and 80% in the FS group (P = 0.13, P = 1.0).

Conclusions: Low morbidity and mortality demonstrate that UHS for combined hemiarch and proximal aortic replacement is safe and feasible. Larger studies are needed to confirm these findings.

Conduction disturbances are among the most frequent complications of transcatheter aortic valve replacement (TAVR), typically occurring within the first 72 h after implantation. However, delayed complete atrioventricular (AV) block is rare and may present late with serious clinical consequences. We describe the case of a 72-year-old man with hypertension who developed complete AV block nearly 1 year after TAVR, underscoring the importance of long-term surveillance in patients with high-risk anatomy. The patient initially presented with progressive exertional dyspnea and was diagnosed with severe low-flow, low-gradient aortic stenosis, with a left ventricular ejection fraction of 33%. Preprocedural computed tomography demonstrated a short membranous septum (4.0 mm) and an annulus-membranous septum distance of 1.2 mm, both of which are recognized predictors of conduction disturbances. He underwent transfemoral TAVR with a self-expanding Qiming L26 valve implanted at a depth of approximately 5 mm. Early recovery was uneventful, aside from a small paravalvular leak, which resolved by the 8-month follow-up, at which time echocardiography showed recovery of systolic function to 60%, and sinus rhythm was observed on electrocardiography. At 11 months following TAVR, a community screening ECG revealed 2:1 AV block, and 3 weeks later, he presented with symptomatic complete AV block and a ventricular escape rhythm at 30 bpm. Repeat CT showed increased frame depth (7.6 and 9.8 mm), suggesting possible valve-septum interaction; however, causal attribution is limited by the absence of immediate/serial CT and electrophysiological mapping, and age-related conduction system disease may have contributed to this finding. A dual-chamber permanent pacemaker was implanted, resulting in complete symptomatic recovery and a stable prosthetic valve function. This case report highlights a rare but clinically important phenomenon of very late conduction block after TAVR and supports a risk-stratified approach to anatomical assessment and long-term rhythm monitoring. However, this inference remains hypothesis-generating, given its single-patient nature.

Objectives: Recent reports suggest that pulmonary hypertension (PH) is associated with a significantly higher acute mortality after transcatheter aortic valve implantation (TAVI). The aim of this study is to characterize patients undergoing TAVI with preoperative echocardiographically determined severe PH and to investigate acute clinical and long-term outcomes.

Methods: From 2008 to 2021, 3,610 patients with preoperatively documented systolic pulmonary artery pressure (sPAP) underwent TAVI at our institution. The cut off for severe PH was defined as sPAP > 55 mmHg as determined by echocardiography. Severe PH was preoperatively identified in 456 patients. This group was compared to 3,154 patients with sPAP ≤ 55 mmHg. Data were retrospectively analysed according to updated Valve Academic Research Consortium (VARC-3) definitions.

Results: TAVI patients with sPAP > 55 mmHg presented with higher median age (sPAP ≤ 55 mmHg: 81.6 years [interquartile range (IQR): 77.2-85.1] vs. sPAP > 55 mmHg: 82.3 (IQR 77.8-85.8), p = 0.01) and higher prevalence of significant left ventricular dysfunction (LVEF < 35%) (9.7 vs. 15.5%, p < 0.001). Acute outcomes were impaired in patients with severe PH. The detrimental effect of severe PH persisted in Kaplan-Meier analysis one-year after TAVI (mortality rate 20.0 vs. 30.2%, p < 0.001) and in 60-month follow-up (52.0 vs. 65.1%, p < 0.001).

Conclusion: TAVI patients with severe PH represent a high-risk subgroup with unfavourable acute outcomes and increased one-year and long-term mortality. Moreover, the presence of severe PH is associated with increased rates of acute adverse events, including bleeding, need for PPM implantation and renal failure.

Introduction: Mitral regurgitation (MR) is a common valvular disease associated with complications such as pulmonary hypertension, atrial fibrillation, and heart failure. However, its full impact on the cardiovascular system, especially on right heart function, is not yet fully understood. Understanding this relationship is important because the right ventricle (RV) is critical for maintaining cardiovascular function. Dysfunction of the RV, which may be contributed by conditions like MR, is strongly associated with poor clinical outcomes. Despite its importance, comprehensively studying MR's effect on the RV has been challenging due to the complex, interdependent nature of cardiovascular dynamics, limited patient data, and the difficulty in synthesizing disparate information to clarify the left heart-right heart connection.

Methods: The primary goal of this study is to investigate the effects of MR on cardiovascular hemodynamics and RV function by integrating 3D models of the left heart with a closed-loop 0D models of the entire cardiovascular system. We further conduct detailed analyses using patient-specific models to explore how various system modifications impact the RV, providing insights into the nuanced effects of MR on the right heart.

