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Robotic mitral surgery: recent advances and outcomes. 机器人二尖瓣手术:最新进展和结果。
IF 2.3 4区 医学 Q3 CARDIAC & CARDIOVASCULAR SYSTEMS Pub Date : 2024-08-20 DOI: 10.1097/hco.0000000000001174
Makoto Hibino,Douglas A Murphy,Michael E Halkos
PURPOSE OF REVIEWThis review explores recent advancements in robotic cardiac surgery, specifically focusing on its application in diverse mitral valve surgeries. The aim is to provide an overview of current clinical practices and supporting evidence in this evolving field.RECENT FINDINGSA literature review indicates a 30% surge in robotic mitral valve repair from 2015 to 2021, paralleled by a decline in sternotomy-based repair per the STS database. Robotic mitral valve repair consistently shows effective and safe outcomes, with comparable mortality but lower morbidity risks than sternotomy and thoracotomy. The robotic approach exhibits lower conversion to valve replacement, shorter ICU stays, and reduced 30-day readmissions. For experienced programs, robotic techniques prove versatile in various pathologies, including rheumatic heart valve disease, infective endocarditis, ischemic cardiomyopathy, and mitral annular calcification necessitating valve replacement. Literature supports their selective use in high-risk scenarios, including redo surgeries and elderly patients.SUMMARYRecent evidence supports the growing use of robotic approaches in mitral valve surgery, highlighting their efficacy with comparable mortality rates but lower morbidity risks. Robotic techniques consistently yield positive outcomes across various pathologies and patient profiles, signaling a potential paradigm shift in mitral valve interventions.
综述目的本综述探讨了机器人心脏手术的最新进展,特别关注其在各种二尖瓣手术中的应用。最新发现STS数据库显示,从2015年到2021年,机器人二尖瓣修复术激增了30%,与此同时,基于胸骨切开术的修复术却出现了下降。与胸骨切开术和胸腔切开术相比,机器人二尖瓣修复术始终显示出有效和安全的结果,死亡率相当,但发病风险较低。机器人方法显示出较低的瓣膜置换转换率、较短的重症监护室住院时间以及较低的30天再入院率。对于经验丰富的项目,机器人技术被证明可用于各种病症,包括风湿性心脏瓣膜病、感染性心内膜炎、缺血性心肌病和二尖瓣环钙化等需要进行瓣膜置换的病症。最近的证据表明,机器人方法在二尖瓣手术中的应用越来越广泛,其疗效显著,死亡率相当,但发病风险较低。机器人技术在各种病理和患者情况下都能取得良好的疗效,预示着二尖瓣介入手术的模式可能发生转变。
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引用次数: 0
Lipoprotein(a) is a highly atherogenic lipoprotein: pathophysiological basis and clinical implications. 脂蛋白(a)是一种高度致动脉粥样硬化的脂蛋白:病理生理学基础和临床意义。
IF 2 4区 医学 Q3 CARDIAC & CARDIOVASCULAR SYSTEMS Pub Date : 2024-08-14 DOI: 10.1097/HCO.0000000000001170
Elias Björnson, Martin Adiels, Jan Borén, Chris J Packard

Purpose of review: Lipoprotein(a) has been identified as a causal risk factor for atherosclerotic cardiovascular disease (ASCVD) and aortic valve stenosis. However, as reviewed here, there is ongoing debate as to the key pathogenic features of Lp(a) particles and the degree of Lp(a) atherogenicity relative to low-density lipoprotein (LDL).

Recent findings: Genetic analyses have revealed that Lp(a) on a per-particle basis is markedly (about six-fold) more atherogenic than LDL. Oxidized phospholipids carried on Lp(a) have been found to have substantial pro-inflammatory properties triggering pathways that may contribute to atherogenesis. Whether the strength of association of Lp(a) with ASCVD risk is dependent on inflammatory status is a matter of current debate and is critical to implementing intervention strategies. Contradictory reports continue to appear, but most recent studies in large cohorts indicate that the relationship of Lp(a) to risk is independent of C-reactive protein level.

Summary: Lp(a) is a highly atherogenic lipoprotein and a viable target for intervention in a significant proportion of the general population. Better understanding the basis of its enhanced atherogenicity is important for risk assessment and interpreting intervention trials.

