Current Opinion in Cardiology最新文献

Purpose of review: This review presents contemporary data on epidemiology, common presentations, investigations and diagnostic algorithms, treatment and prognosis. It particularly focuses on topics of most relevance to heart failure specialists, including what left ventricle (LV) function changes can be expected after treatment and outcomes to all standard and advanced heart failure therapies.

Recent findings: Around 5% of sarcoidosis patients have clinically manifest cardiac sarcoidosis (CS), presenting with significant arrhythmias (such as conduction disturbances and ventricular arrhythmias) or newly developed unexplained heart failure. These cardiac symptoms (including sudden cardiac death) may be the initial manifestations of CS. While cardiac magnetic resonance imaging (CMR) is the preferred method for identifying fibrosis in the myocardium, FDG-positron emission tomography (FDG-PET) helps in identifying active inflammation within the myocardium and aids in managing immunosuppressive treatment. The concept of isolated CS is much debated. However very importantly, recent data have shown that some patients diagnosed with 'clinically and imaging isolated CS' are subsequently found to have genetic cardiomyopathy. The management of CS involves a comprehensive approach including medications for immunosuppression, all standard heart failure medication and, in high-risk patient's implantable cardioverter defibrillators (ICDs). In CS patients with terminal heart failure who do not respond to medical and surgical interventions, heart transplantation and ventricular assist devices should be considered. Long-term results after transplantation are generally favorable and comparable to non-CS patients. The degree of left ventricular dysfunction remains a crucial prognostic factor in CS cases. Outcomes for CS have very significantly improved, over the last two decades due to earlier diagnosis, advanced heart failure treatments, and the strategic use of ICD therapy.

Summary: Outcomes for CS have significantly improved, over the last two decades due to earlier diagnosis, advanced heart failure treatments, and the strategic use of ICD therapy.

Purpose of review: Review advancements in therapies for transthyretin (ATTR-CM) and immunoglobulin light chain (AL-CM) cardiac amyloidosis.

Recent findings: In ATTR-CM, tafamidis remains the cornerstone therapy, with Food and Drug Administration (FDA) approval for over 5 years. Acoramidis, another transthyretin stabilizer, has very recently been FDA-approved following positive results in the ATTRibute-CM trial. Vutrisiran, a transthyretin gene silencer, demonstrated efficacy in the HELIOS-B trial and awaits FDA review. Eplontersen's CARDIO-TTRansform trial, the largest ATTR-CM study to date, is expected to report by late 2025. Innovative approaches such as NTLA-2001 (a CRISPR-Cas9 therapy) and fibril depleters like ALXN2220 and coramitug are advancing in clinical trials. In AL-CM, daratumumab, cyclophosphamide, bortezomib, and dexamethasone (Dara-CyBorD) has established itself as the standard of care. Novel antiplasma cell therapies include CAR-T cells and bispecific antibodies (teclistimab) and fibril depleters. Birtamimab improved survival in advanced AL-CM during the VITAL trial and is under investigation in AFFIRM-AL. Anselamimab is in phase III CARES trials, whereas AT-02 undergoes early-phase testing for ATTR-CM and AL-CM.

Summary: The therapeutic landscape for ATTR-CM and AL-CM is rapidly evolving, driven by novel therapies targeting diverse mechanisms. Ongoing clinical trials promise to further refine the standard of care and improve outcomes for patients with cardiac amyloidosis.

Purpose of review: Infective endocarditis (IE) is a complex disease with increasing global incidence. This review explores recent trends in IE infection patterns, including healthcare-associated IE (HAIE), drug-use-associated IE (DUA-IE), multidrug-resistant organisms (MDROs), and challenges in managing prosthetic valve and device-related infections.

Recent findings: Staphylococcus aureus has emerged as the leading cause of IE, especially in HAIE and DUA-IE cases. Increasingly prevalent MDROs, such as methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci, pose further clinical challenges. Advances in molecular diagnostics have improved the detection of culture-negative endocarditis. The introduction of the AngioVAC percutaneous aspiration device promises to change the management of right and possibly some left sided IE. Multidisciplinary team management and early surgery have demonstrated improved outcomes including partnerships with psychiatry and addictions services for those with intravenous DUA-IE.

Summary: IE presents significant diagnostic and therapeutic challenges due to evolving infection patterns, MDROs, and HAIE. Early diagnosis using advanced imaging, appropriate early antimicrobial therapy, and multidisciplinary care, including timely surgery, are critical for optimizing patient outcomes.

Purpose of review: Management of tricuspid regurgitation and annular dilation during mitral valve repair remains controversial. We review the latest evidence on indications to repair the tricuspid valve during mitral valve repair and discuss surgical strategies and complications.

Recent findings: Concomitant tricuspid valve repair of moderate tricuspid regurgitation is effective in reducing tricuspid regurgitation progression at 2 years, but has not shown benefit to late survival, quality of life, or functional benefit, and is associated with increased permanent pacemaker implantation (PPM) rates, which is associated with reduced late survival. Progression of less than moderate tricuspid regurgitation with annular dilation alone is uncommon, obviating the need for concomitant repair.

Summary: Repairing concomitant moderate tricuspid regurgitation at the time of mitral repair reduces tricuspid regurgitation progression at 2 years, at the cost of a higher PPM implantation rate. However, repairing less than moderate tricuspid regurgitation for annular dilation alone has not been shown to reduce tricuspid regurgitation progression, bringing current guideline recommendations surrounding repair for annular dilation into question. Longer-term follow-up data, at 5 years, will shed further light on this topic.

