Cardiovascular diagnosis and therapy最新文献

[This corrects the article DOI: 10.21037/cdt-2024-691.].

Background and objective: The angiosome concept, introduced by Taylor et al. and further applied by Neville et al., divides the body into three-dimensional blocks of tissue supplied by specific source arteries. This anatomical framework has been instrumental in guiding targeted revascularization strategies, thus enhancing blood flow to ischemic wounds. Building upon this, the woundosome concept was recently introduced, which focuses on individualized perfusion targeting, based on (I) anatomic variations; (II) the presence and extent of collateral circulation; and (III) wound characteristics. The woundosome concept may offer a potentially more tailored approach, paving the way for more thoughtful tissue revascularization. This review aims to investigate the role of angiosome- and woundosome-directed endovascular revascularization for the improvement of outcomes in patients with chronic limb-threatening ischemia (CLTI).

Methods: We conducted a systematic search in PubMed, Web of Science, and Cochrane Library from 1990 to February 2025 using combinations of the terms "angiosome", "woundosome", "critical limb ischemia", "diabetic foot ulcer", "direct revascularization", and "indirect revascularization". After screening 480 records, 14 studies were included in our analysis. Data were extracted regarding study design, patient population, revascularization strategy, and outcomes (wound healing, limb salvage). Findings were narratively synthesized with respect to study methodology and limitations.

Key content and findings: Most retrospective studies reported improved wound healing and limb salvage rates following angiosome-guided direct revascularization (DR), particularly when inline flow could be restored. However, comparable outcomes were observed with indirect revascularization (IR) in the presence of robust collateral circulation. Evidence for woundosome-guided revascularization remains limited but suggests that a perfusion-oriented, individualized strategy may be especially valuable in anatomically complex cases.

Conclusions: Incorporating angiosome- and woundosome-based strategies in CLTI management may improve limb- and patient-related outcomes. The decision on which particular territory needs primary attention and how many vessels require revascularization largely depends on the patency of feeding arteries in the wound area. In the future, a standardized way to measure the intra- and post-procedural arterial flow to the wound would be necessary, to study the clinical applications of the mentioned strategies. Future studies should therefore prospectively validate woundosome-guided strategies and integrate standardized perfusion assessment tools to guide individualized treatment decisions.

Background and objective: Imaging for peripheral artery disease (PAD) is frequently misallocated: advanced cross-sectional studies are over-ordered for low-risk claudication, while high-risk chronic limb-threatening ischemia (CLTI) patients often receive no timely anatomic study. This narrative review summarizes current guideline pathways, quantifies real-world deviations, and identifies value-based remedies that better align modality and timing with clinical need.

Methods: Data sources were PubMed, professional-society websites [American College of Cardiology/American Heart Association (ACC/AHA), European Society for Vascular Surgery/European Society of Cardiology (ESVS/ESC), American College of Radiology (ACR)], and gray literature in a timeframe of January 2015-February 2025. Eligible items were English-language PAD imaging guidelines/consensus statements, registry/claims analyses, cohort/comparative studies, and cost/equity evaluations; single-case reports and non-vascular imaging were excluded. We extracted guideline-recommended diagnostic pathways, compared them with contemporary utilization and cost data, categorized misallocation and operational drivers.

Key content and findings: Across four contemporary guidelines, the benchmark diagnostic sequence is physiologic testing with the ankle-brachial index or toe-brachial index (ABI/TBI), followed by duplex ultrasonography (DUS); when results would change management, computed tomography angiography (CTA) or magnetic resonance angiography (MRA) should be performed, with catheter-based digital subtraction angiography (DSA) reserved for intervention. Cross-sectional imaging increased three-fold in Medicare from 2011-2021, while first-line physiologic testing declined. Only 54% of CLTI patients receive CTA/MRA within 30 days, and each month of delay raises major amputation risk. Imaging access is poorest among minoritized, socio-economically disadvantaged, and rural groups, whereas supplier-induced demand amplifies scans in affluent settings. Misallocation exposes patients to avoidable radiation and contrast, strains radiology capacity, and contributes >US $4 billion in annual CLTI costs. Evidence shows guideline-aware clinical decision support can cut rarely-appropriate imaging by 10-40%, limb-salvage fast-track pathways reduce major amputations by ~30% and expanding sonographer staffing shifts after-hours demand away from CTA.

Conclusions: PAD imaging is misaligned with value-based medicine: over-applied where benefit is marginal and under-applied where it is limb-saving. Implementing sequencing guardrails, decision-support tools, expedited CLTI workflows, and workforce remedies can rebalance utilization, enhance equity, and improve clinical and economic outcomes.

