Heart最新文献

Background: Safety and efficacy of supervised exercise training (ET) remain unclear in left ventricular assist device (LVAD) patients. A systematic review with an individual participant data (IPD) meta-analysis was performed to determine: (1) safety, (2) the effects of ET on peak oxygen consumption (peakVO₂), 6 min walk distance (6MWT) and quality of life (QoL) and (3) the effects of ET on different subgroups of patients with LVAD (age, sex, body mass index (BMI), time post LVAD implantation, baseline exercise performance).

Methods: IPD were retrieved from all published randomised, controlled trials that compared the efficacy of ET versus standard care in LVAD patients. One-stage and two-stage (sensitivity analysis) meta-analyses were used to determine the effects of ET overall and for subgroup and ET effects interactions.

Results: Four trials that included 119 LVAD patients (89.1 % males; age: mean (SD), 53 (14) years; BMI: 28 (5) kg/m²; ejection fraction: 19 (6)%) were analysed. ET was safe and improved peakVO₂ (mean difference (95% CI) +1.43 (0.39 to 2.45) mL/kg/min, p=0.004), 6MWT distance (+48 (95% CI 24 to 73) m, p<0.001), QoL (+0.66 (95% CI 0.26 to 1.05) standardised units, p<0.001) more than standard care. Males, older patients, 1 year post LVAD implantation and those with lower baseline BMI and (sub)maximal exercise performance had larger benefit of ET.

Conclusions: ET is safe and improves (sub)maximal exercise performance and QoL in LVAD patients, and should be considered in management of LVAD.

Prospero registration number: CRD42023480119.

Myocarditis is an inflammatory disease of the heart muscle that can be triggered by various causes, including viruses, autoimmune response, molecular mimicry and exposure to immune-stimulating drugs or vaccines. Most cases of myocarditis heal, and cardiac dysfunction, if present, recovers; however, selected forms may require targeted therapy to improve outcomes. We herein review five conditions presenting with or mimicking myocarditis that require targeted diagnostic approaches, including endomyocardial biopsy, and/or targeted treatments. Giant cell myocarditis is an intense and unresolving inflammation of the heart, characterised by rapid progression, significant arrhythmias, heart failure and shock, that is unlikely to resolve without immunosuppression therapy. Myocarditis related to immune checkpoint inhibitors is a rare but potentially fatal adverse effect of the use of cancer immunotherapy with checkpoint inhibitors, requiring immunosuppressive therapy. Eosinophilic myocarditis can be triggered by allergy, hypersensitivity reactions, infections or can be idiopathic and is characterised by eosinophilic infiltrates in the heart and other organs, associated with thrombosis and necessitating targeted therapy. Myocarditis is a frequent cardiovascular manifestation of systemic immune-mediated inflammatory diseases such as systemic lupus erythematosus, and injury is caused by an autoimmune response in the myocardium and cytokine-mediated damage, requiring targeted therapy. Genetic pathogenic mutations in desmoplakin and other desmosomal genes can present with 'hot phases' mimicking myocarditis associated with an increased risk of arrhythmias, heart failure, and sudden cardiac death.

As transcatheter aortic valve implantation (TAVI) is increasingly used in younger and lower-risk patients, long-term valve durability has become a growing concern. Bioprosthetic valve degeneration (BVD) is multifactorial, encompassing calcific and non-calcific structural deterioration, non-structural deterioration, valve thrombosis and procedural or device-related factors. This review aims to provide a look across the spectrum of understanding BVD, presenting insights from fundamental and translational science through to the clinic to give a comprehensive overview of the mechanisms underlying BVD in TAVI valves. This review highlights the pivotal role of multimodality imaging in detection, classification and monitoring of degeneration and discusses the emerging pharmacological and engineering innovations aimed at preventing degeneration. Finally, reintervention strategies, including redo-TAV and surgical explantation, are explored with an emphasis on CT-based planning and bench-testing insights that have enhanced our understanding of BVD and inform ongoing procedural refinement. These perspectives support a proactive and tailored approach to managing transcatheter aortic valve degeneration across the patient's lifetime.