Purpose of review: Cardiac tumours present significant clinical challenges due to their wide differential, complex anatomical and physiological implications, as well as the potential for widespread invasion in the case of malignancies. This review synthesizes recent findings surrounding the diagnosis and management of specifically right-sided cardiac tumours, with a particular focus on surgical resection and reconstructive techniques.

Recent findings: Management of cardiac tumours can be categorized into three key phases. First: early and accurate diagnosis is critical for improving outcomes, especially in malignancies. Advances in imaging modalities like MRI, CT, PET-CT, and biopsy techniques enhance diagnostic accuracy. Second: surgical resection is a cornerstone treatment for both benign and malignant right-sided cardiac tumours. Surgery is often curative for benign tumours, while for malignant tumours, R0 resection (complete microscopic removal) in appropriate candidates correlates with better survival. Third: managing cardiac malignancies necessitates a multidisciplinary approach, integrating additional therapies such as chemotherapy, radiation, and emerging immunotherapies tailored to patient and tumour characteristics.

Summary: Managing right-sided cardiac tumours demands interdisciplinary expertise. Standardized protocols are limited by the rarity of cases and insufficient high-quality data. International collaboration and sharing of experiences through prospective registries and clinical studies are essential to advancing knowledge and improving patient outcomes.

Purpose of review: This review provides a contemporary, evidence-based update on the pathophysiological mechanisms and rapidly evolving therapeutic options for recurrent pericarditis.

Recent findings: Recent studies have elucidated the pathogenesis of recurrent pericarditis, identifying autoinflammation as a key mechanism and interleukin-1 (IL-1) as a central modulator of the inflammatory cascade. Multiple clinical trials have investigated novel therapeutic approaches, particularly focusing on IL-1 inhibition. The recent FDA approval of IL-1 pathway blockade for recurrent pericarditis has revolutionized treatment, offering patients significantly improved quality of life and symptom management.

Summary: The enhanced understanding of the autoinflammatory nature of recurrent pericarditis, coupled with groundbreaking advances in targeted therapies, has transformed the treatment landscape for affected patients. The emergence of IL-1 inhibitors as an effective therapeutic option promises substantial improvements in clinical outcomes and patient well being. Clinicians must familiarize themselves with these new treatments, their efficacy, and potential limitations to optimize patient care and guide therapeutic decision-making in this challenging condition.

Purpose of review: The operating room (OR) infrastructure and equipment such as gloves, were historically designed at a time when most surgeons were male. Today, there are increasing numbers of females in the OR and we should ensure that there is not a disproportionate risk of ergonomic stress and risk of work-related injuries. This review provides a perspective on the representation of female cardiac surgeons globally and examines the unique ergonomic challenges they may face.

Recent findings: Female cardiac surgeons represent approximately 17% of practitioners in our sample of cardiac surgery centers, underscoring significant underrepresentation. Female cardiac surgeons report higher incidences of work-related musculoskeletal injuries and ergonomic challenges compared to their male colleagues. This could negatively impact their physical health and performance. Studies further highlight the inadequacy of standardized surgical tools and workstations in accommodating sex-specific anthropometry, contributing to the disproportionate strain experienced by female surgeons.

Summary: To mitigate gender disparities in cardiac surgery, there is a need to optimize OR infrastructure and surgical instrumentation to accommodate sex-based anatomical differences. Implementing ergonomic solutions, such as adjustable workstations and gender-specific surgical tools, could reduce musculoskeletal injuries and improve overall surgeon performance. Addressing these disparities represents a critical step toward fostering an equitable and inclusive surgical workforce, enhancing both the health and career longevity of female cardiac surgeons.

Purpose of review: Over the past 25 years, robotic-assisted mitral valve surgery has gained significant recognition because of its potential to minimize patient trauma and improve clinical outcomes. This field has evolved from early efforts in minimally invasive mitral procedures to more refined and technically sophisticated approaches, driven by the need for smaller incisions and reduced recovery times.

Recent findings: This review will delve into the historical evolution of robotic-assisted mitral valve surgery, detailing the technical advancements that have shaped current practices and outlining the essential training pathways for a career as robotic mitral valve surgeon.

Summary: The development of robotic systems has marked a turning point, offering surgeons greater precision and dexterity, crucial adjuncts in complex mitral valve repairs.

Purpose of review: Catecholaminergic polymorphic ventricular tachycardia (CPVT) is a devastating heritable channelopathy that can lead to sudden cardiac death in children and young adults. This review aims to explore genetics, the cardiac and extracardiac manifestations of mutations associated with CPVT, and the challenges involved with managing phenotypically variable variants.

Recent findings: The understanding of the genetics and mechanisms of CPVT continues to grow with recent discoveries including alternative splicing of cardiac TRDN and calmodulin gene variants. Additionally, there is an increasing recognition of the extra-cardiac manifestations such as epilepsy, neurodevelopmental delay, and glucose homeostasis abnormalities in RyR2 variant carriers. Advances in precision medicine, including the development of iPSC-derived cardiomyocytes, are valuable models for developing targeted therapeutics.

Summary: CPVT remains a complex disorder with cardiac and neurological manifestations impacting management. Early genetic testing and personalized treatment, including beta-blockers, flecainide, and ICDs, is important in improving outcomes. Ongoing research into the mechanism of each mutation will help in developing more effective, personalized therapeutics.