Background: Coronary artery disease is the second leading cause of death across all age groups, while the prevalence of atrial fibrillation (AF) is increasing in the general population. This situation highlights the significant issue of concomitant surgical treatment for these two conditions. We aimed to investigate the safety and efficiency of pulmonary vein isolation (PVI) and left atrial appendage occlusion (LAAO) as concomitant procedures in patients undergoing off- vs. on-pump beating-heart coronary artery bypass grafting (CABG) at our centre.

Methods: This retrospective single-centre cohort included consecutive patients with AF who underwent CABG with concomitant epicardial PVI between December 2021 and November 2024 at Robert Bosch Hospital. Patients without preoperative AF, emergency cases, and those undergoing non-CABG concomitant procedures were excluded. Of 44 included patients, 27 had off-pump CABG (OPCAB) and 17 had on-pump beating-heart CABG. Primary endpoints were sinus rhythm (SR) maintenance with or without antiarrhythmic drugs (AADs) and overall survival (OS); secondary endpoints were major adverse cardiac and cerebrovascular events (MACCE) and anticoagulation status at follow-up. Group comparisons used χ² and Mann-Whitney U tests (two-sided, P<0.05).

Results: Follow-up was 100% at a median of 24 months. SR without AADs was observed in 77.7% of OPCAB and 64.7% of on-pump beating-heart patients; with AADs, rates were 81.4% and 70.5%, respectively. OS was in the OPCAB group 92%, respectively 94% in the on-pump beating-heart group. No strokes or myocardial infarctions occurred during follow-up; therefore MACCE-free, survival equalled OS. Oral anticoagulation was discontinued in 18.2% of patients, all in SR. No statistically significant between-group differences were detected for rhythm or survival outcomes.

Conclusions: In patients with AF undergoing CABG, concomitant PVI yielded high SR maintenance and excellent mid-term survival in both off-pump and on-pump beating-heart settings, with no stroke or myocardial infarction observed at follow-up. These findings support the feasibility and safety of integrating PVI into CABG-including OPCAB-for appropriately selected patients.

Background: Hypertrophic cardiomyopathy (HCM) is a genetically heterogeneous cardiac disorder often caused by variants in sarcomeric genes such as MYH7. The p.Tyr134His variant in MYH7 has previously been reported only once in a Korean HCM patient and was classified as a variant of uncertain significance (VUS), with no further supporting evidence available. This study adds to the literature by providing additional clinical and genetic evidence for this rare variant, suggesting a possible Korean-specific founder effect.

Case description: We identified eight unrelated Korean patients with HCM, all carrying the heterozygous MYH7 NM_000257.4:c.400T>C (p.Tyr134His) variant. These patients underwent exome sequencing across multiple clinical centers in South Korea. Clinical presentations varied from asymptomatic cases to those with arrhythmia, syncope, or structural changes such as asymmetric septal hypertrophy. No other pathogenic variants in known cardiomyopathy genes were identified in all eight patients. The variant was absent in major public and Korean population databases but present only in Korean HCM patients from our in-house cohort. In silico tools, including REVEL, AlphaMissense, and 3Cnet, consistently predicted deleterious effects.

Conclusions: Our findings provide clinical and population-level evidence supporting the pathogenicity of the p.Tyr134His variant in MYH7, potentially representing a rare Korean-specific founder mutation. However, as functional studies have not yet been performed, the pathogenic mechanism remains unconfirmed. Therefore, while current evidence remains of uncertain significance, further experimental validation may provide additional evidence to reclassify the variant as likely pathogenic.

Background and objective: Mitral valve disease (MVD) is a major contributor to global cardiovascular morbidity and mortality. Early identification is critical to prevent progression to heart failure, atrial fibrillation, and irreversible myocardial remodeling. Existing reviews have largely focused on advanced MVD, individual imaging modalities, or guideline summaries, with limited emphasis on early, asymptomatic disease, quantitative diagnostic thresholds, comparative multimodal imaging, and recent innovations. This narrative review uniquely synthesizes evidence published between 2020 and 2025 to provide an updated, modality-integrated overview of early-stage MVD, emphasizing emerging technologies, global accessibility considerations, and a practical multimodal diagnostic framework.

Methods: A comprehensive literature search was conducted using PubMed, Scopus, and Google Scholar from January 2020 to August 2025. Original studies, meta-analyses, high-quality narrative or state-of-the-art reviews, and consensus statements addressing early diagnosis of MVD were included. Non-English publications, case reports, and studies focusing exclusively on advanced disease were excluded. Study selection and data extraction were performed by the author, and alternative available versions were retrieved when full texts were unavailable.