Results and discussion: This analysis provides several clinically relevant insights. First, progressive MR markedly increases RV afterload and predisposes the RV to dysfunction, even when intrinsic RV contractility is preserved or enhanced. Second, MR-specific severity indices and left-heart metrics alone fail to capture the true burden on the right heart; RV impairment can progress despite stable or only modestly changing MR descriptors. Finally, these findings highlight the need to incorporate direct assessment of RV structure and function into the evaluation of MR, as RV vulnerability plays a critical role in determining patient risk and guiding management decisions.

Background: This study aimed to evaluate the early diagnostic value of Serum-Amyloid-A to High-Density-Lipoprotein-Cholesterol Ratio (SHR) for coronary artery disease (CAD) with clinically relevant stenoses and develop a machine learning diagnostic model based on eXtreme Gradient Boosting (XGBoost).

Methods and results: Data from 1,108 CAD patients (with coronary luminal diameter stenosis ≥50% or evidence of functional myocardial ischemia) and 962 controls were retrospectively analyzed. Receiver operating characteristic (ROC) analysis showed SHR (area under the curve (AUC) = 0.769) outperformed C-reactive protein (CRP) (p = 0.006) and Serum amyloid A (SAA) (p < 0.001). Four XGBoost models were constructed, and the best model (CRP + SAA + SHR + 13 other variables) achieved an AUC of 0.876. SHR correlated nonlinearly with age (p < 0.001), and its diagnostic efficacy was higher in younger patients (40 years old, OR = 16.29) than in older adults (80 years old, OR = 4.37). Machine learning models can address the decline in diagnostic capability of SHR in the elderly population.

Conclusion: SHR is a superior composite biomarker for early diagnosis of CAD with clinically relevant stenoses, outperforming CRP and SAA. Machine learning model integrating multiple indicators shows excellent diagnostic performance. Elevated SHR indicates higher CAD risk in younger individuals, providing a new strategy for early screening of CAD with clinically relevant stenoses.

Introduction: Sleep deprivation is known to induce cardiovascular responses. Several studies have shown the beneficial effect of caffeine on neurobehavioral performance during sleep deprivation, but less is known about its influence on the cardiovascular and inflammatory responses associated with sleep deprivation. The aim of this study is to evaluate the impact of acute caffeine intake on (1) peripheral blood pressures, and (2) heart rate, and cutaneous vascular conductance (CVC) and related biomarkers of endothelial activation, during total sleep deprivation (TSD), considering habitual caffeine consumption.

Methods: 41 subjects followed a randomized, placebo-controlled, cross-over study and underwent 2 conditions of TSD (38 h), one with caffeine intake at 09:00 and 14:00 (2.5 mg/kg), and the other with placebo intake.

Results: We confirm that TSD increases systolic and diastolic arterial pressures (p = 0.001 and p = 0.002 for main effects respectively) and heart rate (p = 0.001), and decreases endothelium-dependent and -independent CVC (p = 0.001). Acute caffeine intake inflates the increase in arterial pressures and IL-6 levels, while it does not affect CVC and levels of E-selectin and monocyte chemotaxis protein-1 (MCP-1). Moreover, chronic caffeine consumption had significant main effects on systolic arterial pressure (p = 0.03), heart rate (p = 0.02), IL-6 levels (p = 0.02), and acetylcholine (ACh)-induced CVC (p = 0.02), and interacted with TSD on E-selectin levels and ACh-induced CVC (p = 0.02 respectively).

Conclusion: Acute caffeine intake provokes immuno-inflammatory and cardiovascular responses, and chronic caffeine consumption should be limited to the lowest efficient doses.

Clinical trial registration: https://clinicaltrials.gov/study/NCT03859882, identifier NCT03859882.

Objectives: Percutaneous coronary intervention (PCI) of calcified lesions using stenting may lead to stent malapposition and stent underexpansion. The combination of intravascular lithotripsy (IVL) followed by drug-coated balloon (DCB) treatment may help overcome this limitation. The aim of this single-center, retrospective, registry-based observational study was to assess the efficacy and safety of plaque modification using IVL followed by DCB-only treatment in patients with severely calcified lesions.

Methods: Severely calcified de novo coronary artery lesions were prepared using IVL followed by the application of paclitaxel-coated DCB in 34 consecutive patients; five patients requiring bail out stenting were excluded from the analysis. The cohort included patients both with stable coronary artery disease (53%) and acute coronary syndromes (47%). The mean age of the patients was 75 years and 56% had diabetes. The majority of patients (76%) were at high bleeding risk based on the Academic Research Consortium criteria. The primary endpoint was MACE [major adverse cardiac events, defined as a composite of target lesion revascularization (TLR), myocardial infarction (MI), and cardiovascular (CV) mortality] at 12 months. The secondary endpoints included individual components of MACE at 6 and 12 months and ARC bleeding (BARC) events.

Results: There were no acute vessel closures or perioperative myocardial infarctions. During 12-month follow-up, the primary end point occurred in 15% (n = 5) of the patients, primarily driven by CV death (9%, n = 3) and one type-2 MI (3%). There was only one ischemia driven TLR within 12 months (3%). The rate of Bleeding Academic Research Consortium (BARC) 2-5 and BARC 3-5 bleeding events was 24% and 6% at twelve months, respectively.