综述目的:脂蛋白(a)已被确定为动脉粥样硬化性心血管疾病(ASCVD)和主动脉瓣狭窄的致病风险因素。然而,正如本文所述,关于脂蛋白(a)颗粒的主要致病特征以及脂蛋白(a)相对于低密度脂蛋白(LDL)的致动脉粥样硬化程度仍存在争议:遗传分析表明,脂蛋白(a)单个颗粒的致动脉粥样硬化性明显高于低密度脂蛋白(约六倍)。研究发现,脂蛋白(a)上的氧化磷脂具有很大的促炎特性,可触发可能导致动脉粥样硬化的途径。脂蛋白(a)与 ASCVD 风险的关联强度是否取决于炎症状态是目前争论的一个问题,也是实施干预策略的关键。相互矛盾的报告不断出现,但最近在大型队列中进行的大多数研究表明,脂蛋白(a)与风险的关系与 C 反应蛋白水平无关。摘要:脂蛋白(a)是一种高度致动脉粥样硬化的脂蛋白,是对相当一部分普通人群进行干预的可行目标。更好地了解其增强致动脉粥样硬化性的基础对于风险评估和解释干预试验非常重要。
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引用次数: 0
Is it feasible to treat atrial fibrillation at the time of minimally invasive coronary artery bypass grafting? 在微创冠状动脉旁路移植术时治疗心房颤动是否可行?
IF 2 4区 医学 Q3 CARDIAC & CARDIOVASCULAR SYSTEMS Pub Date : 2024-08-14 DOI: 10.1097/HCO.0000000000001173
Stephen D Waterford, Niv Ad

Purpose of review: Coronary artery bypass grafting remains the most common operation performed by cardiac surgeons. As a result, a cardiac surgeon with a typical practice will most commonly encounter atrial fibrillation when performing coronary artery bypass grafting. In this review, we first emphasize the importance of treating atrial fibrillation in patients undergoing coronary bypass grafting. We review benefits of concomitant surgical ablation and its importance relative to complete coronary revascularization. We then discuss options to treat atrial fibrillation in a more minimally invasive manner in these patients, while still preserving treatment efficacy.

Recent findings: Surgical ablation at the time of coronary artery bypass grafting surgery could be as important as complete revascularization. Bi-atrial ablation provides superior rhythm control compared to left-sided ablation only.

Summary: We highlight various options for surgical ablation at the time of coronary artery bypass grafting surgery, and provide an algorithm for ablation in individual patients.

回顾的目的:冠状动脉搭桥术仍然是心脏外科医生最常进行的手术。因此,一般情况下,心脏外科医生在进行冠状动脉搭桥术时最常遇到心房颤动。在这篇综述中,我们首先强调了治疗冠状动脉搭桥术患者心房颤动的重要性。我们回顾了同时进行手术消融的益处及其相对于完全冠状动脉血运重建的重要性。然后,我们讨论了以更微创的方式治疗这些患者心房颤动的方案,同时仍能保持治疗效果:最新研究结果:在进行冠状动脉旁路移植手术时进行手术消融可能与完全血管再通一样重要。总结:我们重点介绍了冠状动脉旁路移植手术时手术消融的各种选择,并提供了针对个别患者的消融算法。
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引用次数: 0
High reliability pediatric heart centers: Always working toward getting better. 高度可靠的儿科心脏中心:不断进步
IF 2.3 4区 医学 Q3 CARDIAC & CARDIOVASCULAR SYSTEMS Pub Date : 2024-07-01 Epub Date: 2024-03-26 DOI: 10.1097/HCO.0000000000001143
Andrea Torzone, Alexandra Birely

Purpose of review: The purpose of this review is to examine high reliability through the lens of a contemporary pediatric heart center, noting that continuous improvement, rather than perfection, should be embraced. Aiming to elevate topics with lesser attention, this review elaborates on key concepts and proposed considerations for maintaining a high reliability heart center.

Recent findings: As provision of care reaches a new complexity, programs are called upon to evaluate how they can bring their teams into the future of pediatric cardiac care. Although much has been written about high reliability in healthcare, it has not been explored within pediatric heart centers. Practical application of high reliability enables a shared mental model and aligns teams toward eliminating patient harm. Suggested facilitators of high reliability within heart center teams include interprofessional collaboration, recognition of nursing expertise, psychological safety, and structural empowerment void of hierarchy.