Cardiac device therapy has significantly evolved since the introduction of the first implantable pacemaker and the subsequent development of the implantable cardioverter-defibrillator (ICD). ICDs are highly effective; however, their main weakness lies in lead-related complications. To avoid the need for venous access and the complications associated with transvenous leads, a fully subcutaneous ICD (S-ICD) system was developed. Despite these advancements, the S-ICD system is limited by its inability to provide bradycardia pacing and antitachycardia pacing. This limitation prompted the development of a modular cardiac rhythm management system, integrating a new leadless pacemaker with an S-ICD that uses unidirectional communication to command the pacemaker to deliver antitachycardia pacing.Conduction system pacing, including His bundle pacing and left bundle branch area pacing (LBBAP), has emerged as a physiological alternative to biventricular resynchronisation therapy and conventional pacing, pending results of large clinical trials. LBBAP offers superior electrical parameters and long-term performance compared with His bundle pacing. The capability to provide defibrillation via the same lead used for LBBAP represents an unresolved challenge that is currently under ongoing research.This state-of-the-art review presents the latest developments and innovations in cardiac device therapy, offering a comprehensive overview of current technologies that increasingly enable therapy to be tailored to individual patient needs.

Background: Fluid restriction is a commonly prescribed non-pharmacological intervention in the management of heart failure (HF). However, data on its efficacy and safety are scarce. Recent randomised clinical trial (RCT) data prompt reassessment of the available evidence.

Methods: CINAHL, EMBASE, PubMed and the Cochrane Library were searched up to 1 May 2025. RCTs were included if adults with HF were randomised to fluid restriction in comparison to a liberal or unrestricted intake, less strict restriction or usual care. Outcomes of interest were mortality, HF hospitalisation, quality of life (QoL), thirst distress, New York Heart Association (NYHA) class and N-terminal pro-Brain Natriuretic Peptide (CRD42022292319). No meta-analysis was performed due to high heterogeneity of the included trials.

Results: In total, four RCTs were included, comprising 682 randomised inpatient, recently discharged and stable outpatient patients (ranging from 46 to 504 patients per trial). Only one study had a low risk of bias. None of the four trials found a significant difference in mortality or HF hospitalisations. For QoL, the results are contradictory, but overall, there is no clear benefit for fluid restriction, but it resulted in more thirst distress. No significant differences in NYHA class or (NT-pro)BNP were observed.

Conclusion: Studies on fluid restriction in patients with HF are scarce, and most of the available studies are at high risk of bias. Although power is lacking, there is no evidence indicating that fluid restriction affects mortality or HF hospitalisations, but there is a signal of harm in terms of thirst distress. Taken together, the current evidence does not support the routine use of fluid restriction in patients with HF.

Background: Ethnic inequalities exist in the management of patients with cancer with acute coronary syndrome (ACS). Given their under-representation in trials, ethnic minority patients are often studied using large registries, but the quality of ethnicity coding in these datasets remains unclear.

Methods: Agreement of ethnicity coding and outcomes for patients with cancer with ACS (2000-2018) was examined across four national datasets: National Cancer Registration and Analysis Service (NCRAS), Myocardial Ischaemia National Audit Project (MINAP), British Cardiovascular Intervention Society database (BCIS) and Hospital Episode Statistics (HES). Three linkages were performed: NCRAS-MINAP, NCRAS-MINAP-BCIS, NCRAS-MINAP-HES, with four groups based on ethnicity agreement: Concordant, Discordant, Missing (1 and ≥2 datasets). Multivariable logistic regression and Cox's Proportional Hazards models assessed 1-year and long-term (≤5 years) cardiac and cancer-related death for each agreement group.