Key content and findings: Echocardiography remains the cornerstone of early MVD assessment due to its accessibility, dynamic evaluation capabilities, and cost-effectiveness. Cardiac magnetic resonance (CMR) offers high precision for quantifying regurgitant volume, myocardial fibrosis, and early remodeling. Computed tomography (CT) provides superior spatial resolution for anatomical assessment and preprocedural planning, while positron emission tomography (PET) contributes metabolic and inflammatory insights, especially in prosthetic valve disease. Emerging innovations, such as artificial intelligence (AI), machine learning (ML), fusion imaging, and four-dimensional (4D) flow CMR, enhance diagnostic precision and prognostication. In resource-limited settings, strategies including tele-echocardiography, portable ultrasound, and global training initiatives are improving accessibility. Integration of imaging with clinical, functional, and patient-reported outcomes promotes a holistic, patient-centered approach.

Conclusions: Advances in multimodal cardiovascular imaging are transforming early MVD detection and management. A patient-centered, AI-enhanced imaging strategy, incorporating echocardiography, CMR, CT, and PET, can significantly improve diagnostic accuracy, optimize intervention timing, and enhance long-term outcomes. Broader implementation of telemedicine, standardized training, and cost-effective imaging technologies will be essential for equitable global adoption.

Background: The relationship between improved glycemic control and mortality reduction in diabetes remains controversial. This study aimed to examine the temporal trends and association between haemoglobin A1c (HbA1c) control status and mortality risk among adults with diabetes.

Methods: This study utilized data from the National Health and Nutrition Examination Survey (NHANES) collected between 1999 and 2014. The statistical significance of linear or nonlinear trends was evaluated using logistic regression. Nonlinear temporal trends were evaluated by including quadratic terms for time in the regression models. To explore the relationships between HbA1c and mortality, the study employed the Cox proportional hazards model for multivariate analysis, along with Kaplan-Meier survival curves for univariate visualization.

Results: With 6,516 participants, the study showed a significant improvement in the control rate of HbA1c among diabetic patients, increasing from 41.61% in 1999 to 58.72% in 2014 (P<0.001). However, there was no noticeable trend in the overall all-cause mortality rate, which was 10.79% in 1999 and 12.08% in 2014 (P=0.608), or in cardiovascular mortality, which was 4.74% in 1999 and 4.24% in 2014 (P=0.371), among diabetic patients. No significant differences were found in the risks of all-cause mortality [hazard ratio (HR): 0.64; 95% confidence interval (CI): 0.36-1.13; P=0.13] or cardiovascular mortality (HR: 1.11; 95% CI: 0.41-3.02; P=0.84) between patients with HbA1c below 7.0% and those with HbA1c 7.0% or higher. Interestingly, the rate of sulfonylureas use went down from 30.25% in 1999 to 12.42% in 2014 (linear P value <0.001).

Conclusions: Despite significant improvements in HbA1c control rates among US adults with diabetes from 1999 to 2014, we observed no corresponding reduction in 5-year mortality risks. Achieving HbA1c <7.0% was not associated with lower mortality risk in this population. These findings suggest that improvements in glycemic control alone may be insufficient to reduce mortality in diabetic populations, highlighting the need for a more comprehensive approach to diabetes management.

Artificial intelligence (AI) has emerged as a widely used tool for writing, including in scientific research and publications. While its application to cardiovascular research is the focus of numerous studies, the policies related to its use for manuscript writing are rapidly evolving and not well understood. We sought to compare the policies of high-impact cardiovascular journals regarding AI for manuscript writing assistance and assess the prevalence of its use. Cardiovascular medicine journals with an SCImago Journal Rank (SJR) ≥3 and h-index ≥100 were screened for an AI policy. Journal policies were assessed for author disclosure requirements, standardization of disclosure section and language, and AI detection software used during the submission process. Each journal with an AI policy that required disclosure of its use was systematically searched to evaluate the prevalence of articles disclosing its use for writing assistance from January 2023 to August 2025. The number of publications with AI disclosure and publication characteristics was recorded. Seventeen journals met inclusion criteria and were screened for an AI policy, of which 14 journals (82%) contained such a policy. Among these, three journals (18%) had an AI policy that required disclosure, but that was not specific to AI use for manuscript writing. One journal (6%) did not require disclosure. The remaining three journals (18%) did not have any AI policy. None of the journals mandated a dedicated AI disclosure section or provided authors with standardized disclosure language. Fifteen journals (88%) used identifiable AI detection software, while only one posted this information publicly. Among the 14 journals with an AI disclosure policy, 11 AI-disclosing works were found. ChatGPT was the most common AI tool used (n=9, 82%). Journal policies regarding AI use for manuscript writing assistance vary widely, and therefore, there is a growing need for standardization. The prevalence of articles disclosing the use of AI was profoundly low across all journals evaluated, with significant variation in how AI use was disclosed. Having clear and consistent policies across journals and requiring authors to disclose their use of AI for manuscript writing is essential to uphold transparency and maintain medical research integrity.