Summary: As the pediatric cardiac population evolves, care becomes more complex with a narrow margin of error. High reliability can guide continuous improvement. Acknowledging culture as the underpinning of all structure and processes allows teams to rebound from failure and supports the mission of rising to exceptional patient challenges.

回顾的目的:本综述的目的是通过当代儿科心脏中心的视角来审视高可靠性,同时指出应坚持不断改进,而不是追求完美。本综述旨在提升关注度较低的话题,详细阐述了维持高可靠性心脏中心的关键概念和建议注意事项:随着医疗服务达到一个新的复杂程度,医疗项目需要评估如何将其团队带入儿科心脏护理的未来。尽管有关医疗保健领域高可靠性的论述已经很多,但在儿科心脏中心还没有进行过探讨。高可靠性的实际应用可以建立一个共同的心理模型,并使团队朝着消除对患者伤害的方向发展。建议在心脏中心团队中促进高可靠性的因素包括专业间合作、对护理专业知识的认可、心理安全以及无等级制度的结构授权。高可靠性可以指导持续改进。承认文化是所有结构和流程的基础,可以让团队从失败中反弹,并支持迎接特殊病人挑战的使命。
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引用次数: 0
Double outlet right ventricle - the 50% rule has always been about the conus. 双出口右心室--50% 规则一直与锥体有关。
IF 2.3 4区 医学 Q3 CARDIAC & CARDIOVASCULAR SYSTEMS Pub Date : 2024-07-01 Epub Date: 2024-02-23 DOI: 10.1097/HCO.0000000000001131
Rebecca Josowitz, Lindsay S Rogers

Purpose of review: There has been much variability in the definition of double outlet right ventricle (DORV) spanning the last century. Historically, emphasis has been placed on the assignment of the great arteries to the right ventricle as a definition of DORV. In this review, we aim to underscore the importance of conal muscle, rather than rules surrounding assignment of great arteries to ventricles. We will be outlining the variability in patient anatomy that results from variations in conal muscle development in DORV, which may not fit perfectly into predefined constructs. This anatomic variability directly determines physiology and surgical repair options.

Recent findings: There is a growing appreciation of the utility of cross-sectional imaging in complex DORV, and the generation of patient-specific 3D models with virtual reality simulations for surgical planning. These models improve the prediction of candidacy for biventricular repair and allow the mapping of complex baffle pathways preoperatively.

Summary: DORV is not a disease entity in itself, but rather a vast spectrum of disorders associated with maldevelopment of conal muscle and often abnormal expansion of one the great vessels. Patient-specific 3D models will be crucial for improved surgical planning and patient outcomes.

综述的目的:在上个世纪,双出口右心室(DORV)的定义一直众说纷纭。从历史上看,DORV 的定义一直强调右心室大动脉的分配。在这篇综述中,我们旨在强调圆锥肌的重要性,而不是围绕大动脉与心室分配的规则。我们将概述由于 DORV 中锥肌发育的变化而导致的患者解剖结构的变异性,这种变异性可能无法完全符合预定义的结构。这种解剖变异直接决定了生理学和手术修复方案:最近的研究结果:越来越多的人认识到横断面成像在复杂 DORV 中的作用,以及通过虚拟现实模拟生成患者特异性三维模型用于手术规划。摘要:DORV本身并不是一种疾病,而是一种与锥体肌发育不良和大血管异常扩张有关的多种疾病。针对患者的三维模型对改进手术规划和患者预后至关重要。
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引用次数: 0
Hypertrophic cardiomyopathy and competitive sports: let 'em play? 肥厚型心肌病与竞技体育:让他们玩吗?
IF 2.3 4区 医学 Q3 CARDIAC & CARDIOVASCULAR SYSTEMS Pub Date : 2024-07-01 Epub Date: 2024-05-10 DOI: 10.1097/HCO.0000000000001148
Mats Steffi Jennifer Masilamani, Bryan Cannon

Purpose of review: Hypertrophic cardiomyopathy (HCM) is one of the most common cardiovascular genetic conditions. Although most patients with HCM typically do well clinically, there is a small but real incidence of sudden cardiac death. A diagnosis of HCM was previously a reason for complete exclusion in sports, particularly competitive sports.However, many of these recommendations are based on expert consensus, and much data has been published in the last decade furthering the scientific knowledge in this area, and allowing athletes who may have been previously excluded the potential to participate in strenuous activities and competitive sports.

