Current Opinion in Cardiology最新文献

Purpose of review: Mechanical prosthetic heart valves have been implanted for decades, but have seen declining utilization in modern cardiac surgery. We aim to explore recent literature on the risks and benefits of mechanical prostheses.

Recent findings: The desire of patients to avoid anticoagulation and good performance of bioprosthetic valves appears to have driven a decline in the percentage of mechanical valve use, with mechanical valves now accounting for <20% of aortic and mitral prosthetic implants. However, modern mechanical valves exhibit excellent hemodynamics and durability. Modern bioprosthetic surgical valves are durable, but still experience structural valve deterioration (SVD), especially in younger patients. Transcatheter aortic valve replacement (TAVR) valves are a special case of bioprostheses in which long-term valve durability remains unclear, but presumably will have similar SVD rates to surgical bioprostheses. The true durability of TAVR-in-surgical aortic valve replacement (SAVR) remains unproven and the promise of this for younger patients is without significant data. Moreover, though bleeding risks due to anticoagulation are real and warfarin alternatives elusive, lower INR targets for mechanical valves may be a safe and promising approach. In keeping with the data on the tradeoffs of SVD and anticoagulation, multiple well conducted retrospective studies have confirmed age cutoffs below which patients have a mortality benefit from mechanical valves.

Summary: Mechanical valves are associated with improved survival in younger patients with excellent hemodynamics and may be underutilized.

Purpose of review: Infective endocarditis (IE) remains a prevalent and high-risk condition despite advances in cardiac care. Increasing attention has been directed toward sex-based differences in physiological presentation, disease progression, and surgical management. This review synthesizes evidence on sex-specific differences in IE, with an emphasis on diagnosis, risk factors, disease manifestations, medical management, surgical intervention, and postoperative outcomes.

Recent findings: While the incidence of IE is more than twice as high in men, women consistently experience worse outcomes. Women present at an older age, with greater comorbidity burden and greater delays in surgical referral. Postoperatively, women are at higher risk of complications - including embolic events, extended ventilation time, and intensive care unit stays - and have significantly higher short-term mortality. Long-term survival is comparable between sexes, suggesting disparities largely influence short-term outcomes.

Summary: Awareness of sex-specific differences in risk factors, clinical presentation, intervention bias, complications, and outcomes of IE is essential for optimizing management and equitable care. Further research into sex-based pathophysiology, comorbidity management, and tailored perioperative strategies is critical to advancing patient-centered treatment and optimizing clinical outcomes.

Purpose of review: National databases reveal increased application of the surgical robot to facilitate mitral valve repair. Single-center and multiinstitutional studies confirm that excellent results are achievable with robotic mitral valve repair. However, not all patients with degenerative mitral valve disease are appropriate candidates for robotic mitral valve repair.

Recent findings: With increased experience, surgeons have successfully applied the surgical robot to perform mitral valve repair in conjunction with concomitant procedures. Concurrently, selection criteria have expanded, enabling more patients to enjoy the benefits of a less invasive approach. A small group of patient-related and anatomic factors are best managed via a standard sternal approach.

Summary: Approaching 15% of all mitral valve repairs for degenerative disease, robotic mitral valve repair has reached an inflection point in its growth. Well tolerated application of this technology requires understanding of both its advantages and its limitations.

Purpose of review: Tumours involving cardiac valves pose complex diagnostic and therapeutic challenges. In this review, we use three theoretical cases as a foundation to explore diagnostic workup, therapeutic interventions, and follow-up for both benign and malignant tumours of the heart valves.

Recent findings: While the differential for valvular masses is broad, the most common valvular tumours are benign. Multimodal imaging, usually beginning with echocardiography, and tissue sampling where feasible, are the core tenants of diagnostic workup. Highly mobile lesions on a stalk that are isolated to the valve are likely to be papillary fibroelastomas. However, malignancy should be considered in cases of immobile lesions with unclear boundaries. Based on available data, left sided benign tumours involving valves should be excised promptly given the safety and efficacy of operative approaches and the risk of embolization. For suspected malignancy, biopsy should be organized and a centre of excellence should be consulted. Given that recurrence is possible for benign lesions, and is effectively certain for malignant lesions, a lifelong follow-up plan is crucial.

Summary: Current treatment paradigms for valvular tumours described herein are based entirely from anecdotal and retrospective data. Future standardization and optimization of treatment protocols depend on the systematic gathering of long-term prospective data.

Purpose of review: Technical progress in noninvasive medical imaging continues to enhance diagnosis and intervention, with three-dimensional (3D) imaging emerging as a significant advancement over traditional methods. While 3D visualization is widely used to evaluate a living heart, precise measurement from such images remains challenging. This review describes a new technique named isosurface geometric measurement on volume-rendered images (IMVR), which facilitates accurate 3D measurement of complex cardiovascular anatomy.

Recent findings: Direct volume rendering provides clear visualization and tissue identification, but the lack of exact spatial boundaries inherently makes measurement of any anatomical feature difficult. However, by superimposing a surface-rendered polygonal mesh (representing isosurface geometry) onto a variably transparent volume image of the heart, IMVR enables significantly easier and more accurate 3D measurement. This technique demonstrates versatility across various cardiovascular, anatomical, and clinical applications, including preinterventional assessment and planning for structural heart diseases, notably expanding 3D imaging's utility toward precision medicine and personalized treatment.

