Current Cardiology Reports

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Orientation of myocardial fibers and arrangement of the Purkinje fibers covering the left ventricular myocardium. A Subepicardial myocardial fibers run in a left-handed direction, mid layer fibers run circumferentially, and subendocardial fibers run in the right-handed direction. (From Nakatani [4], reproduced with permission from the Korean Society for Echocardiography.) B This helical orientation comes together to create the anatomic heart and contributes to normal LVEF generation. (From Deng et al. [3], reproduced with permission from the Hindawi Publishing Company.) C, D The His-Purkinje system is a delicate, intricate meshwork that integrates itself into the myocardium and uniformly depolarizes the meticulously oriented myocardial fibers. (From de Almeida et al. [5], reproduced with permission from Springer)
The initial insult of dyssynchronous electrical activation leads to multiple downstream metabolic, electrical, and structural changes that worsen dyssynchrony and perpetuate cardiomyopathy. (Image reproduced from: Nguyên et al. Oxford University Press; 2018;20:1898–909, by permission of Oxford University Press) [65•]
2022 AHA/ACC/HFSA guidelines for the management of heart failure
2021 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy
Purpose of the Review Dyssynchrony occurs when portions of the cardiac chambers contract in an uncoordinated fashion. Ventricular dyssynchrony primarily impacts the left ventricle and may result in heart failure. This entity is recognized as a major contributor to the development and progression of heart failure. A hallmark of dyssynchronous heart failure (HFd) is left ventricular recovery after dyssynchrony is corrected. This review discusses the current understanding of pathophysiology of HFd and provides clinical examples and current techniques for treatment. Recent Findings Data show that HFd responds poorly to medical therapy. Cardiac resynchronization therapy (CRT) in the form of conventional biventricular pacing (BVP) is of proven benefit in HFd, but is limited by a significant non-responder rate. Recently, conduction system pacing (His bundle or left bundle branch area pacing) has also shown promise in correcting HFd. Summary HFd should be recognized as a distinct etiology of heart failure; HFd responds best to CRT.
Mechanism of action of COVID vaccines and development of myopericarditis
Purpose of Review To review myocarditis and pericarditis developing after COVID-19 vaccinations and identify the management strategies. Recent Findings COVID-19 mRNA vaccines are safe and effective. Systemic side effects of the vaccines are usually mild and transient. The incidence of acute myocarditis/pericarditis following COVID-19 vaccination is extremely low and ranges 2–20 per 100,000. The absolute number of myocarditis events is 1–10 per million after COVID-19 vaccination as compared to 40 per million after a COVID-19 infection. Higher rates are reported for pericarditis and myocarditis in COVID-19 infection as compared to COVID-19 vaccines. Summary COVID-19 vaccine–related inflammatory heart conditions are transient and self-limiting in most cases. Patients present with chest pain, shortness of breath, and fever. Most patients have elevated cardiac enzymes and diffuse ST-segment elevation on electrocardiogram. Presence of myocardial edema on T2 mapping and evidence of late gadolinium enhancement on cardiac magnetic resonance imaging are also helpful additional findings. Patients were treated with non-steroidal anti-inflammatory drugs and colchicine with corticosteroids reserved for refractory cases. At least 3–6 months of exercise abstinence is recommended in athletes diagnosed with vaccine-related myocarditis. COVID-19 vaccination is recommended in all age groups for the overall benefits of preventing hospitalizations and severe COVID-19 infection sequela.
Shows a risk chart for a moderate risk country. (From [2••], Reprinted by permission of Oxford University Press on behalf of the European Society of Cardiology)
Shows an illustrative risk chart for use in a medium risk country. It will be noted that gender differences are modest, perhaps because the highest risk men have already died. (From [3••], Reprinted by permission of Oxford University Press on behalf of the European Society of Cardiology)
Purpose of Review Prior European Society of Cardiology (ESC) guidelines endorsed the SCORE 10-year cardiovascular disease (CVD) risk calculator to inform the total risk approach to CVD prevention, including the use of preventive interventions like lipid lowering therapies. However, SCORE was released in 2003, did not allow for estimation of fatal and non-fatal CVD events, and was limited to adults aged 40 to 70 years. The ESC’s Cardiovascular Risk Collaboration (CRC) was tasked with updating SCORE (SCORE2) and with extending the upper age range of adults eligible for risk estimation (SCORE2-OP). This review summarises these two deliverables. Recent Findings Published in 2021, these updated risk scores allow for estimation of 10 year total (fatal + non-fatal) risks of a first atherosclerotic cardiovascular event in adults (SCORE2) and older persons (SCORE2-OP), calibrated for use in four European risk regions. The models account for competing risk of non-CVD death. These were extensively validated with excellent calibration and C-statistics ranging from 0.67 to 0.81. Summary SCORE2 and SCORE2-OP have informed the 2021 ESC Guidelines on cardiovascular disease prevention in clinical practice. In addition to endorsing these two updated risk calculators, these guidelines have, for the first time, recommended the use of age-related risk categories. This change was motivated to prevent overreliance on age when making CVD prevention decisions.
A multifaceted patient-centered care of heart failure by nurse practitioners
Integrating palliative care across the HF experience. “Core domains of primary palliative care (e.g., symptom assessment and management, psychosocial support, advance care planning) may be seamlessly integrated within usual heart failure (HF) disease and device management. When appropriate, specialty palliative care services may be initiated to address complex or intractable palliative needs. The timing of these referrals should be based on patient need, not prognosis, and can be initiated at any point during the HF trajectory. Given that symptoms, functional status, and quality of life are not perfectly correlated, it is important that palliative needs such as symptoms and quality of life be routinely and systematically monitored throughout the patient’s HF care trajectory” [46]. (Reprinted from: Kavalieratos D, et al. J Am Coll Cardiol. 2017 Oct 10;70(15):1919–1930, with permission from Elsevier) [46]
Purpose of Review The goal of this paper is to highlight the multifaceted approach heart failure (HF) nurse practitioners (NPs) use to manage patients. We were seeking to answer if NPs have the scope of clinical skills to manage the complexity of HF patients. Recent Findings NP care in HF has been shown to reduce readmissions, improve timeliness of visits, decrease cost, and improve quality outcomes in small heterogeneous studies. Summary The evidence supports that NPs provide multifaceted, patient-centered care for at all stages on the continuum of HF. Our goals as NPs are to reduce the healthcare financial strain and improve access to high quality care. Telehealth is an emerging technology that shows promise in HF management by improving access and decreasing readmissions. Telehealth use and recognition increased with the COVID-19 pandemic. Future research should focus on NP run clinics, cost effectiveness, and quality of care.