Recent findings: With recent publications on participation in sports with HCM, as well as an emphasis on shared decision-making, more athletes with HCM are participating in competitive sports, even at a professional level. Even contact sports in the presence of an implantable cardioverter-defibrillator are no longer mutually exclusive in the current era.

Summary: Previous guidelines were likely overly restrictive for patients with HCM. Although there is a risk of sudden death that cannot be ignored, the potential for shared decision making as well as medical guidance are entering a new era in all aspects of medicine, particularly in sports participation.

综述目的:肥厚型心肌病(HCM)是最常见的心血管遗传病之一。虽然大多数 HCM 患者的临床表现通常良好,但心脏性猝死的发生率虽小,却真实存在。然而,这些建议中的许多建议都是基于专家共识,过去十年中发表的许多数据进一步丰富了这一领域的科学知识,使以前可能被排除在外的运动员有可能参加剧烈活动和竞技运动:最近的研究结果:随着最近有关 HCM 运动员参与体育运动的出版物以及对共同决策的重视,越来越多的 HCM 运动员开始参与竞技体育,甚至是职业体育。总结:以前的指南可能对 HCM 患者限制过多。虽然猝死的风险不容忽视,但在医学的各个方面,尤其是在运动参与方面,共同决策和医疗指导的潜力正在进入一个新时代。
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引用次数: 0
Effects of bempedoic acid on markers of inflammation and Lp(a). 鱼贝多酸对炎症指标和脂蛋白(a)的影响
IF 2.3 4区 医学 Q3 CARDIAC & CARDIOVASCULAR SYSTEMS Pub Date : 2024-07-01 Epub Date: 2024-03-04 DOI: 10.1097/HCO.0000000000001137
Sukhila Reddy, Abhizith Deoker

Purpose of review: To study the effect of bempedoic acid on markers of inflammation and lipoprotein (a) to help determine if the drug would be useful to treat patients with elevated cardiovascular risks and residual cardiovascular risk despite optimal low-density lipoprotein cholesterol (LDL-C) levels.

Recent findings: Bempedoic acid is found to cause significant reduction in LDL-C and high-sensitivity C-reactive protein (hs-CRP) in various randomized clinical trials. Multiple meta-analyses have also found that bempedoic acid therapy leads to reduction in non-high-density lipoprotein cholesterol (non-HDL-C), total cholesterol (TC) and apolipoprotein B (ApoB) levels. However, it has minimal effect on lipoprotein (a) (Lp(a)) level.

Summary: Bempedoic acid is a new lipid-lowering agent that inhibits enzyme ATP-citrate lyase in the cholesterol biosynthesis pathway. Major risk of cardiovascular events and its associated morbidity and mortality are proportional to LDL-C and inflammatory markers levels. It was found that bempedoic acid significantly lowers LDL-C, hs-CRP and other inflammatory markers levels. This drug could potentially be used in patients with elevated cardiovascular risk, in patients with residual cardiovascular risk despite attaining LDL-C goal and in statin intolerant patients.

综述目的:研究鱼腥草酸对炎症指标和脂蛋白(a)的影响,以帮助确定该药物是否有助于治疗心血管风险升高的患者,以及在低密度脂蛋白胆固醇(LDL-C)达到最佳水平后仍存在心血管风险的患者:最近的研究结果:在多项随机临床试验中发现,本鱼藤酸可显著降低低密度脂蛋白胆固醇和高敏C反应蛋白(hs-CRP)。多项荟萃分析还发现,双鱼藤酸疗法可降低非高密度脂蛋白胆固醇(non-HDL-C)、总胆固醇(TC)和载脂蛋白 B(ApoB)水平。摘要:鱼腥草酸是一种新型降脂药,可抑制胆固醇生物合成途径中的 ATP-柠檬酸酶。心血管事件的主要风险及其相关的发病率和死亡率与低密度脂蛋白胆固醇和炎症指标水平成正比。研究发现,贝门冬氨酸能明显降低低密度脂蛋白胆固醇、hs-CRP 和其他炎症指标的水平。这种药物可用于心血管风险升高的患者、已达到低密度脂蛋白胆固醇目标但仍有心血管风险的患者以及他汀类药物不耐受的患者。
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引用次数: 0
Leaders need to look in the mirror. 领导者需要照照镜子。
IF 2.3 4区 医学 Q3 CARDIAC & CARDIOVASCULAR SYSTEMS Pub Date : 2024-07-01 Epub Date: 2024-03-11 DOI: 10.1097/HCO.0000000000001138
Josh Koch

Purpose of review: There is commonly a discrepancy between optimal physician leader behavior and actual physician leader behavior. Identifying and addressing this discrepancy is essential to optimize culture in high-risk care units.

