Current Opinion in Cardiology最新文献

Purpose of review: This review highlights the growing importance of patient reported outcomes (PROs) in cardiac surgery trials. Cardiac surgery trials have traditionally focused on cardiovascular events such as survival, stroke or myocardial infarction. However, as surgical outcomes have continued to improve, incorporating the patient's perspective through PROs has become increasingly critical. Incorporating PROs as key study outcomes provides essential patient data, while also overcoming the methodological limitations of classic composite endpoints.

Recent findings: Continued advancements in cardiac surgery have significantly reduced classic endpoint differentials, making it challenging to evaluate interventions with their use alone. PROs offer more granular details on the effects of surgical interventions compared to classic clinical events and are widely used in other medical fields. More recently, cardiac surgery trials have begun successfully implementing PROs, though there is need for greater utilization across the discipline.

Summary: The integration of PROs into cardiac surgery trials allows for better understanding of the impact of surgical interventions on patients' daily lives. While barriers exist, efforts to develop and standardize PRO measures promise to enhance the relevance of cardiac surgery clinical trials and ultimately improve patient care.

Purpose of review: Predicting and preventing coronary obstruction in transcatheter aortic valve replacement (TAVR) is crucial due to its high mortality risk.

Recent findings: In native TAVR, predicting coronary obstruction requires assessing aortic cusp height, coronary artery height, valve-to-coronary distance, and leaflet calcium volume. The VIVID classification has been proposed for evaluating the risk of coronary obstruction in TAVR for failed bioprosthetic surgical valves. After TAVR with the Sapien 3 valve, the feasibility of redo TAVR and coronary access decreases with a shallower implantation of the initial Sapien 3. In redo TAVR of Sapien 3 within an Evolut valve, positioning the Sapien 3 outflow at node 4 improves redo TAVR feasibility and coronary accessibility compared to positioning at nodes 5 or 6. For valve sizing in redo TAVR with Sapien 3, in-vivo CT sizing results in smaller valve sizes than bench sizing, reducing coronary risk and improving redo TAVR feasibility. Leaflet modification and coronary stenting techniques and a dedicated leaflet-splitting device have been proposed to maintain coronary perfusion in high-risk cases.

Summary: Coronary preservation in high-risk TAVR remains a significant challenge, requiring further research into preprocedural planning and leaflet modification strategies.

Purpose of review: The role of imaging in diagnosis of pulmonary hypertension is multifaceted, spanning from estimation of pulmonary arterial pressures, understanding pulmonary artery-right ventricular interaction, and identification of the cause. The purpose of this review is to provide a comprehensive overview of multimodality imaging in evaluation of pulmonary hypertension as well as the novel applications of imaging techniques that have improved our detection and understanding of pulmonary hypertension.

Recent findings: There are diverse imaging modalities available for comprehensive assessment of pulmonary hypertension that are expanding with new tracers (e.g., hyperpolarized xenon gas, 129 Xe) and imaging techniques (C-arm cone-bean computed tomography). Artificial intelligence applications may improve efficiency and accuracy of screening for pulmonary hypertension as well as further characterize pulmonary vasculopathies using computed tomography of the chest. In the face of increasing imaging options, a "value-based imaging" approach should be adopted to reduce unnecessary burden on the patient and the healthcare system without compromising the accuracy and completeness of diagnostic assessment.

Summary: Future studies are needed to optimize use of multimodality imaging and artificial intelligence in comprehensive evaluation of patients with pulmonary hypertension.

Purpose of review: There are several multifactorial risk assessment tools used to predict mortality in patients with pulmonary arterial hypertension (PAH). These tools are also used to guide clinical decision-making including changes in therapy and referrals for transplantation. While the prominent driver of morbidity and mortality in PAH is right ventricular failure, most available risk assessment tools do not include parameters specific to right ventricular structure or function. Several cardiac imaging parameters are known to be associated with survival and may enhance the predictive ability of existing risk scores.

Recent findings: This review compiles the existing literature surrounding the improved predictive power of existing risk assessment tools when combined with echocardiographic and cardiac magnetic resonance imaging findings. The review also discusses scenarios in which imaging findings may influence clinical decision making outside of risk scores.

Summary: Decision making in PAH is complex and multifaceted. Cardiac imaging is an important component in the management of PAH and should be considered carefully and in conjunction with existing risk assessment tools.

Purpose of review: The diagnosis and management of coronary artery disease (CAD) involves complex delivery of care. Artificial intelligence (AI) proves to be a timely solution to challenges with diagnostics and timely and appropriate, quality of care.

Recent findings: Artificial intelligence has the capacity to improve care for patients with CAD at every step of the way including diagnosis, medical management, in the cath lab and operating room, and even at home. Integration of multiple data sources increases the utility of the individual data sources and can also improve the overall prediction accuracy compared to single dataset predictions. Applications in the cath lab and operating room involve augmented reality and rely on hardware improvements to deliver advanced analytics. User interphases have seen significant growth to operationalize the analytics and placing information in front of physicians and patients to improve accessibility.