for the association between air pollution and CVD or all-cause mortality. Solid lines reflect a stronger association whereas dotted lines reflect a weak association between exposure to air pollutants and CVD outcomes. Red lines reflect association of long-term exposure to air pollutants with CVD outcomes while black lines reflect association of short-term exposure to air pollutants with CVD outcomes. OS, oxidative stress; ROS, reactive oxygen specifies; ANS, automatic nervous system; CVD, cardiovascular disease; CHD, coronary heart disease; PM, particulate matters; NO2, nitrogen dioxide; SO2, sulfur dioxide; O3, ozone; CO, carbon monoxide; HPA, hypothalamic and pituitary-adrenal; HPO, hypothalamic and pituitary-ovary; HPG, hypothalamic and pituitary–gonadal
Purpose of Review Although environmental exposure such as air pollution is detrimental to cardiovascular disease (CVD), the effects of different air pollutants on different CVD endpoints produced variable findings. We provide updated evidence between air pollutants and CVD outcomes including mitigation strategies with meta-analytic evidence. Recent Findings An increased exposure to any class of air pollutants including particulate matter (PM), gas, toxic metals, and disruptive chemicals has been associated with CVD events. Exposure to PM < 2.5 μm has been consistently associated with most heart diseases and stroke as well as CVDs among at-risk individuals. Despite this, there is no clinical approach available for systemic evaluation of air pollution exposure and management. Summary A large number of epidemiological evidence clearly suggests the importance of air pollution prevention and control for reducing the risk of CVDs and mortality. Cost-effective and feasible strategies for air pollution monitoring, screening, and necessary interventions are urgently required among at-risk populations and those living or working, or frequently commuting in polluted areas.
Conceptualizations of caregiver distress and correlated constructs
Purpose of Review Caregivers of patients with coronary artery disease (CAD) are integral to the health care system and contribute substantially to patients’ management. The purpose of this review is to provide a narrative synthesis of existing research on caregiving for patients who experienced an acute coronary syndrome (MI/unstable angina) and/or coronary revascularization (PCI/CABG). Recent Findings Thirty-one articles are included in this review. Overall, caregiver distress is low to moderate, ranging from 6 to 67% of caregivers, and seems to dissipate over time for most caregivers. Interventions have demonstrated success in reducing the distress of caregivers of patients with CAD. Due to the heterogeneity in study samples, measurements used, and timing of assessments and programming, these results are far from definitive. Summary Although evidence is accumulating, further advancement in caregiving science and clinical care is required to adequately understand and respond to the needs of caregivers throughout the patient’s illness trajectory.
Acute heart failure classifications
Proposed overview of management of acute heart failure patients
Purpose of Review Acute heart failure (AHF) is among the leading causes for unplanned hospital admission. Despite advancements in the management of chronic heart failure, the prognosis of AHF remains poor with high in-hospital mortality and increased rates of unfavorable post-discharge outcomes. With this review, we aim to summarize current data on AHF epidemiology, focus on the different patient profiles and classifications, and discuss management, including novel therapeutic options in this area. Recent Findings There is significant heterogeneity among patients admitted for AHF in their baseline characteristics, heart failure (HF) aetiology and precipitating factors leading to decompensation. A novel classification scheme based on four distinct clinical scenarios has been included in the most recent ESC guidelines, in an effort to better risk stratify patients and guide treatment. Intravenous diuretics, vasodilators, and inotropes remain the cornerstone of management in the acute phase, and expansion of use of mechanical circulatory support has been noted in recent years. Meanwhile, many treatments that have proved their value in chronic heart failure demonstrate promising results in the setting of AHF and research in this field is currently ongoing. Summary Acute heart failure remains a major health challenge with high in-hospital mortality and unfavorable post-discharge outcomes. Admission for acute HF represents a window of opportunity for patients to initiate appropriate treatment as soon as possible after stabilization. Future studies are needed to elucidate which patients will benefit the most by available therapies and define the optimal timing for treatment implementation.
Purpose of Review Cardiac amyloidosis (CA) is an often under-recognized cause of heart failure with preserved ejection fraction. The goal of the current paper was to review imaging modalities available for detecting cardiac amyloidosis. We wished to determine what modalities are available for the diagnosis of cardiac amyloidosis and what modalities could be utilized in the future. Recent Findings Early and delayed planar imaging of the chest currently plays a central role in the workup and diagnosis of CA. However, novel positron emission tomography (PET) tracers could play a large role in CA imaging in the future. There is an increasing body of literature supporting the use of targeted amyloid-binding PET radiotracers such as ¹¹C-Pittsburgh compound B (¹¹C-PIB), ¹⁸F-florbetapir, -flutemetamol, and -florbetaben for the detection of cardiac amyloid. Summary While planar imaging currently plays a large role in the workup of CA, PET imaging could play an increasing important role in the future. The quantitative abilities of novel PET tracers could theoretically allow for the serial monitoring of patients and detection of response to therapy, and the sensitive nature of the tracers could allow for even earlier disease detection. Further work with large randomized controlled trial data is needed in the development and validation of PET tracers for cardiac amyloid and represents an exciting development within the realm of nuclear cardiology.
Results of the search strategy and study selection process
Comparison of the prevalence of obesity between migrating population residing in countries from the EU or UK and non-migrating population residing in the country of origin
Comparison of the prevalence of diabetes between migrating population residing in countries from the EU or UK and non-migrating population residing in the country of origin
Background The potential effect of migration on increasing cardiometabolic risk factors remains partially understood. We aim to synthesize the evidence comparing the burden of diabetes and adiposity of migrating populations in Europe, with that of their country of origin. Methods We conducted a scoping literature review. We searched PubMed for studies investigating the effect of migration on diabetes or adiposity outcomes among migrants in countries from the European Union or the United Kingdom compared to the population in the country of origin. Studies were qualitatively synthesized in evidence tables and the demographic characteristics, study design, risk factors investigated, and outcomes were quantitatively summarized using measures of central tendency. Findings Of 1175 abstracts retrieved, 28 studies were eligible. Most of the studies included migrating populations residing in Western (50%), Northern (39%), and Southern Europe (11%) originating from countries in Africa (46%), Asia (29%), or European overseas (25%) regions of which 85% were classified as low-middle-income countries. Most of the studies (93%) had a cross-sectional design. The median number of individuals in the country of origin was greater [917; IQR: 231–1378] than in the receiving country [249; 150–883]. Thirty-five percent of the studies investigated migration as an independent risk factor, whereas 28% contextualized migration into lifestyle changes. The majority of the studies (57%) reported both diabetes and adiposity outcomes. Within the limited evidence available, controversial results were found as some studies showed poorer outcomes for the migrating populations, while others showed the opposite. Conclusion Studies assessing the impact of migration by comparing migrating populations and the population of origin on diabetes and adiposity outcomes have gained interest. So far, the available evidence is highly heterogeneous to inform public health strategies in the receiving countries. We recommend further research including a more robust methodology and in-depth characterization of the migrant populations.
Case of an 81-year-old female with hypertension and no prior history of coronary artery disease (CAD) who presented with typical chest pain. Initial SPECT/CT myocardial perfusion imaging (MPI) study did not show evidence of significant CAD (a). Given the typical nature of her symptoms, she was subsequently referred for a rubidium PET/CT MPI 1 month later, which demonstrated extensive ischemia in the left anterior descending (LAD) coronary artery on relative perfusion images (a). Myocardial blood flow (MBF) analysis (b) revealed a significant decrease of hyperemic MBF and flow reserve in all coronary territories, indicating the presence of severe multivessel CAD. On invasive coronary angiography (c), severe extensive CAD involving the LAD, the first diagonal, the circumflex artery, the right coronary artery, and the posterior decending artery was confirmed
Results of a systematic review on the prognostic value of myocardial flow reserve (A) and stress myocardial blood flow (B). MACE, major adverse cardiovascular event.