Recent findings: Unit culture is directly linked to improving well tolerated and effective care. Adoption of strategies to better address bad behavior is necessary.

Summary: To address a toxic culture in a high-risk unit, physician leaders must first look inwards and take personal responsibility for their actions and words. It is a much easier task to talk about healthy culture than it is to walk it.

审查目的:最佳医生领导行为与实际医生领导行为之间通常存在差异。发现并解决这一差异对于优化高风险护理单元的文化至关重要:科室文化与提高护理的耐受性和有效性直接相关。总结:要解决高风险科室中的有毒文化问题,医生领导必须首先向内看,为自己的言行承担个人责任。谈论健康文化比实践健康文化要容易得多。
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引用次数: 0
Pemafibrate and other triglyceride-lowering therapies to reduce risk of cardiovascular and metabolic disease. 培马贝特和其他降低甘油三酯的疗法,以降低心血管疾病和代谢疾病的风险。
IF 2.3 4区 医学 Q3 CARDIAC & CARDIOVASCULAR SYSTEMS Pub Date : 2024-07-01 Epub Date: 2024-03-11 DOI: 10.1097/HCO.0000000000001136
Michael Miller

Purpose of review: Although high triglycerides are consistently associated with elevated risk of cardiovascular disease (CVD), therapies that reduce triglyceride levels have inconsistently translated into reduced CVD risk.

Recent findings: To date, three clinical trials have tested triglyceride-lowering therapies in patients with hypertriglyceridemia (HTG) and elevated risk of incident/recurrent CVD. In REDUCE-IT (Reduction of Cardiovascular Events with Icosapent Ethyl-Intervention Trial), assignment to IPE, a highly purified eicosapentanoic acid (EPA), resulted in a 25% reduction in nonfatal myocardial infarction), nonfatal stroke, cardiovascular death, coronary revascularization and hospitalization for unstable angina. By contrast, the combination of EPA and docosahexanoic acid (DHA) carboxylic fatty acids used in the STRENGTH trial (Statin Residual Risk With Epanova in High Cardiovascular Risk Patients With Hypertriglyceridemia) failed to reduce CVD risk. Most recently, PROMINENT (Pemafibrate to Reduce Cardiovascular Outcomes by Reducing Triglycerides in Patients with Diabetes) also failed to demonstrate reduction in CVD events despite use of a potent triglyceride-lowering, fibric-acid derivative. However, improvement in HTG-associated metabolic complications (e.g. nonalcoholic fatty liver disease) was observed with pemafibrate as well as with another potent triglyceride-lowering therapy (i.e. pegozafermin). Moreover, trials are underway evaluating whether the most fatal metabolic complication of HTG, pancreatitis, may be reduced with highly potent triglyceride-lowering therapies (e.g. apolipoprotein C3 inhibitors).

Summary: Taken together, HTG is associated with increased risk of CVD and attendant adverse metabolic sequalae. To this end, a potentially promising and evidence-based landscape is emerging for treating a clinical phenotype that in the past has been insufficiently addressed.