Conclusions: PCI using IVL in combination with an application of paclitaxel-DCB strategy was feasible in the treatment of severely calcified coronary artery lesions in this cohort. This novel approach may be particularly advantageous for patents at high risk of bleeding, although further studies are needed to confirm this potential benefit.

Brugada Syndrome (BrS) is a rare but clinically significant inherited arrhythmia disorder characterized by a type 1 ECG pattern and an increased risk of sudden cardiac death (SCD). Since its first description in 1992, BrS has been the subject of intensive investigation, yet risk stratification remains one of its greatest challenges. While survivors of cardiac arrest and patients with documented ventricular fibrillation (VF) are clear candidates for implantable cardioverter-defibrillators (ICDs), predicting risk in asymptomatic or intermediate-risk individuals is less straightforward. Over the past two decades, multiple risk scores have been developed-including the Sieira, Shanghai, BRUGADA-RISK, and PAT-each integrating combinations of clinical, ECG, electrophysiological study (EPS), and genetic data. Performance metrics vary, with C-statistics ranging from 0.70 to 0.82 in derivation cohorts, but external validation has often been limited. Importantly, current ESC and AHA/ACC guidelines only endorse syncope and EPS inducibility as validated predictors, reflecting the cautious stance of expert panels in the face of heterogeneous data. Nonetheless, the emergence of structured risk models has improved our ability to stratify intermediate-risk patients and stimulated further innovation. Looking ahead, opportunities lie in integrating artificial intelligence applied to raw ECG waveforms, wearable technology for dynamic monitoring, advanced cardiac imaging biomarkers, and polygenic risk scores. Multinational collaboration and federated learning will be essential to overcome statistical fragility and ensure global applicability. Ultimately, BrS risk scores should be considered decision-support tools that enrich but do not replace clinical judgment. Shared decision-making remains central, particularly in asymptomatic patients where ICD implantation is not a clear-cut choice.

Objective: This study aimed to identify the independent risk factors for calf muscular vein thrombosis (CMVT) in elderly patients experiencing an acute exacerbation of chronic obstructive pulmonary disease (AECOPD).

Methods: A retrospective study was conducted involving 128 elderly patients (age ≥60 years) with AECOPD. Patients were categorized into CMVT and non-CMVT groups based on lower extremity venous color Doppler ultrasound findings. Clinical characteristics and laboratory parameters were compared between the groups. Statistically significant variables from univariate analysis were incorporated into a multivariate logistic regression analysis to identify independent risk factors. The predictive performance of these factors was evaluated using receiver operating characteristic (ROC) curve analysis.

Results: Multivariate logistic regression identified reduced calf circumference [Odds Ratio (OR) = 0.25, 95% Confidence Interval (CI): 0.1-0.59], elevated red blood cell (RBC) count (OR = 19.85, 95% CI: 1.08-363.96), and elevated D-dimer level (OR = 1.84, 95% CI: 1.13-3.01) as independent risk factors for CMVT. ROC curve analysis demonstrated good predictive performance for these factors, with areas under the curve (AUC) of 0.986 for calf circumference, 0.788 for RBC count, and 0.976 for D-dimer.

Conclusion: Reduced calf circumference, elevated RBC count, and elevated D-dimer level are significant independent risk factors for CMVT in elderly AECOPD patients. Monitoring these indicators could aid clinicians in the early identification and prevention of CMVT in this vulnerable population.

Background: The impact of epicardial adipose tissue (EAT) on the risk of non-obstructive coronary artery disease (CAD) remains unclear. This study aims to investigate the association between EAT and ischemia with non-obstructive coronary arteries (INOCA).

Methods: This study enrolled 281 patients with angina or other symptoms suggestive of myocardial ischemia who underwent single-photon emission computed tomography myocardial perfusion imaging (SPECT-MPI). All patients had confirmed non-obstructive coronary artery disease (stenosis <50%) by either coronary angiography (CAG) or coronary CT angiography (CCTA) within 3 months before or after MPI. Based on MPI results, patients were categorized into ischemic and non-ischemic groups. Epicardial adipose tissue (EAT) density and volume were measured, and relevant clinical parameters were collected for analysis.

Results: The results revealed that 37.72% of the patients had INOCA, and these patients exhibited significantly higher body mass index (BMI) and EAT density. No statistically significant difference in EAT volume was observed between groups. Both EAT density (OR = -1.846, 95% CI: 1.353-2.559, p < 0.05) and volume (OR = -1.703, 95% CI: 1.151-2.551, p < 0.05) were identified as independent risk factors for INOCA. Furthermore, EAT density demonstrated a linear relationship with disease risk. In statin users, the positive association between EAT density and INOCA was attenuated. (β = -0.039, p = 0.046).

Conclusions: EAT density is an independent risk factor for INOCA, with its increase showing a linear association with INOCA risk. Further, statin use was associated with a reduction in this EAT density-related INOCA risk.