Current Opinion in Cardiology最新文献

Purpose of review: Immune-mediated inflammatory diseases (IMIDs) such as rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), psoriasis (PsO), and systemic sclerosis (SSc) are associated with significantly increased risk of ischemic heart disease (IHD), driven by chronic inflammation, and often compounded by undertreated traditional cardiovascular risk factors. Conventional risk scores frequently underestimate this burden.

Recent findings: Advanced cardiovascular imaging techniques, such as coronary CT angiography (CCTA), cardiac magnetic resonance (CMR), and nuclear imaging techniques, offer enhanced detection of subclinical atherosclerosis, myocardial inflammation, and coronary microvascular dysfunction.

Summary: This review highlights the role of imaging tools in improving risk stratification and guiding personalized care, while underscoring the need for ongoing research to validate their clinical utility and ensure equitable implementation.

Purpose of review: Minimally invasive cardiac surgery (MICS) coronary artery bypass grafting (CABG), first established two decades ago, offers multivessel revascularization via a small left anterior thoracotomy and without the need for cardiopulmonary bypass, potentially leading to lower complication rates and faster recovery. However, adoption of MICS CABG has been slow, in part due to lack of randomized trial data. Here, we review important retrospective studies, as well as ongoing and completed MICS CABG trials.

Recent findings: The majority of studies remain single-center observational studies demonstrating that MICS CABG yields comparable perioperative morbidity and mortality to conventional CABG, with excellent angiographic graft patency, comparable long-term outcomes and faster recovery times. There are two ongoing randomized controlled trials, the MIST and MICS-CABG PRPP trials, both comparing quality of life and recovery in the early postoperative period between patients undergoing MICS CABG versus sternotomy CABG.

Summary: The MIST and MICS-CABG PRPP trials will for the first time provide prospective, randomized data on the benefits of MICS CABG. However, both trials involve highly experienced MICS CABG surgeons. As such, the findings will likely not be generalizable to the general cardiac surgery community and MICS CABG will remain a boutique operation offered in highly specialized centers.

Purpose of review: This review summarizes the most recent literature regarding the surgical management of postmyocardial infarction (MI) ventricular septal rupture and the optimal timing and performance of the operation.

Recent findings: There are conflicting data surrounding the optimal timing of surgical intervention for post-MI ventricular septal rupture. Patients often present in hemodynamic compromise which limits the ability to delay their intervention. A lack of randomized control trials mandates reliance on retrospective cohort studies that have a selection bias in favor of delayed surgery due to unstable patients requiring emergent intervention. Similarly, mechanical circulatory support may be associated with poorer outcomes in part due to selection bias. There is a trend towards better prognosis in patients with lower preoperative lactate and lower vasopressor requirements.

Summary: A diagnosis of a post-MI ventricular septal rupture carries a poor prognosis. Without surgical intervention, the likelihood of 1-year survival is very low. Percutaneous treatment options have limited success, and the gold standard remains surgical intervention. Surgical timing is often dictated by patients being hemodynamically unstable and requiring emergent surgery. When a patient can have delayed intervention, there is a trend towards better outcomes. Optimized hemodynamics, metabolic parameters, and initial medical management are associated with improved outcomes. Mechanical circulatory support is of benefit in sicker patients if it can assist with preoperative optimization.

Purpose of review: All revascularization modalities in patients with prior coronary artery bypass grafting (CABG) have been shown to have higher rates of procedural complications and worse outcomes compared to patients without prior CABG. However, patients' clinical presentations often necessitate revascularization. This review outlines the different treatment options for patients with prior CABG presenting with ischemia depending on clinical presentation, focusing on the advantages and challenges of different techniques and emerging evidence.

Recent findings: While still high risk, recent studies have shown improvement in outcomes in both surgical and interventional revascularization options in post-CABG patients. Redo CABG, still recommended in patients with left anterior descending disease and an available internal mammary conduit, has had improved outcomes over the past two decades. Percutaneous coronary intervention (PCI) is preferred in most cases, with native-vessel PCI generally preferred over vein-graft PCI when feasible. Bypassed arteries often have high rates of chronic total occlusions, and the vein grafts themselves can be useful in retrograde approaches.

Summary: Revascularization in patients with prior CABG remains high risk and should be reserved for high-risk ischemia or symptoms refractory to medical management. The choice of intervention is often dictated by the clinical presentation and coronary anatomy, with specific techniques available to improve both native-vessel and saphenous vein graft PCI success rates.

Purpose of review: Early (<10 days) recovery of the left ventricular ejection fraction (LVEF) in Takotsubo syndrome (TTS) has been associated with better short- and long-term clinical outcomes compared to delayed recovery (>10 days). This review aims to comprehensively address the literature regarding its clinical implications, the pathological basis underlying a chronic inflammatory heart failure phenotype; as well as the potential pharmacological and nonpharmacological therapies that might aid in LVEF recovery and improve clinical outcomes in TTS.

Recent findings: We describe the clinical findings of the two large studies addressing this topic, derived from ongoing prospective registries (RETAKO and InterTAK) in which inflammatory biomarkers are the strongest independently associated factor with late left ventricular (LV) recovery (>10 days). This is in line with the previous studies suggesting a chronic inflammatory phenotype with elevated inflammatory biomarkers (e.g. interleukin-6) that persists even 5 months after the index event and long-lasting myocardial energetic impairment >1 year after the TTS episode.