(Reproduced from: Juarez-Orozco et al. Eur Heart J Cardiovasc Imaging, 2018. 19(10): p. 1179–1187, by permission of Oxford University Press) [52]
Scatter plot of myocardial flow reserve (or coronary flow reserve, CFR) and hyperemic myocardial blood flow (MBF) by cardiovascular death, showing the 4 different phenotypes of response in terms of MFR and MBF in patients with stable coronary artery disease. Impaired hyperemic MBF and MFR is associated with the worse prognosis. CFR appears to be a better predictor of cardiovascular death than hyperemic MBF.
(Reproduced from: Gupta et al. Circulation, 2017. 136(24): p. 2325–2336, with permission from Wolters Kluwer Health, Inc.) [69]
Relationship between myocardial flow reserve (MFR) and fractional flow reserve (FFR). Abnormal MFR combined with normal FFR is seen in cases of diffuse epicardial disease and/or microvascular disease. Abnormal FFR with normal MFR can be seen in cases of focal epicardial stenosis, typically in younger individuals
Purpose of Review The purpose of this review is to provide an overview of the role of PET MPI in the detection of CAD, focussing on the added value of MBF for diagnosis and prognostication. Recent Findings Positron emission tomography (PET) myocardial perfusion imaging (MPI) is increasingly used for the risk stratification of patients with suspected or established coronary artery disease (CAD). PET MPI provides accurate and reproducible non-invasive quantification of myocardial blood flow (MBF) at rest and during hyperemia, providing incremental information over conventional myocardial perfusion alone. Summary Inclusion of MBF in PET MPI interpretation improves both its sensitivity and specificity. Moreover, quantitative MBF measurements have repeatedly been shown to offer incremental and independent prognostic information over conventional clinical markers in a broad range of conditions, including in CAD. Quantitative MBF measurement is now an established and powerful tool enabling accurate risk stratification and guiding patients’ management. The role of PET MPI and flow quantification in cardiac allograft vasculopathy (CAV), which represents a particular form of CAD, will also be reviewed.
Example of basic clinical CMR protocol. Sequences marked with an asterisk (*) are optional. The syringe represents the administration of intravenous contrast (gadolinium)
CMR protocols focused on the specific clinical scenario
Common aetiologies of heart failure in oncology patients
Different patterns of myocardial late enhancement
Common aetiologies of chest pain in oncology patients
Purpose of Review Cardiac magnetic resonance imaging has a significant and expanding role to play in contemporary cardio-oncology. This review seeks to explore the current and future roles of this imaging modality in the cardio-oncology setting. Recent Findings Cardiac magnetic resonance imaging is required in diagnosing, monitoring and treating all types of cardiotoxicities (acute coronary syndromes, arrhythmias, myocarditis, pericardial disease, heart failure) and in all types of cancers (breast, gastrointestinal, renal, prostate, haematological etc.). Newer imaging sequences and techniques can help provide additional information and shorten imaging times. Summary Cardiac magnetic resonance imaging is an integral part of the holistic management of cardio-oncology patients, with increasingly expanding applications in the area.
Purpose of Review Transcatheter mitral valve replacement (TMVR) is an evolving and rapidly expanding field within structural interventions, offering renewed treatment options for patients with high-risk mitral valve disease. We aim to highlight and illustrate the importance of cardiac CT in the planning of TMVR. Recent Findings As TMVR has evolved, so has the specific nuances of cardiac CT planning, we now understand the importance of accurate annular sizing and valve simulation to predict complications such as neo-LVOT obstruction and paravalvular leak (PVL). More so than any other modality, cardiac CT remains instrumental in accurately planning TVMR from feasibility, device sizing, access, and fluoroscopic angles. Summary Cardiac CT remains the key modality in TMVR evaluation, often the first step in determining patient eligibility through comprehensive procedural planning as well as informing potential outcomes and prognosis. In this review, we discuss the critical role of cardiac computed tomography (CT) and the specific considerations involved in TMVR.
Left panel: different phenotypes according to the relationship between the mitral valve leaflets, the hinge point of the posterior leaflet (asterisk), and the mitral annular plane (dotted line) in systole; MAD is indicated by the bold black bar. In (i), a normal mitral valve without MAD or MVP is illustrated, (ii) MVP without MAD (atrial displacement of posterior hinge point), (iii) MVP without MAD; (iv) MVP with MAD. Right panel: isolated systolic MAD (absent in diastole) was recently coined as pseudo-MAD, because the apparent disjunction is created by juxtaposition of the bulging mitral leaflet to the left atrial wall [48]. In pseudo MAD, there is always MVP; if the annular plane is erroneously set at the leaflet bending point in the atrium (asterisk), then pseudo-MAD occurs (red double arrow). Note that the MVP definition is based on displacement of the leaflet (> 2 mm) above the line through both annular hinge points [9, 44]. Therefore, MAD can only exist in the absence of MVP if the hinge point is set at the upper border of the MAD (black asterisk and black dotted line in (ii)), which is only possible in true MAD. In pseudo MAD, the true hinge point is located at the lower border of the MAD (red asterisk and red dotted line in (ii)) and as such, the MAD + /MVP- phenotype is (by definition) not possible, unless pseudo MAD and true MAD co-exist
Purpose of Review To provide an overview of mitral annular disjunction (MAD) and to discuss important challenges in diagnosis and management of MAD. Recent Findings MAD has regained interest in the context of sudden cardiac death (SCD) in patients with mitral valve prolapse (MVP), coined as the “arrhythmic” MVP syndrome. In addition, MAD in isolation was recently suggested to be associated with severe arrhythmia and SCD. Summary There is a lack of consensus on the definition of MAD and the imaging modality to be used for diagnosing MAD, and the therapeutic implications of MAD remain uncertain. Furthermore, the exact mechanism underlying the association of MAD with SCD remains largely unexplored.
Purpose of Review We discuss the relationship between sleep and circadian factors with cardiovascular disease (CVD) risk, including physiologic, behavioral, and psychological mechanisms along this pathway. Recent Findings The relationship between short and long sleep duration, as well as insomnia, with CVD risk is well-established. Recent work has highlighted how other sleep factors, such as sleep regularity (i.e., consistency of sleep timing), multidimensional sleep health, and circadian factors like chronotype and social jetlag, relate to CVD risk. Sleep-focused interventions (e.g., cognitive behavioral therapy for insomnia and sleep extension) may be effective to reduce CVD risk and disease burden. Summary Sleep is increasingly recognized as an integral component of cardiovascular health. This was underscored by the recent inclusion of sleep duration as a health behavior in the American Heart Association’s Life’s Essential 8 for defining optimal cardiovascular health.