Summary: This review article summarizes recent advances in cardiac imaging, highlighting an efficient IMVR technique, which combines volume-rendered images with superimposed surface-rendered image to facilitate accurate 3D measurements of cardiac anatomical features.

Purpose of review: This review explores the contemporary minimally invasive strategies in management of aortic valve disease, highlighting the innovative advancements in robotic approaches, particularly right transaxillary robotic aortic valve replacement (RAVR).

Recent findings: Over the past two decades, there has been increasing interest by patients and providers for less invasive alternatives to conventional sternotomy for treatment of aortic valve disease. Such strategies include transcatheter and minimally invasive surgical approaches such as mini-sternotomy, right anterior thoracotomy and robotic-assisted techniques. A major milestone was achieved in January 2020 with the introduction of RAVR, utilizing the established right transaxillary lateral 3 cm mini-thoracotomy platform commonly used for robotic mitral surgery.

Summary: RAVR provides a nonsternotomy, rib-sparing surgical option that offers the longitudinal benefits of conventional surgical aortic valve replacement (SAVR). As transcatheter aortic valve replacement (TAVR) expands into nonprohibitive risk populations, RAVR may provide similar minimally invasive advantages yet with the added benefit of comprehensive therapy to include concomitant procedures, particularly in low and intermediate surgical risk patients. Importantly, RAVR has facilitated a transformative advance in cardiac surgery, providing a platform for nearly all cardiac surgery with progressive complexity.

Purpose of review: Cardiovascular disease (CVD) remains a leading cause of morbidity and mortality despite major advances in pharmacological, devices, and surgical care. Gene editing technologies have introduced a transformative approach to correct pathogenic variants and modulate disease pathways. This review highlights recent progress in editing technologies that are currently or may soon be applied to address cardiovascular disorders, summarizes recent preclinical and clinical studies that demonstrate improved precision and efficacy, and examines technical and translational challenges that must be overcome for broader clinical application.

Recent findings: We summarize preclinical advances, including refined target selection, improved delivery strategies, and enhanced therapeutic efficiency. We highlight emerging technologies that aim to overcome longstanding constraints such as limited vector cargo capacity, protospacer-adjacent motif (PAM) incompatibility, chromatin accessibility, suboptimal editing efficiency, and off-target activity. We also summarize the increasing clinical experience with in-vivo editing - particularly using lipid nanoparticle (LNP) and adeno-associated virus (AAV)-based platforms - that has also revealed important safety considerations, including vector immunogenicity, systemic inflammation, and organ-specific toxicities.

Summary: Despite rapid progress, successful clinical translation of gene and base editing for CVD continues to hinge on two central challenges: efficient and precise delivery and mitigation of immunogenicity and toxicity from both delivery vectors and gene-editing enzymes. Although next-generation editors and targeted delivery systems have expanded the scope of feasible cardiovascular applications, overcoming these biological barriers remains the critical step toward achieving well tolerated, durable, one-time genomic therapies. Continued innovation in vector engineering, tissue-selective delivery, and immunologic risk mitigation will be essential for advancing editing technologies into cardiovascular care.

Purpose of review: Cardiac autonomic dysfunction plays a crucial role in the pathogenesis of common cardiovascular diseases. The review discusses current and emerging techniques in the evaluation of cardiac autonomic tone.

Recent findings: Assessment techniques include invasive nerve recordings, neurochemical staining, serum biomarkers, advanced imaging, and autonomic reflex testing. Noninvasive modalities such as heart rate variability and skin sympathetic nerve activity have improved clinical feasibility. Novel radiotracers and serum-based assays are emerging to map neurotransmitter dynamics and receptor activity with greater precision.

Summary: No single method captures the full spectrum of autonomic function. A multimodal approach, integrating structural, functional, and molecular tools, offers a more comprehensive evaluation. Future strategies combining imaging, transcriptomics, and biomarkers may enable earlier detection and guide personalized neuromodulation therapies in cardiovascular care.

Purpose of review: Since postoperative atrial fibrillation (POAF) after cardiac surgery remains a common clinical problem and is associated with adverse clinical outcomes, considerable research efforts are spent to better understand and inform its management. This review highlights recent studies on this topic.

Recent findings: A PubMed review of published research on POAF after cardiac surgery over the past two years was conducted. Papers were selected on the basis of their potential value to enhance clinical practice. This search yielded studies which have advanced our understanding on the incidence of late-onset POAF after cardiac surgery and its predictive factors. This information may be useful for clinicians on the optimal timing for atrial fibrillation detection after cardiac surgery. Due to a lack of dedicated randomized trial data, the optimal stroke prevention approach remains uncertain in this patient population.

Summary: POAF after cardiac surgery is an active area of research. Recent studies have provided additional insights on the risk of late-onset atrial fibrillation (>3 months) after cardiac surgery. This information may help clinicians identify patients who are more likely to experience recurrent atrial fibrillation after cardiac surgery. Ongoing randomized trials will help clarify the optimal stroke prevention strategy in this patient population.