Summary: Late LV recovery in TTS is linked to a worse short- and long-term prognosis, identifying these patients for closer monitoring might be clinically relevant for the early detection of complications. Mechanistical research needs to be undertaken to elucidate the cellular and molecular pathways implicated in late LV recovery, this could aid in the selection of pharmacological and nonpharmacological therapies to aid LV recovery.

Purpose of review: Stress perfusion cardiac magnetic resonance imaging (CMR) has gained increasing adoption across North America and Europe for the evaluation of symptomatic suspected or established ischemic heart disease (IHD).

Recent findings: Over the past decade, stress perfusion CMR has demonstrated excellent diagnostic and prognostic performance, particularly in patients at intermediate or high risk of IHD or with established coronary artery disease (CAD). After the landmark ISCHEMIA trial, stress CMR may play an important role in selecting patients for invasive management strategies and determination of revascularization technique. Artificial intelligence has streamlined CMR scanning techniques and in-line automation of quantitative pixelated perfusion maps. Quantitative stress CMR can evaluate absolute myocardial blood flow and perfusion reserve that improves risk stratification and detection of coronary microvascular disease (CMD). CMD detection may assist clinicians with diagnosis of chest pain in patients without obstructive CAD and improve prognostication and detection of pathophysiological mechanisms in a variety of cardiomyopathies.

Summary: Quantitative stress perfusion CMR will play an important clinical role in evaluating patients at risk of IHD and cardiomyopathy with iterative cost and time efficiency owing to continued integration of artificial intelligence techniques. More widespread adoption will likely improve cost effective cardiac care and reduce adverse clinical outcomes.

Purpose of review: To critically appraise the 2024 ESC Guidelines for chronic coronary syndrome (CCS), developed in collaboration with EACTS, emphasizing invasive-treatment recommendations, their underlying rationale and key areas requiring further clarification for clinical implementation.

Recent findings: The document formally incorporates indications for myocardial revascularization and the criteria for choosing between percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) into the single CCS guideline framework. It calls for Heart-Team decisions whenever CABG and PCI are equally recommended and introduces modality-specific criteria based on anatomical complexity, SYNTAX score, and clinically relevant comorbidities. CABG remains the preferred strategy for anatomically complex disease, including left main and multivessel involvement, especially when PCI cannot achieve equivalent completeness of revascularization or in patients with comorbidities associated with a favorable prognosis (e.g., diabetes mellitus, heart failure). PCI is recommended for less complex lesions in which comparable completeness is feasible for patients whose primary goal is symptom relief or those at high surgical risk. Apart from patient selection, the document provides limited procedural detail, offers limited guidance on secondary prevention measures, and lacks explicit recommendations on the optimal timing of intervention.

Summary: The 2024 guideline re-establishes a unified, multidisciplinary European approach to the management of CCS, reaffirming the prognostic value of guideline-directed revascularization and the central role of the Heart Team in selecting the optimal strategy. Supplementary documents are required to fill procedural, secondary prevention and implementation gaps.

Purpose of review: Minimally invasive coronary artery bypass grafting (MICS CABG) offers the benefits of surgical revascularization without sternotomy but remains underutilized due to technical demands and a lack of structured training. This review outlines a stepwise framework for safe adoption.

Recent findings: Studies and real-world experience confirm that off-pump CAB (OPCAB) proficiency, systematic technical progression, and mentorship in high-volume centers are essential for safe learning. Recent training innovations and simulator-based techniques improve outcomes and reduce complications during the learning curve.

Summary: Wider adoption of MICS CABG hinges on structured training rooted in OPCAB, technical sequencing, and surgical mentorship. Programs emphasizing patient safety, proper case selection, and skill development can expand access to minimally invasive coronary surgery.

Purpose of review: Immune-mediated inflammatory diseases (IMIDs) such as rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), psoriasis (PsO), and systemic sclerosis (SSc) are associated with significantly increased risk of ischemic heart disease (IHD), driven by chronic inflammation, and often compounded by undertreated traditional cardiovascular risk factors. Conventional risk scores frequently underestimate this burden.

Recent findings: Advanced cardiovascular imaging techniques, such as coronary CT angiography (CCTA), cardiac magnetic resonance (CMR), and nuclear imaging techniques, offer enhanced detection of subclinical atherosclerosis, myocardial inflammation, and coronary microvascular dysfunction.

Summary: This review highlights the role of imaging tools in improving risk stratification and guiding personalized care, while underscoring the need for ongoing research to validate their clinical utility and ensure equitable implementation.

Purpose of review: Minimally invasive coronary artery bypass grafting (MICS CABG) offers the benefits of surgical revascularization without sternotomy but remains underutilized due to technical demands and a lack of structured training. This review outlines a stepwise framework for safe adoption.

Recent findings: Studies and real-world experience confirm that off-pump CAB (OPCAB) proficiency, systematic technical progression, and mentorship in high-volume centers are essential for safe learning. Recent training innovations and simulator-based techniques improve outcomes and reduce complications during the learning curve.

Summary: Wider adoption of MICS CABG hinges on structured training rooted in OPCAB, technical sequencing, and surgical mentorship. Programs emphasizing patient safety, proper case selection, and skill development can expand access to minimally invasive coronary surgery.