Background: Epidemiological evidence suggests an association between non-alcoholic fatty liver disease (NAFLD) and incident atrial fibrillation (AF); however, the magnitude of this association and its prognostic value in predicting the recurrence of AF after radiofrequency catheter ablation (RFCA) have not been fully characterized. The present study was designed to elucidate the complex interplay between NAFLD and the risk of AF recurrence after ablation.

Methods: A total of 1,182 patients with AF who underwent initial RFCA from June 2018 to December 2022 at the First Affiliated Hospital of Zhengzhou University were included in this retrospective cohort study. The Kaplan-Meier method was used to plot AF recurrence curves after ablation. Multivariable Cox models were then used to examine the associations between NAFLD and the recurrence of AF. Analyses were also conducted to assess whether the predictive effect of NAFLD was consistent across different subgroups.

Results: Over a 1-year follow-up period, 30.1% of the patients experienced recurrent AF. The multivariable Cox analysis revealed that NAFLD was an independent risk factor for the recurrence of AF after controlling for model 2 (hazard ratio =1.37, 95% confidence interval: 1.10-1.70, P=0.005). These correlations remained statistically significant across various models. Further, incorporating NAFLD in the fully adjusted basic risk model significantly increased the ability of the model to predict AF recurrence, with the C-statistic increasing from 0.672 to 0.686 (P=0.03). Additionally, diabetes mellitus (DM) (P value for interaction =0.049) and female sex (P value for interaction =0.02) had a statistically significant interactive effect with NAFLD in predicting the recurrence of AF.

Conclusions: NAFLD was found to be independently associated with the recurrence of AF after ablation. Moreover, the AF recurrence rate after RFCA was higher in the NAFLD patients who had DM or were female. The study showed that NAFLD may serve as a dependable marker for assessing AF recurrence risk in clinical practice.

Background: Increased aortic pulse wave velocity (aPWV), a marker of arterial stiffness, is associated with poor prognosis in patients with or at risk for heart failure with preserved ejection fraction (HFpEF). Increasingly, advanced imaging using cardiac magnetic resonance imaging (MRI) is used to evaluate cardiac dysfunction, including coronary microvascular dysfunction (CMD). To facilitate investigation linking CMD with HFpEF, we compared MRI-measured aPWV with traditional invasive or noninvasive measurements of aPWV.

Methods: We studied 118 participants (90.7% women) with or at risk for HFpEF due to suspected CMD in a cross-sectional design at Cedars-Sinai Medical Center between October 2025 and February 2022. aPWV was measured by: (I) MRI through-plane phase-contrast imaging at the ascending and distal descending aorta (MRI-aPWV) (n=78), (II) invasively via catheter pullback (cath-aPWV) (n=68), and (III) carotid-femoral applanation tonometry (cf-aPWV; SphygmoCor XCEL, Atcor Medical) (n=87). MRI-aPWV was compared to cath-aPWV and cf-aPWV using Pearson correlation and Bland-Altman plots.

Results: Mean age was 58±11.8 years, and mean aPWV were 8.48±3.21 m/s (MRI-PWV), 7.51±2.79 m/s (cath-aPWV), and 8.68±1.83 m/s (cf-aPWV). MRI-aPWV strongly correlated with cf-aPWV with r=0.74 [95% confidence interval (CI): 0.61-0.83, P<0.001] with mean difference -0.18 and standard deviation (SD) 2.14. Comparison of MRI-aPWV to cath-aPWV showed a modest correlation of 0.52 (95% CI: 0.29-0.69, P<0.001) with a mean difference of -0.74 and SD 2.78.

Conclusions: MRI measurement of aPWV shows good agreement with traditional invasive and noninvasive measurements in participants with or at risk for HFpEF. Reliable measurement of arterial stiffness combined with cardiac MRI measures of ventricular remodeling, fibrosis, scar and perfusion may offer pathophysiology insights and treatment targets for HFpEF.