Purpose of Review Summarize developments in the early postoperative care of patients undergoing cardiac transplantation or left ventricular assist device implantation. Provide a practical approach with personal insights to highly complex patients at risk for prolonged hospitalization. Recent Findings Advancements in technology allow for percutaneous mechanical circulatory support of both the right and left ventricles either isolated or combined via subclavian and neck vessels. Since the adult heart allocation system has been changed to reduce waitlist mortality, the use of temporary mechanical circulatory support has increased. This has influenced preoperative optimization by enabling ambulation and majorly changed postoperative strategy. New doors have been opened for a multidisciplinary approach to facilitate rapid weaning of inotropic medications, limitation of sedation, early liberation from mechanical ventilation, and mobilization. Summary Individualized percutaneous mechanical circulatory support offers new possibilities for the early postoperative management of highly complex patients undergoing cardiac transplantation or durable left ventricular assist device implantation.
PRISMA flow diagram of the study selection process
Risk of bias graph: review authors’ judgements about each risk of bias item presented as percentages across all included studies
Risk of bias summary: review authors’ judgements about each risk of bias item for each included study
Inclusion and exclusion criteria
Search strategy
Introduction Although poor medication adherence is considered an impacting risk factor for worsening heart failure (HF) outcomes, adherence rates in HF patients continue to be considerably low. To improve this condition, several studies investigated the impact of many determinants on medication adherence; however, few authors explored the role of depression on it. Purpose of Review The purpose of this systematic review was to explore the association between depressive symptoms and medication adherence in HF patients. In particular, the research question was is depression a barrier to medication adherence in HF patients? Methods A systematic review of quantitative analysis studies was undertaken. Six electronic databases were searched between the end of October and March 2022. Thirty-one trials were included, all of them assessed depression, adherence to medication, and their possible relationship. Results As was intended, findings showed that the impact of a mild to moderate level of depression was significant on adherence to treatment in HF patients. However, many other risk factors emerged, like family support and health practices (es. low sodium diet). Conclusion The detection of depression in the setting of HF should be crucial to HF patients' physical health and quality of life. Future research should take depression into account, exploring this area through self-report and qualitative interview as well.
Mechanisms of stress on cardiovascular physiology. Chronic and acute stressors contribute to an increased inflammatory response and autonomic imbalance, which can lead to adverse cardiometabolic effects, endothelial dysfunction, abnormal vascular reactivity, and abnormal immune function. These factors ultimately can contribute to adverse cardiovascular events. ACTH, adrenocorticotrophic hormone; CAM, cell adhesion molecules; E, epinephrine; HTN, hypertension; MMP, matrix metalloproteinases; NAFLD, nonalcoholic fatty liver disease; NE, norepinephrine; RAS, renin-angiotensin system. Figure created using
Correlates of mental stress-induced myocardial ischemia (MSIMI). MSIMI is associated with several factors and is a phenomenon that is not benign. MI, myocardial infarction; PTSD, post-traumatic stress disorder
Mental stress-induced myocardial ischemia and events in coronary artery disease. MSIMI is associated with twofold increased events in patients with CAD compared to those with no ischemia, and almost a fourfold increased risk when combined with conventional stress ischemia. MI, myocardial infarction. (Figure reprinted with permission from JAMA. 2021. 326(18): 1818–28. Copyright© (2021) American Medical Association. All rights reserved)
Purpose of Review To summarize recent evidence on mental stress-induced myocardial ischemia (MSIMI), its mechanisms, and clinical significance. Recent Findings MSIMI can occur in patients with normal cardiac stress testing, is only weakly related to severity of coronary artery disease (CAD), and it is often silent. Among patients with CAD, MSIMI is associated with a twofold increased risk of major adverse cardiovascular events compared to those who do not have MSIMI. Certain groups such as young women with myocardial infarction and those with psychological comorbidities are more susceptible to MSIMI. Abnormal microvascular vasoreactivity and inflammation are implicated mechanisms in MSIMI. Increased brain activity in regions that modulate autonomic reactivity to emotional stress and fear is associated with MSIMI. Summary MSIMI has important prognostic implications in patients with CAD. Stress can no longer be ignored as a risk factor in cardiology care. Clinical trials testing effective strategies to target MSIMI are needed.
Purpose of Review There is emerging evidence that the post-acute and chronic phases of COVID-19 infection are associated with various significant cardiovascular sequelae. Recent Findings Long COVID has been shown to be associated with multiple cardiovascular sequelae including direct myocardial injury, arrhythmias, and cardiomyopathies. Hypotheses on the mechanism of myocardial injury include direct viral infiltration and autoimmune dysregulation. Long COVID is associated with persistent cardiac ischemia in patients with no previous history of coronary disease, atrial and ventricular arrhythmias, and the development of new-onset heart failure in previously healthy patients. Onset of long COVID may be related to severity of the initial SARS-CoV2 infection. Cardiac MRI is a valuable tool in assessing myocarditis and the development of cardiomyopathies in the setting of long COVID. Summary Both patients with and without pre-existing cardiovascular disease are at risk of developing myocardial injury in the setting of long COVID. Future studies will elucidate both cardiovascular mortality and cardiac rehabilitation in the post-acute and chronic phases of COVID-19.
Primary care PTSD screen for DSM-5 (PC-PTSD-5). This is a 5-item screen to identify patients with probable PTSD. A cut-point of 4 and above is considered probable PTSD. Further evaluation for PTSD is recommended for patients with a positive screen.
Purpose of Review Posttraumatic stress disorder (PTSD) may be an important risk factor for cardiovascular disease (CVD). We explore the literature linking PTSD to CVD, potential mechanisms, interventions, and clinical implications. We outline gaps in current literature and highlight necessary future research. Recent Findings PTSD has been independently associated with deleterious effects on cardiovascular health through biological, behavioral, and societal pathways. There are evidence-based psychotherapeutic interventions and pharmacotherapies for PTSD that may mitigate its impact on CVD. However, there are limited studies that rigorously analyze the impact of treating PTSD on cardiovascular outcomes. Summary Trauma-informed CVD risk stratification, education, and treatment offer opportunities to improve patient care. These approaches can include a brief validated screening tool for PTSD identification and treatment. Pragmatic trials are needed to test PTSD interventions among people with CVD and evaluate for improved outcomes.
Factors associated with hypertension in patients with CKD
Purpose of Review Hypertension is often difficult to control in patients with CKD as manifested by suboptimal control rates in this population. Use of thiazides in CKD patients has been limited as these agents are thought to be ineffective in reducing blood pressure in people with advanced CKD. This review summarizes recent studies impacting indications and safety of use of thiazide in patients with CKD and discusses the mechanism of how thiazides reduce blood pressure. Recent Findings Chlorthalidone reduces blood pressure compared to placebo in patients with advanced CKD, challenging the belief that thiazide diuretics lose efficacy at lower levels of GFR. Summary Recent clinical trial data indicate that thiazides are effective in patients with advanced kidney disease for blood pressure lowering. However, monitoring of electrolytes and kidney function is important to ensure patient safety when prescribing these agents in patients with CKD.