Summary: AI can revolutionize the way in which we deliver care to patients with CAD by improving access, enhancing diagnosis and treatment, and empowering patients to remain engaged in their health. Initiatives should be directed with a clinical goal in mind while respecting data privacy and protection procedures and accounting for the ethical responsibilities we have toward our patients and society.

Purpose of review: Cardiomyopathy caused by pathogenic variants in the desmoplakin gene has recently emerged as an entity distinct from other genetic cardiomyopathies. This review summarizes recent literature, including the first large cohort studies of this disease, that have begun to characterize its natural history and specific management challenges.

Recent findings: Desmoplakin cardiomyopathy may be characterized by episodic "hot phases", cutaneous findings, and a high risk of sudden cardiac death. Gene-specific risk factors for sudden cardiac death have begun to be elucidated.

Summary: Genetic testing in arrhythmogenic cardiomyopathy and recurrent myocarditis can identify patients with desmoplakin variants who may have a unique phenotype that requires gene-specific management. More research is needed in this population to further guide treatment, counseling, and risk stratification.

Purpose of review: The optimal revascularization strategy for chronic coronary syndrome (CCS) is rapidly evolving due to emerging evidence and technological advancements. This review will discuss the guidelines for the management of CCS, examining how they align with and respond to recent high-quality studies. We will also discuss the evolution of the guidelines and highlight key differences.

Recent findings: While broad consensus exists between the most recent European and American guidelines, notable differences exist in the management of multivessel disease with preserved ejection fraction and left main disease. The role of the Heart Teams has become increasingly vital particularly when the guidelines do not fit the clinical scenarios, and the evidence is controversial.

Summary: Determining the optimal management strategy for patients with CCS requires careful consideration of anatomic complexity, comorbidities, and individual patient preferences. While advances in percutaneous coronary intervention (PCI) and medical therapy have been widely discussed, it is equally important to contextualize these with emerging innovations in surgical revascularization. Techniques such as multiple arterial grafting and minimally invasive surgical approaches represent significant progress in coronary artery bypass surgery. Randomized trials that compare state-of-the-art percutaneous and surgical revascularization techniques are thus needed.

Purpose of review: Systemic congestion is a common manifestation in pulmonary hypertension (PH) associated with morbidity and mortality. Its extent can be difficult to define and is usually determined by subjective medical history and physical examinations, leading to delay in decision-making. We conducted a literature review to collect evidence on imaging tools aimed at detecting and defining severity of venous congestion in PH.

Recent findings: We discussed pathophysiology and outlined a structured approach in the management of venous congestion. Point-of-care ultrasound becomes more accessible and aids in gauging the severity of systemic congestion. Venous excess ultrasound (VExUS) grading system analyzes the inferior vena cava, hepatic vein, portal vein, and intrarenal vein and provides a comprehensive assessment of systemic congestion. Nonetheless, almost all available studies were performed in unselected populations, and data on PH is scarce. Herein, we discuss the imaging methods proposed in systemic congestion as they apply to PH.

Summary: VExUS offers fast, convenient assessment of volume status. Despite the promising data on VExUS, it should be emphasized that ultrasound should be placed in the context of a comprehensive evaluation and should not replace basic examination. Further research is needed to establish its role in PH and verify its clinical utility in guiding fluid management.

Purpose of review: Cardiac amyloidosis is characterized by systolic and diastolic abnormalities due to deposition of amyloid fibril within the myocardial extracellular space. Technological advances in multimodality cardiac imaging now helps in accurate diagnosis and prognosis of this disease. With technological advances in imaging, it is now easier to follow up these patients whether they are getting response to therapy.

Recent findings: Left ventricular global longitudinal strain assessment is an important noninvasive tool to track response to treatment in cardiac amyloidosis patient.

Summary: Present era has shown the importance of using multimodality imaging to understand the pathophysiology of this disease which has been supplemented by both imaging and blood biomarkers. These help in prognosticating the disease burden and to assess treatment response. Future research is now focused on the use of artificial intelligence and precision medicine to detect of changes earlier in the course of treatment.

Purpose of review: Developing a professional identity in medicine is a crucial journey for healthcare professionals, as it encapsulates the blending of personal values, skills, knowledge, and the ethos of the medical profession. To examine the pathway towards developing a professional identity, we must define precisely what that represents.

Recent findings: The journey to develop both a professional identity and an academic career presence has long been the focus of educators and mentors. The idea of teaching a student how to develop a professional identity has not always been seen as the role of medical training.

Summary: The effort committed to developing an identity and a career should be satisfying.Throughout a long career, job satisfaction waxes and wanes. Having a diverse portfolio of interests and commitments allows for the backfill of motivation. Ultimately building a professional identity and career within cardiac critical care is a journey. There is never an end, but rather a progression and evolution.