US Cardiology Review最新文献

Transcatheter aortic valve replacement (TAVR) is the standard of care for patients with symptomatic severe aortic stenosis at high or prohibitive surgical risk. The 2020 valvular heart disease guidelines from the American College of Cardiology and American Heart Association now include TAVR as a class I indication for patients aged 65-80 years and not at high or prohibitive risk. The longer life expectancy of this patient population raises the issue of TAVR valve durability and the management of bioprosthetic valve failure of TAVR valves. In this review, the authors discuss bioprosthetic valve dysfunction and summarize existing data regarding redo-TAVR and surgery for failed TAVR. Finally, they propose an approach to evaluate patients with failed TAVR and plan for a second TAVR procedure as indicated.

Cardiogenic shock is a complex hemodynamic state that, despite improvements in care, often remains challenging to treat and confers a high mortality rate. Timely application of advanced strategies, including advanced hemodynamic management and mechanical circulatory support, is of the utmost importance for this critically ill patient population. Based on data and historic experiences with similar life-threatening conditions, a national system in the US of regionalized, structured care for patients with cardiogenic shock has the potential to improve outcomes and save lives. To enact this, national and state leaders, as well as federal regulatory bodies, physician thought leaders, industry representatives, and national organizations, must collaborate and advocate for a clear, structured cardiac shock center network with a tiered model for delivery of care for the sickest population of cardiac patients.

Cardiogenic shock (CS) remains a deadly disease entity challenging patients, caregivers, and communities across the globe. CS can rapidly lead to the development of hypoperfusion and end-organ dysfunction, transforming a predictable hemodynamic event into a potential high-resource, intense, hemometabolic clinical catastrophe. Based on the scalable heterogeneity from a cellular level to healthcare systems in the hemodynamic-based management of patients experiencing CS, the authors present considerations towards systematic hemodynamic-based transitions in which distinct clinical entities share the common path of early identification and rapid transitions through an adaptive longitudinal situational awareness model of care that influences specific management considerations. Future studies are needed to best understand optimal management of drugs and devices along with engagement of health systems of care for patients with CS.

Background: Transcatheter aortic valve replacement (TAVR) is a globally established therapy. However, there is significant variability in the antithrombotic management post-procedure. The data on antiplatetet and direct antithrombin agents suggest antiplatelet agents suffice. The degree of leaflet thickening on cardiac CT and the clinical implications of this finding remain poorly understood. Here, the authors aim to examine a low-risk cohort treated with dual antiplatelet therapy and the corresponding cardiac CT and clinical findings.

Methods: This is a descriptive single center study examining patients who received dual antiplatelet therapy post-TAVR from 2017 to 2019. Patients underwent clinical, echocardiographic and cardiac CT follow up. Signs and symptoms of ischemic stroke, valve function, gradient, and cardiac CT findings of hypo-attenuated leaflet thickening and reduced leaflet mobility were recorded for all those who completed 6 months of follow-up. The study was registered and approved by the Ethics Committee.

Results: A total of 116 patients were included. Hypo-attenuated leaflet thickening was detected in 11 patients. Only one had accompanying reduced leaflet mobility and an increase in gradient. This patient did not have any evidence of stroke or valve dysfunction. After switching to rivaroxaban, the gradient improved and a repeat cardiac CT demonstrated resolution of the leaflet thickening.

Conclusion: This study illustrates the utility of cardiac CT in detecting leaflet thickening and restricted mobility post-TAVR in low-risk individuals treated with dual antiplatelet therapy. However, its role in guiding antithrombotic regimens cannot be ascertained from this study and additional larger scale studies comparing different regimens in both symptomatic and asymptomatic patients are necessary.

Trial registration: N/A.

Although great strides have been made in the pathophysiological understanding, diagnosis and management of cardiogenic shock (CS), morbidity and mortality in patients presenting with the condition remain high. Acute MI is the commonest cause of CS; consequently, most existing literature concerns MI-associated CS. However, there are many more phenotypes of patients with acute heart failure. Medical treatment and mechanical circulatory support are well-established therapeutic options, but evidence for many current treatment regimens is limited. The issue is further complicated by the fact that implementing adequately powered, randomized controlled trials are challenging for many reasons. In this review, the authors discuss the history, landmark trials, current topics of medical therapy and mechanical circulatory support regimens, and future perspectives of CS management.

The introduction of robots into healthcare has brought a wealth of opportunity for technical advancements, ranging from cleaning robots to disinfect hospital rooms to the high-tech surgical robots used in the operating room. Robotic-assisted percutaneous coronary intervention (R-PCI) has been a more recent development in the field, and is particularly revolutionary in that it serves to benefit the interventional cardiologist as well as the patient. Published data on R-PCI have shown its feasibility, safety, and more recently, its potential benefits. This review examines the current role of the robot in the catheterization laboratory, the authors' experience with the most current generation of the robot, and what is yet to come.

MI is a leading cause of morbidity and mortality worldwide. Coronary artery thrombosis is the final pathologic feature of the most cases of acute MI primarily caused by atherosclerotic coronary artery disease. The concept of vulnerable plaque has evolved over the years but originated from early pioneering work unveiling the crucial role of plaque rupture and subsequent coronary thrombosis as the dominant cause of MI. Along with systemic cardiovascular risk factors, developments of intravascular and non-invasive imaging modalities have allowed us to identify coronary plaques thought to be at high risk for rupture. However, morphological features alone may only be one of many factors which promote plaque progression. The current vulnerable-plaque-oriented approaches to accomplish personalized risk assessment and treatment have significant room for improvement. In this review, the authors discuss recent advances in the understanding of vulnerable plaque and its management strategy from pathology and clinical perspectives.

Transcatheter aortic valve replacement (TAVR) has become a widely adopted treatment modality for severe aortic stenosis. Transfemoral access is the approach of choice; however, approximately 25% of patients undergoing TAVR also have concomitant peripheral arterial disease. The recent advent of intravascular lithotripsy has enabled preservation of transfemoral access in some patients; although, a proportion still require alternative, non-femoral access. Alternative access sites can be broadly categorized into transthoracic and peripheral, facilitated by surgical or percutaneous techniques. In this review, the technical details and clinical outcomes of various TAVR accesses are discussed. Initially, transthoracic approaches were most common, but recently, the trend has been toward alternative peripheral access due to superior outcomes. Although there are no randomized data to support all the alternative access sites, the experiences reported provide available options for a large portion of patients to be candidates for TAVR. The intervention site should be selected by a multidisciplinary heart team based on patient anatomical factors and institutional expertise.

Significant mitral regurgitation (MR), frequently seen in the presence of severe aortic stenosis (AS), results in an association that negatively affects prognosis and imposes particular challenges for both the assessment of the severity of valvular lesions and decisions regarding treatment allocation. This article reviews the available literature with regards to the assessment of MR and AS in the presence of both; surgical management and results in patients with concomitant AS and MR; the effect of MR on outcomes in patients undergoing transcatheter aortic valve replacement; the effect of transcatheter aortic valve replacement on MR severity; and percutaneous treatment for MR after transcatheter aortic valve implantation. The authors aim to provide assistance in the decision-making process to treat patients with either a higher-risk double-valve procedure or a simpler, but perhaps incomplete, single-valve option.