Schematic diagram of myocardial strain. A Three types of strain are defined along longitudinal, circumferential, and radial, respectively. B, C Circumferential and radial strains are obtained from short-axis sections, whereas longitudinal strain is obtained from long-axis sections. Cd: circumferential strain in diastole, Cs: circumferential strain in systole, Ld: longitudinal strain in diastole, Ls: longitudinal strain in systole, Rd: radial strain in diastole, Rs: radial strain in systole. In the long-axis plane, the longitudinal deformation corresponds to apex-base shortening/lengthening. In the short-axis plane, circumferential strain is tangential to the epicardial wall (oriented along the perimeter), and radial strain is oriented toward the center of the ventricular cavity. Ventricular sections close to the apex have a counterclockwise systolic rotation, whereas sections close to the base have a clockwise rotation
A Implemented tagging lines are orthogonal to the imaging slice in conventional CMR tagging methods. B In contrast, the tag planes generated in SENC are parallel to and inside the imaging slice, to record through-plane strain
The advent of methods for cardiac magnetic resonance and echocardiography. Adapted from references: [19, 42, 47, 111, 112]
A Auto-correlation-based tissue Doppler imaging (TDI). B Cross-correlation based 2D speckle tracking (STE). Vt: Velocity toward the transducer. Va: velocity away from the transducer. VL: Longitudinal velocity along the myocardial contraction. VT: Transverse velocity perpendicular to myocardial contraction
A Fundamental concept of the light-sheet imaging strategy. B Displacement analysis of focal myocardial mechanical deformation (DIAMOND) in zebrafish embryos. (Adapted with permission from: Chen et al. [77•])
Purpose of Review Heart failure results in the high incidence and mortality all over the world. Mechanical properties of myocardium are critical determinants of cardiac function, with regional variations in myocardial contractility demonstrated within infarcted ventricles. Quantitative assessment of cardiac contractile function is therefore critical to identify myocardial infarction for the early diagnosis and therapeutic intervention. Recent Findings Current advancement of cardiac functional assessments is in pace with the development of imaging techniques. The methods tailored to advanced imaging have been widely used in cardiac magnetic resonance, echocardiography, and optical microscopy. In this review, we introduce fundamental concepts and applications of representative methods for each imaging modality used in both fundamental research and clinical investigations. All these methods have been designed or developed to quantify time-dependent 2-dimensional (2D) or 3D cardiac mechanics, holding great potential to unravel global or regional myocardial deformation and contractile function from end-systole to end-diastole. Summary Computational methods to assess cardiac contractile function provide a quantitative insight into the analysis of myocardial mechanics during cardiac development, injury, and remodeling.
Distinguishing athlete’s heart from pathologic cardiac disease states. This Venn diagram highlights the important similarities and differences between the athlete’s heart and pathologic cardiac disease states, including their overlapping features as indicated by the red arrows. Abbreviations: LV, left ventricle; RV, right ventricle; LVEDD, left ventricular end-diastolic diameter; LV GLS, left ventricular global longitudinal strain; LVWT, left ventricular wall thickness; LVEF, left ventricular ejection fraction; RVEF, right ventricular wall ejection fraction; WMA, wall motion abnormality; LA, left atrium; RVEDD, right ventricular end-diastolic diameter; RBBB, right bundle branch block (used with permission from ASE’s Comprehensive Echocardiography, 3rd Edition, permission conveyed through Copyright Clearance Center, Inc.) [8]
Effects of training and detraining on wall thickness as seen on ECG and echocardiography. Abbreviations: ECG, electrocardiogram; echo, echocardiogram. The top panel demonstrates the baseline ECG and M-mode echocardiography of an elite athlete at peak training. There are T-wave abnormalities associated with LV hypertrophy. The bottom panel represents subsequent ECG and M-mode echocardiography from the same athlete 6 weeks after detraining. T wave inversions have normalized, and wall thickness is overall decreased (used with permission from ASE’s Comprehensive Echocardiography Textbook, 3.rd Edition, permission conveyed through Copyright Clearance Center, Inc.) [8]
Purpose of Review The athlete’s heart exhibits unique structural and functional adaptations in the setting of strenuous and repetitive athletic training which may be similarly found in pathologic states. The purpose of this review is to highlight the morphologic and functional changes associated with the athlete’s heart, with a focus upon the insights that echocardiography provides into exercise-induced cardiac remodeling. Recent Findings Recent studies are aiming to investigate the long-term effects and clinical consequences of an athlete’s heart. The “gray-zone” continues to pose a clinical challenge and may indicate scenarios where additional imaging modalities, or longitudinal follow-up, provide a definitive answer. Summary Echocardiography is likely to remain the first-line imaging modality for the cardiac evaluation of elite athletes. Multimodality imaging combined with outcome and long-term follow-up studies both during training and after retirement in both men and women may help further clarify the remaining mysteries in the coming years.
cardiac catheterization laboratory interventional diagnostic procedure protocol. Proposed step-by-step approach to the guidewire-based assessment of coronary vascular function using thermodilution or Doppler and then vasoreactivity testing using acetylcholine (Ach). This simple approach focuses on thermodilution, which is straightforward to include during daily practice. Note that some operators may prefer to perform vasoreactivity testing first without the guidewire, allowing Ach challenge prior to any short-acting nitrate administration. HMR hyperemia microvascular resistance; IC intracardiac; LVEDP left ventricular end-diastolic pressure; LV gram left ventriculogram; NHPR nonhyperemic pressure ratio; seg segment; TT transit time (for a bolus of normal saline). (Reproduced from JACC Cardiovasc Interv. 2020;13(16):1847–64;; Creative Commons user license) [74]
Purpose of Review Persistent or recurrent angina after percutaneous coronary intervention (PCI) has substantial patient morbidity and economic impact. As knowledge of the pathophysiology of this condition has evolved, new tools for accurate diagnosis and treatment have become available. We provide a current, comprehensive review of mechanisms of post-PCI angina, diagnostic strategies, and therapeutic options. Recent Findings The routine use of functional testing during PCI may enable more accurate revascularization. Coronary vasomotor disorders commonly cause angina after PCI in the absence of obstructive epicardial CAD. Invasive coronary vasoreactivity testing can enable phenotype-guided therapy of coronary vasomotor disorders with improvement in angina. Multiple nonpharmacologic modalities to treat refractory angina are under development. Summary A comprehensive approach to the diagnosis of persistent or recurrent angina after PCI with noninvasive and invasive techniques is required. An individualized, phenotype-guided management using lifestyle, pharmacologic, and nonpharmacologic modalities is necessary to optimize outcomes.
Purpose of Review Transcatheter valve therapies for mitral and tricuspid regurgitation are alternative methods to more invasive surgical treatment in candidates with high or prohibitive surgical risk. Echocardiography is the primary imaging modality for patient selection, pre-procedural planning, intra-procedural guidance, and post-procedural follow-up. Recent Findings This article outlines the applications of transcatheter valve repair therapy for mitral and tricuspid regurgitation based on the current cardiovascular guidelines and a growing body of evidence. Summary In this review, we provide a stepwise approach echocardiography in the guidance of the MitraClip device as currently the only FDA-approved transcatheter edge-to-edge repair device.