综述的目的:尽管甘油三酯高一直与心血管疾病(CVD)风险升高有关,但降低甘油三酯水平的疗法并不能降低心血管疾病风险:迄今为止,已有三项临床试验对高甘油三酯血症(HTG)和心血管疾病发生/复发风险升高患者的降甘油三酯疗法进行了测试。在 REDUCE-IT(伊可沙芬乙酯减少心血管事件干预试验)中,接受 IPE(一种高度纯化的二十碳五烷酸(EPA))治疗后,非致命性心肌梗死、非致命性中风、心血管死亡、冠状动脉血运重建和因不稳定型心绞痛住院的人数减少了 25%。相比之下,STRENGTH 试验(高甘油三酯血症心血管高危患者服用 Epanova 后的他汀类药物残留风险)中使用的 EPA 和二十二碳六羧酸(DHA)羧基脂肪酸组合未能降低心血管疾病风险。最近,PROMINENT(通过降低糖尿病患者的甘油三酯来减少心血管后果的培马贝特)也未能证明降低心血管事件,尽管它使用了一种强效降甘油三酯的纤维酸衍生物。不过,使用培马贝特和另一种强效降甘油三酯疗法(即培果铁胺)后,与高甘油三酯相关的代谢并发症(如非酒精性脂肪肝)得到了改善。此外,目前正在进行试验,评估高甘油三酯血症最致命的代谢并发症--胰腺炎是否可以通过强效降甘油三酯疗法(如载脂蛋白 C3 抑制剂)来减少。为此,一种潜在的、有希望的、以证据为基础的方法正在出现,用于治疗过去未得到充分治疗的临床表型。
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引用次数: 0
Management of hypertension in heart transplant recipients: an ongoing conundrum. 心脏移植受者的高血压管理:一个持续的难题。
IF 2.3 4区 医学 Q3 CARDIAC & CARDIOVASCULAR SYSTEMS Pub Date : 2024-07-01 Epub Date: 2024-03-27 DOI: 10.1097/HCO.0000000000001145
Juan Duarte Torres, Selim R Krim

Purpose of review: Hypertension remains one of the most common clinical problems leading to significant posttransplant complications. This study reviews the pathophysiology of hypertension in the postcardiac transplant phase and provides an update on currently available antihypertensive therapies for heart transplant patients.

Recent findings: The true prevalence of hypertension in the heart transplant population remains unknown. Effective blood pressure (BP) control is key to prevent left ventricular remodeling, diastolic dysfunction and stroke. Calcium channel blockers (CCBs) are the most commonly and preferred agents in the early posttransplant phase and may have renal protective effects. Angiotensin-converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs) can all be used as second line antihypertensive agents and may have a role in preventing other long-term complications such as calcineurin-inhibitor induced nephropathy. Although more data are needed, sodium-glucose co-transporter 2 inhibitors (SGLT2i) appeared to be well tolerated and could be considered especially in the presence of type diabetes and chronic kidney disease. Conversely, angiotensin receptor-neprilysin inhibition (ARNI) have not been studied in the heart transplant population therefore cannot be recommended at this time.

Summary: Hypertension is very common after heart transplant. Early steroid wean and traditional risk factor modification play an important part in the management of post-heart transplant hypertension. CCB, ACEI, ARB are the preferred antihypertensive agents to improve postcardiac transplant complications. Novel therapies such as SGLT2i appear well tolerated and may have benefits in both BP and glycemic control in heart transplant; however, larger trials are needed.

审查目的:高血压仍然是导致移植后严重并发症的最常见临床问题之一。本研究回顾了心脏移植术后阶段高血压的病理生理学,并提供了目前针对心脏移植患者的降压疗法的最新进展:最近的研究结果:心脏移植人群中高血压的真实发病率仍然未知。有效控制血压是预防左心室重塑、舒张功能障碍和中风的关键。钙通道阻滞剂(CCB)是移植后早期最常用和首选的药物,可能具有肾脏保护作用。血管紧张素转换酶抑制剂(ACEIs)、血管紧张素受体阻滞剂(ARBs)均可作为二线降压药物,并可能在预防其他长期并发症(如钙神经蛋白抑制剂诱发的肾病)方面发挥作用。钠-葡萄糖协同转运体 2 抑制剂(SGLT2i)似乎耐受性良好,尤其是在糖尿病和慢性肾病患者中可以考虑使用,但还需要更多的数据。相反,血管紧张素受体-去甲肾上腺素抑制剂(ARNI)尚未在心脏移植人群中进行过研究,因此目前还不能推荐使用。在心脏移植术后高血压的治疗中,早期停用类固醇和改变传统的危险因素非常重要。CCB、ACEI、ARB 是改善心脏移植术后并发症的首选降压药物。SGLT2i等新型疗法似乎耐受性良好,可能对心脏移植术后的血压和血糖控制都有益处;但还需要进行更大规模的试验。
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引用次数: 0
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Current Opinion in Cardiology
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