Heart International最新文献

Hypertrophic cardiomyopathy is the most common monogenic cardiovascular disease that is caused by sarcomeric protein gene mutations. A hallmark of the most common form of the disease is outflow obstruction secondary to systolic narrowing of the left ventricular outflow tract from septal hypertrophy, mitral valve abnormalities and, most importantly, hyperdynamic contractility. Recent mechanistic studies have identified excessive myosin adenosine triphosphatase activation and actin-myosin cross-bridging as major underlying causes. These studies have led to the development of mavacamten, a first-in-class myosin adenosine triphosphatase inhibitor and the first specific therapy for hypertrophic obstructive cardiomyopathy. Preclinical and subsequent pivotal clinical studies have demonstrated the efficacy and safety of mavacamten. A remarkable improvement among treated patients in peak oxygen consumption, functional capacity, symptom relief and post-exercise left ventricular outflow tract gradient, along with dramatic reductions in heart failure biomarkers, suggests that this new medication will be transformative for the symptom management of hypertrophic obstructive cardiomyopathy. There is also hope and early evidence that mavacamten may delay or obviate the need for invasive septal reduction therapies. In this article, we review the current evidence for the efficacy and safety of mavacamten and highlight important considerations for its clinical use.

Although bifurcation stenting can be often managed with a simple provisional approach, in some settings, more complex techniques are appropriate. Based on our clinical experience and on data from literature, we propose a simple algorithm that may assist in selecting cases for elective double stenting. We found that, when the side branch is of adequate dimensions and affected by significant disease (longer than 10 mm and/or with presence of ostial calcifications), double stenting is associated with a lower incidence of adverse events, compared with provisional stenting.

Second-generation drug-eluting stents (DES) are considered standard of care for revascularization of patients undergoing percutaneous coronary intervention. Besides the polymer and antiproliferative drug used, the metallic backbone of DES is an attractive target for further development. Ultrathin-strut DES (≤70 μm strut thickness) are more flexible, have an improved trackability and crossability compared to conventional second-generation DES. Importantly, ultrathin-strut DES reduce the risk of in-stent restenosis, thereby decreasing the risk of angiographic and clinical restenosis. In this narrative review, we will discuss the clinical outcomes of the commercially available ultrathin-strut DES.

Mitral regurgitation (MR) is the most prevalent valvular heart disease globally. Mitral valve surgery is the gold-standard treatment for MR. However, a significant portion of patients with mitral valve disease are at high or prohibitive surgical risk. Transcatheter mitral valve replacement (TMVR) has emerged as a potential treatment option for this vulnerable population. Numerous TMVR devices are currently being investigated, with early data demonstrating feasibility and efficacy of TMVR. In this article, we explore the unique challenges of designing a TMVR system and describe the TMVR systems under clinical evaluation.

The treatment of endovascular leaks after endovascular abdominal aortic repair can be challenging, particularly in patients with a lack of vascular access. We describe the case of a critically ill elderly patient with an endoleak resulting from structural failure of an endograft years after endovascular abdominal aortic repair. The patient was treated with an aorto-uni-iliac endoprosthesis, but a few days later a new endoleak appeared and femoral or axillar access was not feasible. We successfully treated the endoleak using a novel technique via bilateral transradial access involving simultaneous insufflation of two peripheral low-profile balloons to achieve a diameter capable of improving the apposition of the stent graft. In selected cases, bilateral radial access allows procedures to be performed that would otherwise be impossible due to the inherent limitation in sheath size that can be used in the radial artery.

Cardiologists and the cardiac catheter laboratory have key roles to play in the management of patients after out-of-hospital cardiac arrest (OHCA). Although immediate catheter laboratory activation is the standard of care in cardiogenic shock and ST elevation myocardial infarction, the majority of patients will present without these features and with an uncertain diagnosis. Even in the latter, early assessment and invasive management may be beneficial, but this is counterbalanced by significant resource utilization, potential to cause harm and the possibility that any diagnostic or therapeutic gains are offset by a poor neurological outcome. Past consensus on the management of the OHCA patient without ST elevation or cardiogenic shock is being challenged by emerging results from new trials in this field. Further randomized trials are ongoing, and are expected to deliver robust data from over 4,000 patients, allowing us to further refine the optimal management strategy in this challenging cohort. This article describes the benefits and pitfalls of a strategy of immediate coronary angiography in these patients, examines the recently published COACT and TOMAHAWK trials in detail, and describes a framework with which to approach the patient after resuscitated OHCA, based on the available evidence to date.

The XIENCE family of everolimus-eluting stents ranks among the most used and most widely studied drug-eluting stents worldwide. In patients at high bleeding risk undergoing non-complex percutaneous coronary intervention with these stents, a shortened dual antiplatelet therapy (DAPT) regimen of 1-3 months appears to be associated with a reduced rate of major bleeding, a similar rate of ischaemic events and a very low incidence of stent thrombosis after DAPT discontinuation compared with DAPT up to 12 months.

For the treatment of peripheral arterial disease, drug-eluting technology is a widely accepted therapeutic option, with significant reduction in intimal hyperplasia and, consequently, use of target lesion revascularization. Nevertheless, the reputation of such devices was damaged after a meta-analysis, published in December 2018, showed increased mortality in patients receiving paclitaxel-eluting devices. Although subsequent studies have failed to establish such correlation, the use of paclitaxel-eluting devices remains heavily restricted. As such, other options and drugs have been developed, for instance sirolimus. In this article we present the available data on drug-eluting technology.

Lead displacement is a common complication of pacemaker device implantation, often resulting in prolonged hospital stays and increased costs. The frequency of long-term lead displacement ranges between 1.8% and 8.0%. In our case, the patient did not present any symptoms and the lead displacement was seen at a relatively late stage. During a routine pacemaker follow up, it was noted that the right ventricular (RV) threshold had increased and deteriorated over time. The pacemaker box had rotated anticlockwise and the RV lead had developed a loop that eventually led to its retraction from the RV implantation position into the pulmonary artery. The patient was asymptomatic; however, he underwent RV lead revision. Patient education, opening an appropriate pocket for the size of the generator, fixing the sleeves to an appropriate tightness and securing the battery with a strong suture all can be used to avoid lead displacement.