Non-invasive imaging techniques in the whole spectrum of cardiac sarcoidosis. FDG PET allows the assessment of the extension and the intensity of active myocardial inflammation. BMIPP SPECT can detect early myocardial damage as well as fibrosis in advanced disease. MPI detects myocardial perfusion defects, which mainly represents areas of fibrosis. CMR provides an integral assessment of myocardial scar through the presence and extent of LGE. Abbreviations: PET, positron emission tomography; FDG, ¹⁸F-fluordeoxyglucose; BMIPP, ¹²³I-beta-methyl-p-iodophenylpentadecanoic; SPECT, single-photon emission computed tomography; MPI, myocardial perfusion imaging; CMR, cardiac magnetic resonance; LGE, late gadolinium enhancement
Cardiac metabolic imaging in active inflammation and myocardial fibrosis. Panel A A case example of a 57-year-old male with diagnosis of isolated CS by EMB and history of severe left ventricular dysfunction requiring ICD. He presents palpitations attributed to NSVT. PET MPI reveals a moderate perfusion defect in the basal anterior and mid-inferoseptal segments with increased corresponding [¹⁸F]FDG myocardial uptake (arrows), consistent with active inflammation. Panel B A case example of a female patient in her 60 s at the time of CS diagnosis. CMR-LGE (left), BMIPP SPECT (center), and polar map of BMIPP SPECT (right). The short-axis, horizontal, and vertical long-axis images of the CMR show LGE in the basal septal, mid-inferior, and anterior walls of the left ventricle (arrows). BMIPP SPECT shows defects uptake in the same segments as CMR-LGE, representing a surrogate metabolic imaging marker of myocardial fibrosis (B adapted and reproduced from Yamamoto et al. [46]). Abbreviations: CS, cardiac sarcoidosis; EMB, endomyocardial biopsy; ICD, implantable cardioverter-defibrillator; NSVT, nonsustained ventricular tachycardia; PET, positron emission tomography; MPI, myocardial perfusion imaging; FDG, ¹⁸F-fluordeoxyglucose; CT, computed tomography; CMR, cardiac magnetic resonance; LGE, late gadolinium enhancement; BMIPP, ¹²³I-beta-methyl-p-iodophenylpentadecanoic; SPECT, single-photon emission computed tomography
Purpose of Review Cardiac sarcoidosis (CS) is an inflammatory disease of unknown etiology that can lead to life-threatening arrhythmias, heart failure, and death. Advanced cardiac imaging modalities have improved the clinician’s ability to detect this disease. The purpose of this review is to discuss the recent evidence of cardiac metabolic imaging as assessed by [¹⁸F]FDG PET and [¹²³I]BMIPP SPECT in the evaluation of CS patients. Recent Findings [¹⁸F]FDG PET is the gold standard to identify myocardial inflammation. [¹²³I]BMIPP SPECT can uncover early myocardial damage as well as advanced stages of CS when fibrosis prevails. In presence of inflammation, myocardial [¹⁸F]FDG uptake is increased, but in contrast, BMIPP myocardial uptake is reduced or even suppressed. Thus, a complementary role of cardiac metabolic imaging by [¹⁸F]FDG PET and BMIPP SPECT has been proposed to detect the whole spectrum of CS. Summary [¹⁸F]FDG PET is considered an important tool to improve the diagnosis and optimize the management of CS. The role of [¹²³I]BMIPP SPECT in diagnosing CS is still under investigation. Further studies are needed to evaluate the clinical utility of combined cardiac metabolic imaging in the diagnosis, prognosis, and for selecting treatments in CS patients.
Purpose of Review Hypertension represents the most important cardiovascular risk factor, affecting over 4.06 billion adults worldwide. In this review, we will discuss potential barriers and their solutions to improve prevention, detection, and management of hypertension. Recent Findings The prevalence of hypertension has been increasing in low- and middle-income countries, requiring new strategies to improve its recognition and proper management. The World Heart Federation (WHF) developed a roadmap for hypertension, advising health system policies and clinical practices as part of its commitment to improving global cardiovascular health. The World Health Organization (WHO) has published in 2021 practical guidelines for the pharmacological treatment of hypertension in adults. Summary Identifying potential roadblocks and solutions deserves high priority to improve the detection, management, and control of hypertension.
Use of positron emission tomography (PET) myocardial perfusion imaging (MPI) for the assessment of allograft vasculopathy
Kaplan–Meier plots for cumulative survival in heart transplant patients based on baseline positron emission tomography (PET-1) coronary flow reserve (CFR, A) and based on PET-1 and follow-up PET (PET-2) CFR values (B). High → high represents patients with CFR > 1.5 at both PET-1 and PET-2. Low → high CFR represents patients with CFR ≤ 1.5 at PET-1 and CFR > 1.5 at PET-2. Low → low CFR represents patients with CFR ≤ 1.5 at both PET-1 and PET-2. High → low represents patients with CFR > 1.5 at PET-1 and CFR ≤ 1.5 at PET-2 (C and D). Similar Kaplan–Meier plots are presented for the combined endpoints of death, myocardial infarction (MI), and revascularization. CI confidence interval (reprinted from Feher A, et al.: JACC Cardiovasc Imaging 2020, 13(1 Pt 1):109–120, with permission from Elsevier) [23••]
Positron emission tomography (PET) coronary flow reserve (CFR) values grouped based on the number of rejection (R) episodes prior to imaging. R0 = no rejection prior to PET (baseline); R1 = 1 rejection episode; R2 = 2 rejection episodes; R3 +  = 3 or more rejection episodes (reprinted from Feher A, et al.: JACC Cardiovasc Imaging 2020, 13(1 Pt 1):109–120, with permission from Elsevier) [23••]
Purpose of Review Cardiac allograft vasculopathy (CAV) is a late-occurring complication of heart transplantation significantly limiting overall graft survival. In the last few years, evidence has been growing about the use of positron emission tomography (PET) myocardial perfusion imaging with integrated myocardial blood flow (MBF) quantification in heart transplant recipients. Recent Findings Multiple studies have demonstrated that PET MBF assessment can be utilized to establish the diagnosis of CAV noninvasively and can be employed for prognostication. PET MBF quantification has also helped to define the link between transplant rejection and CAV. In addition, limited data suggests that PET MBF quantification can be used in heart transplant patients for serial monitoring of CAV. Summary PET myocardial perfusion imaging integrating MBF quantification shows great promise for the evaluation of CAV with good diagnostic and prognostic performance.