Results: Among three linkages, just over half of the ethnicities were concordant (range: 52.4%-53.8%). Discordance was relatively low (range 1.2%-5.5%) while missingness ranged between 28.6% and 43.4% in 1 dataset and 1.6%-12.6% in ≥2 datasets. Ethnicity correlation between individual datasets was poor, lowest between NCRAS and BCIS (r=0.318). We observed higher 1-year and long-term cardiac and cancer deaths in several of the Missing (1 and ≥2 datasets) groups across the three linkages, compared with the Concordant group.

Conclusion: Across four national datasets for patients with cancer with ACS, nearly half of patients had missing ethnicity in at least one dataset, which was associated with higher cardiac or cancer mortality. Inconsistency in ethnicity coding represents a missed opportunity to examine health inequalities in this high-risk and understudied population.

Background: Type A intramural haematoma (TAIMH) and type A aortic dissection (TAAD) are both managed surgically as acute aortic syndromes, but whether their clinical profiles and outcomes differ remains unclear. We performed the first comprehensive meta-analysis to compare patient characteristics, operative findings and complications between TAIMH and TAAD.

Methods: Systematic searches of six databases identified studies comparing TAIMH and TAAD, with data pooled using random-effects models and Hartung-Knapp-Sidik-Jonkman corrections for small samples. Subgroup and meta-regression analyses assessed the influence of treatment strategy, geography and baseline factors. The primary outcome was in-hospital mortality; secondary outcomes were 30-day, operative mortality and perioperative complications.

Results: 16 studies including 6457 patients (1288 TAIMH; 5169 TAAD) were analysed. Compared with TAAD, patients with TAIMH were older, more often female and had more hypertension but less connective-tissue disease, severe aortic regurgitation and malperfusion. TAIMH was associated with shorter aortic cross-clamp and cardiopulmonary bypass times and fewer total arch replacements. Perioperative mortality was significantly lower in TAIMH (in-hospital risk ratio (RR) 0.49, 95% CI 0.35 to 0.68; 30-day RR 0.59, 95% CI 0.40 to 0.88; operative RR 0.31, 95% CI 0.16 to 0.60), with fewer postoperative acute kidney injury (RR 0.57, 95% CI 0.42 to 0.76), consistent across eastern and western populations.

Conclusions: TAIMH differs pathophysiologically and prognostically from classical TAAD, demonstrating lower perioperative mortality despite affecting an older population. These findings support distinct risk stratification and tailored surgical strategies for TAIMH and should inform updates to future aortic-disease guidelines.

Prospero registration number: CRD42024599964.

Background: Insomnia symptoms are prevalent in older adults and linked to cardiovascular disease (CVD), but the role of long-term symptom trajectories remains unclear. We investigated associations between insomnia symptoms, their trajectories over time and incident CVD in a population-based cohort.

Methods: This longitudinal study included 12 102 participants aged ≥50 years without baseline CVD from the US Health and Retirement Study (2002-2018). Insomnia symptoms (non-restorative sleep, difficulty initiating/maintaining sleep, early awakening) were assessed at baseline; trajectories were modelled over 4 years (2002-2006) using latent class analysis. Cox models estimated HRs for incident CVD (heart disease or stroke), adjusted for sociodemographics, lifestyle and comorbidities.

Results: During a median of 10.2-year follow-up, 3962 incident CVD events occurred. Compared with no symptoms, participants with one, two, or three to four symptoms had higher CVD risk (HR 1.16, 95% CI 1.05 to 1.27; HR 1.16, 95% CI 1.05 to 1.28; HR 1.26, 95% CI 1.15 to 1.38, respectively). Four trajectories were identified: persistent low (56.3%), decreasing (27.1%), increasing (7.2%) and persistent high (9.5%). Compared with persistent low, increasing (HR 1.28, 95% CI 1.10 to 1.50) and persistent high (HR 1.32, 95% CI 1.15 to 1.50) trajectories were associated with elevated CVD risk.

Conclusions: Greater burden of insomnia symptoms at baseline and trajectories over time were associated with higher CVD incidence in older adults.