Korean Circulation Journal最新文献

The coexistence of severe aortic stenosis (AS) and coronary artery disease (CAD) presents complex diagnostic and therapeutic challenges, particularly as transcatheter aortic valve replacement (TAVR) expands to younger, lower-risk populations. CAD prevalence in AS patients ranges from 27.7% in low-risk cohorts to 74.9% in high-risk populations, synergistically worsening ventricular function and prognosis. Diagnostic evaluation remains challenging due to overlapping symptomatology and altered coronary physiology in severe AS. While invasive coronary angiography remains the gold standard, coronary computed tomography (CT) angiography with CT-derived fractional flow reserve (FFR) shows promise as a non-invasive alternative. Standard FFR thresholds may not be reliable in AS patients, with emerging evidence suggesting AS-specific cutoffs may be needed. Treatment strategies must balance the complexity of CAD with patient risk profiles. Current guidelines recommend bypass surgery with surgical aortic valve replacement for complex multivessel disease, while percutaneous coronary intervention (PCI) with TAVR is preferred for less complex lesions or high-risk patients. The optimal timing of PCI relative to TAVR remains debated, with recent data favoring a "TAVR-first" approach for non-critical lesions. As TAVR extends to younger patients, lifetime management considerations become paramount, including valve durability, future coronary access, and planning for potential re-interventions. Commissural alignment techniques during TAVR are crucial for preserving future coronary access. A multidisciplinary Heart Team approach with robust shared decision-making is essential for optimizing individualized care in this evolving field.

Background and objectives: The optimal strategy for the maintenance or discontinuation of evidence-based medication is unclear in heart failure (HF) patients with improved left ventricular ejection fraction (LVEF). We tested the feasibility and safety of withdrawing mineralocorticoid receptor antagonists (MRAs) in this population.

Methods: This is an open-label, prospective, randomized controlled pilot trial including HF patients whose LVEF improved from ≤35% to ≥50% after guideline-directed medical therapy. While testing withdrawal of MRA, other medications were maintained. The primary endpoint was the proportion of patients showing deteriorations in LVEF by ≥10% at 6-month follow-up. The secondary endpoints were numerical changes in echocardiographic parameters, changes in blood natriuretic peptide levels, and adverse clinical events relevant to HF.

Results: We randomly assigned 62 HF patients with improved LVEF to the withdrawal or continuation groups. Two (6.7%) patients in the withdrawal group and one (3.2%) patient in the continuation group showed deterioration in LVEF by ≥10% at 6 months; one of the 2 patients in the withdrawal group who showed a decline in LVEF had LVEF of less than 50% at follow-up. Re-initiation of MRA did not occur in any patients. Compared with baseline, echocardiographic parameters, including LV end-diastolic volume index, global longitudinal strain, and natriuretic peptides, were similar at follow-up in both groups.

Conclusions: MRA withdrawal was associated with a low risk of significant deterioration of cardiac function in HF patients with improved LVEF of ≥50%. MRA withdrawal may be feasible and safe in this population.

Trial registration: ClinicalTrials.gov Identifier: NCT04367051.

Background and objectives: This study evaluated the efficacy of atrial fibrillation (AF) rhythm control therapy in improving functional mitral regurgitation (MR) and tricuspid regurgitation (TR) and its association with clinical outcomes.

Methods: Among 2,574 patients with AF screened from 2003 to 2023, 817 pairs of patients were selected through propensity matching to compare rhythm control therapy (antiarrhythmic drugs, catheter ablation, or electrical cardioversion) with no rhythm control. MR and TR severity were assessed at baseline and follow-up echocardiography conducted at least 3-month intervals. Clinical outcomes included all-cause mortality and heart failure-related hospitalizations.

Results: Rhythm control was associated with a reduction in moderate or greater MR (7.3% to 4.9%, p=0.008) and attenuation of TR progression (9.1% to 9.3%, p=0.796), contrary to the worsening trends in the no rhythm control group. Sinus restoration was more frequent in the rhythm control group compared to the no rhythm control group (60.2% vs. 48.1%, p<0.001). Patients maintaining sinus rhythm after rhythm control showed the greatest MR improvement (7.3% to 3.5%, p=0.002). Rhythm control was also associated with reverse cardiac remodeling, including reductions in left atrial volume index and improved left ventricular ejection fraction (both p<0.001). Clinical outcomes were more favorable in the rhythm control group, particularly among patients with improved regurgitation or restored sinus rhythm.

Conclusions: AF rhythm control therapy is associated with improved functional MR, attenuated TR progression, enhanced sinus rhythm maintenance, and favorable clinical outcomes. Echocardiography can provide valuable information for identifying the optimal timing of rhythm control intervention and assessing treatment response.

Backgrounds and objectives: Data on the optimal duration of dual antiplatelet therapy (DAPT) by age in patients undergoing percutaneous coronary intervention (PCI) are limited. This study assessed clinical outcomes based on age groups and DAPT duration, focusing on patients aged ≥75 years.