Medtronic 670G insulin pump (left) with Guardian Sensor 3 continuous glucose monitor (right)
Illustration of hybrid closed-loop system. A continuous glucose monitor measures the interstitial glucose concentration and sends the glucose measurement to the control algorithm. The algorithm calculates the dose of insulin required based on the glucose received. The insulin pump then delivers the insulin dose. The cycle repeats
Tandem Control-IQ hybrid closed-loop system. A Insulin infusion set with subcutaneous cannula. B Dexcom G6 continuous glucose monitor. C Tandem t:slim X2 insulin pump with infusion tubing
Omnipod patch pump (top right) with personal diabetes manager (left) and Dexcom G6 continuous glucose monitor (bottom right)
Purpose of Review The incidence of type 1 diabetes (T1D) is rising in all age groups. T1D is associated with chronic microvascular and macrovascular complications but improving glycemic trends can delay the onset and slow the progression of these complications. Utilization of technological devices for diabetes management, such as continuous glucose monitors (CGM) and insulin pumps, is increasing, and these devices are associated with improvements in glycemic trends. Thus, device use may be associated with long-term prevention of T1D complications, yet few studies have investigated the direct impacts of devices on chronic complications in T1D. This review will describe common diabetes devices and combination systems, as well as review relationships between device use and cardiovascular outcomes in T1D. Recent Findings Findings from existing cohort and national registry studies suggest that pump use may aid in improving cardiovascular risk factors such as hypertension and dyslipidemia. Furthermore, pump users have been shown to have lower arterial stiffness and better measures of myocardial function. In registry and case–control longitudinal data, pump use has been associated with fewer cardiovascular events and reduction of cardiovascular disease (CVD) and all-cause mortality. Summary CVD is the leading cause of morbidity and mortality in T1D. Consistent use of diabetes devices may protect against the development and progression of macrovascular complications such as CVD through improvement in glycemic trends. Existing literature is limited, but findings suggest that pump use may reduce acute cardiovascular risk factors as well as chronic cardiovascular complications and overall mortality in T1D.
Purpose of Review Finerenone is a novel, non-steroidal mineralocorticoid receptor antagonist (MRAs) that has been investigated for the management of cardiorenal conditions. This article provides an overview of recent evidence of benefits on cardiovascular (CV) outcomes. Recent Findings The recently published phase III FIDELIO-DKD and FIGARO-DKD, alone and pooled, in patients with CKD and diabetes demonstrate that finerenone reduces the composite of CV death, non-fatal myocardial infarction, nonfatal stroke, and hospitalization for heart failure (HF) with hospitalization for HF being the primary driver of this composite. Summary Finerenone is indicated to reduce renal and CV outcomes in patients with CKD and diabetes. Future investigations of this agent include patients with non-diabetic CKD, HF with preserved ejection fraction, and with the use of sodium-glucose transporter type 2 inhibitors.
Modeling SARS-CoV-2 viral susceptibility, toxicity, and therapeutic screening with stem cell-derived cardiac cells. A Pluripotent stem cells differentiated into various cardiac cell types are used to model viral entry, susceptibility, pathogenesis, and toxicity after exposure to SARS-CoV-2. B Stem cell-derived cardiac tissues can be cultured in two or three dimensions and with multiple cell types to serve as a screening platform for effective therapeutics. Many different classes of therapeutics that reduce SARS-CoV-2 infection have been identified with these platforms
Human pluripotent stem cell models for studying SARS-CoV-2 infection in the heart
Although SARS-CoV-2, the causative virus of the global COVID-19 pandemic, primarily affects the respiratory tract, it is now recognized to have broad multi-organ tropism and systemic effects. Early reports indicated that SARS-CoV-2 infection could lead to cardiac damage, suggesting the virus may directly impact the heart. Cardiac cell types derived from human pluripotent stem cells (hPSCs) enable mechanistic interrogation of SARS-CoV-2 infection in human cardiac tissue. Purpose of Review To review the studies published since the emergence of the COVID-19 pandemic which utilize hPSCs and their cardiovascular derivative cell types to interrogate the tropism and effects of SARS-CoV-2 infection in the heart, as well as explore potential therapies. Recent Findings Recent studies reveal that SARS-CoV-2 is capable of infecting and replicating within hPSC-derived cardiomyocytes and sinoatrial nodal cells, but not as extensively in their non-parenchymal counterparts. Additionally, they show striking viral effects on cardiomyocyte structure, transcriptional activity, and survival, along with potential mechanisms and therapeutic targets. Summary Cardiac models derived from hPSCs are a viable platform to study the impact of SARS-CoV-2 on cardiac tissue and may lead to novel mechanistic insight as well as therapeutic interventions.
Purpose of Review To highlight the current global experience with DCD heart transplantation and explore the evolution of, and compare preservation strategies; examine early clinical outcomes, and discuss the growing use of DCD donors as a new frontier in heart transplantation. Recent Findings The two strategies of DCD heart preservation include NMP using the OCS Heart and TA-NRP followed by either: NMP or CSS. Better understanding the limits of cold ischaemia following TA-NRP will aid in distant procurement. Asystolic warm ischaemia plays an important role in determining immediate post-operative graft function and potential need for mechanical support. Large volume DCD heart transplant units show no difference in survival between DCD and DBD donor heart transplants. Summary In a previously non-utilised source of donor hearts, often viewed as an “unknown frontier” in heart transplantation, DCD hearts are a suitable alternative to brain-dead donor hearts and are likely to remain a permanent part of the heart transplantation landscape. Global uptake is currently increasing, and as understanding of preservation strategies and tolerable ischaemic times improve, utilisation of DCD hearts will continue to grow.
Purpose of Review Atherosclerosis is the largest cause of death in the western world with the role of sex yet to be determined. The purpose of this review is to investigate the role sex may play in the development of atherosclerosis. Recent Findings Differences in plaque burden play a role in atherosclerotic outcome. Men have a higher prevalence of plaque burden, while women have less plaque rupture, necrotic core, and calcium. Differences in hormones, vascular anatomy, and overall lifestyle all play a role. Estrogen’s cardioprotective effect is well known, but there is a lack of consensus on testosterone’s role. Summary There are varying rates of atherosclerosis between the sexes. Studies have also shown varying differences in the progression of plaque and the type of plaques between sexes. Further investigations need to be done to solidify the role sex may play as a variable in the development of atherosclerosis and how that may impact future treatment goals.
Normal and abnormal aortic pathologies. A–C TTE assessment of various segments of aorta. D A large TAA in a patient with bicuspid aortic valve. E Type 1 aortic dissection with a large intimal flap and severe AR. F Perpendicular views of a complex aortic plaque at distal arch with a corresponding 3D image
Range of normal aortic root dimensions on echocardiography in relationship to body surface area among different age groups. (Reprinted from: Goldstein et al. J Am Soc Echocardiogr. 2015;28(2):119–82, with permission from Elsevier) [14]
Purpose of Review Aortic aneurysm is the second most common aortic disease associated with significant morbidity and mortality. We summarize the role of echocardiography in the evaluation of aortic aneurysms in assessing the different etiologies, associated complications, and the role in serial follow-up. In addition, we discuss the limitations of echocardiographic evaluation and the role of multimodality imaging. Recent Findings Echocardiographic tools such as 2D/3D and Doppler imaging have helped improve the quality of aortic evaluation in acute and long-term follow-up. Moreover, multimodality imaging (CT and MR angiography) has advanced the field of aortic imaging. Summary Echocardiography is an essential and critical tool for the evaluation of normal aorta and various aortic pathologies. It provides valuable information with its diverse modalities such as TTE and TEE. Echocardiography along with complimentary multimodality imaging is critical to identify the acute aortic syndromes and other associated complications of aortic aneurysms, and in long-term follow-up.