Methods: We analyzed data from 10,487 patients across 5 Korean randomized trials examining the impact of DAPT durations on clinical outcomes after drug-eluting stent implantation. Patients were categorized into 2 groups: ≥75 years (n=1,571) and <75 years (n=8,916). Each group was further stratified into short-term DAPT (1-6 months) and standard DAPT (12 months). The primary outcome was major bleeding within 12 months of PCI. Major adverse cardiovascular and cerebrovascular events (MACCE) and net adverse clinical events (NACE), a composite of MACCE and major bleeding, were also compared.

Results: Patients aged ≥75 had a higher risk of major bleeding and MACCE than those aged <75. In patients aged ≥75, standard DAPT was associated with a higher risk of major bleeding than short-term DAPT (hazard ratio [HR], 2.34; 95% confidence interval [CI], 1.17-4.68; p=0.016). In patients aged <75 years, the risk was comparable (HR, 1.45; 95% CI, 1.00-2.10; p=0.053), with no significant interaction between groups (p=0.207). The risks of MACCE and NACE did not differ significantly between DAPT strategies or age groups.

Conclusions: Standard DAPT strategy may increase bleeding risk in elderly patients without reducing ischemic events, despite no significant age-treatment interaction.

Trial registration: ClinicalTrials.gov Identifier: NCT01145079 (RESET), NCT01308281 (IVUS-XPL), NCT01752894 (DETECT-OCT), NCT02494895 (TICO), NCT02513810 (One-Month-DAPT).

Background and objectives: CENTUM is a biodegradable everolimus-eluting stent comprising a cobalt-chromium open-cell stent platform. In this prospective trial, we aimed to evaluate the effectiveness and safety of CENTUM™ in a clinical setting.

Methods: A prospective, single-arm, multi-center observational registry was designed to assess the clinical outcomes after CENTUM implantation in all-comers who underwent percutaneous coronary intervention. The primary endpoint was a composite of cardiac death, nonfatal myocardial infarction, and target lesion revascularization at 12 months. The secondary endpoints included stent thrombosis and other clinical events (all-cause death, myocardial infarction, stroke, target vessel revascularization, and bleeding).

Results: Total 490 patients were enrolled, and 451 completed the study. The mean age was 67.1 years, and 52.8% of the patients presented with acute coronary syndrome. The primary endpoint was observed in 1.11% of the patients. Definite/probable stent thrombosis was observed in 0.44% of the patients, whereas total clinical events recorded was 4.43%.

Conclusions: CENTUM was effective and safe at 12 months in all patients who underwent percutaneous coronary intervention. Our findings support the broader application of CENTUM in patients with coronary artery disease.

Trial registration: Clinical Research Information Service Identifier: KCT0009898.

Background and objectives: Dilated cardiomyopathy (DCM) has a variable prognosis and generally poor outcomes. Genetic testing could identify high-risk patients. This study aimed to evaluate the prognostic impact of genetic testing in patients with DCM.

Methods: This retrospective study included consecutive patients with DCM who underwent targeted panel sequencing or whole genome sequencing at Samsung Medical Center from 2018 to 2023. Patients were divided into genotype-positive and genotype-negative groups based on the presence of pathogenic or likely pathogenic variants. The primary outcome was a composite of cardiac death, heart transplantation, and left ventricular assist device implantation at 5 years. The primary outcome was compared according to the results of genetic testing.

Results: In total, 239 patients were analyzed and followed for a median of 2.6 years. Among the patients, 79 (33.1%) were genotype-positive, and 160 (66.9%) were genotype-negative. The genotype-positive group had a significantly higher risk of the primary outcome than the genotype-negative group (hazard ratio, 1.80; confidence interval, 1.10-2.95; p=0.020). Further dividing genotype-negative patients based on the presence of a variant of uncertain significance (VUS) revealed a stepwise increase in the incidence of the primary outcome among the 3 groups (no variant 22.3%, VUS 43.9%, genotype-positive 42.9%; overall log-rank p=0.032). Also, the incidence of the primary outcome differed significantly in genotype-positive patients according to the affected functional gene group (overall log-rank p=0.003).

Conclusions: Patients with DCM exhibited varying prognoses according to genotype. Further research is needed to refine risk stratification and the clinical application of genetic testing in DCM.

Shared decision-making (SDM) is the process that promotes the agreement between treatment choices based on patient values and medical knowledge. For chronic stable angina, this involves facilitating decision-making between percutaneous coronary intervention and guideline-directed medical therapy according to personalized risks and benefits associated with these 2 treatment options. In severe aortic valve stenosis, SDM again comes to play, this time to select between transcatheter aortic valve implantation and surgical aortic valve replacement. The implementation of SDM in South Korea faces challenges, including limited patient involvement and preference for physician-driven decisions. Structural improvements cover multidisciplinary heart team discussion and patient education tools which integrate SDM well into enhancing patient-centered care by addressing these barriers to improve treatment accessibility and outcome in the South Korean healthcare system.