Beyond lowering cholesterol, statins may also exert beneficial effects, including improvement of endothelial function leading to improved blood flow, modulation of the sympathetic nervous and renin angiotensin aldosterone system, or immunomodulation. All of these pathophysiological pillars can be imaged using dedicated nuclear cardiac imaging techniques, including perfusion, neurohumoral, or inflammatory-targeted imaging and thus, those SPECT or PET radiotracers may allow to decipher the beneficial effects on every pathophysiological pathway. NE, norepinephrine; MIBG, metaiodobenzylguanidine; CXCR4, C-X-C motif chemokine receptor 4; FAPI, fibroblast activation inhibitor. Created with
Purpose of Review Statins are routinely applied in patients with coronary artery disease, as they allow significantly to reduce blood cholesterol levels. Although those drugs are endorsed by current guidelines and prescribed routinely, a substantial portion of patients are still statin-intolerant and image-piloted strategies may then be helpful to identify patients that need further intensified treatment, e.g., to initiate treatment with proprotein convertase subtilisin / kexin type 9 inhibitors (PCSK9i). In addition, it has also been advocated that statins exhibit nonlipid, cardio-protective effects including improved cardiac nerve integrity, blood flow, and anti-inflammatory effects in congestive heart failure (HF) patients. Recent Findings In subjects after myocardial infarction treated with statins, 123II-metaiodobenzylguanidine (MIBG) scintigraphy has already revealed enhanced cardiac nerve function relative to patients without statins. In addition, all of those aforementioned statin-targeted pathways in HF can be visualized and monitored using dedicated cardiac radiotracers, e.g., ¹²³I-MIBG or ¹⁸F-AF78 (for cardiac nerve function), ¹⁸F-flurpiridaz (to determine coronary flow) or ⁶⁸Ga-PentixaFor (to detect inflammation). Summary Statins exhibit various cardio-beneficial effects, including improvement of cardiac nerve function, blood flow, and reduction of inflammation, which can all be imaged using dedicated nuclear cardiac radiotracers. This may allow for in vivo monitoring of statin-induced cardioprotection beyond lipid profiling in HF patients.
Purpose of the Review The purpose of this review is to understand the underlying mechanism that leads to pericarditis in systemic autoimmune and autoinflammatory diseases. The underlying mechanism plays a vital role in the appropriate management of patients. In addition, we will review the current landscape of available cardiac imaging modalities with emphasis on pericardial conditions as well as proposed treatment and management tailored toward pericardial autoimmune and autoinflammatory processes. Recent Findings Approximately 22% of all cases of pericarditis with a known etiology are caused by systemic autoimmune diseases such as systemic lupus erythematosus, rheumatoid arthritis, systemic sclerosis, and vasculitis. In recent years, there have been advancements of imaging modalities including cardiac MRI, cardiac CT scan, and PET scan and their respective nuances in regard to contrast use, technique, and views which clinicians may utilize to better understand the extent of a patient’s pericardial pathology and the trajectory of his or her disease process. Summary In this review, we will discuss systemic autoimmune and autoinflammatory diseases that involve the pericardium. We will also review different imaging modalities that are currently used to further characterize such conditions. Having a deeper understanding of such techniques will improve patient outcomes by helping clinicians tailor treatment plans according to the unique underlying condition.
Trajectory of heart failure in DTGA/Atrial switch anatomy. The trajectory of heart failure in the adult patient with D-TGA post atrial switch operation is unique from typical acquired heart failure phenotypes. Patients with an atrial switch operation often have systemic ventricular failure that precedes pulmonary ventricular failure by decades. The unusual characteristic of this group is that they are often asymptomatic until very late in the disease course. This coupled with a long history of systemic ventricular dysfunction, can make monitoring this group challenging, especially since systemic ventricular dysfunction is often present for much of their adult life. However, it is important to recognize that despite relatively preserved exercise capacity, once early heart failure symptoms begin (i.e., diuretic use), a downward spiral may ensue quite rapidly (dotted black line/arrow) requiring urgent orthotopic heart transplant (OHT) work-up. To assist with managing these patients after heart failure symptoms begin, implantable hemodynamic monitors (IHMs) may be helpful to monitor subpulmonic ventricular function and surveillance of the pulmonary vascular bed for evidence of pulmonary vascular disease, and progression toward worsening heart failure and need for OHT work-up (blue dotted line). Created with
Potentially reversible causes of heart failure in complex ACHD. Patients with D-TGA/atrial switch operations and those with Single Ventricle/Fontan physiology share similar causes of heart failure (in purple), however it is important to recognize that there are unique patterns and causes of heart failure equally distinct in each case. Being aware of these potentially reversible causes should inform the work-up and potential therapeutic strategy for each subset of patients. Created with
Reasonable approach to heart failure evaluation in D-TGA/Atrial switch anatomy. In patients with D-TGA/Atrial switch operation, once signs/symptoms of heart failure are recognized, it is reasonable to look for reversible causes of heart failure (HF). If present, several management strategies may be aimed at correcting reversible causes (green box). However, in those without reversible causes, management will center on volume management, continued hemodynamic monitoring which may be assisted by the placement of an implantable hemodynamic monitor (IHM) and eventual consideration for mechanical-circulatory support (MCS) and/or orthotopic heart transplant (OHT) in end-stage disease. Created with
Purpose of Review Adult congenital heart disease (ACHD) patients have demonstrated improved survival, especially those with severely complex disease, mainly single-ventricle/Fontan physiology and those with a systemic right ventricle. We describe the heart failure phenotypes of complex CHD, reversible causes for heart failure, and considerations for advanced therapy. Recent Findings While initially marketed for application to patients with acquired causes for heart failure, newer devices and technologies have started to be used in the ACHD population. After reversible causes for heart failure in CHD are addressed, it is reasonable to consider use of new device-based technologies and orthotopic heart transplant (OHT) for end-stage disease. Summary New heart failure technology and organ transplant should carefully be considered and applied in complex ACHD, where there may be significant improvement in morbidity and mortality.
Role of Runx1 transcription factor in heart failure. Activation of CBFβ–Runx1 heterodimer leads to transcription of p53 gene and its downstream target genes (Bax, Noxa and Puma), it also upregulates transcription of fibrotic genes such as smad3, TGF-β and collagen I. Runx1 activates the TGF-β1/Smads signalling pathway. This leads to cardiac fibrosis, apoptosis, hypertrophy as well as cardiac dysfunction. The gene transcription can be reversed by Ro5-3335 and dihydrolycorine, whereas TGF-β1/Smads signalling pathway is inhibited by MiR-101. CBFβ, core binding factor β; Runx1, runt-related transcription factor 1; p53, tumour protein p53; NOXA, phorbol-12-myristate-13-acetate-induced protein 1; PUMA, p53 upregulated modulator of apoptosis; BAX, bcl-2-like protein 4; BAK, Bcl-2 homologous antagonist/killer; smad3, SMAD family member 3; TGF-β1, transforming growth factor beta 1. This figure was created with
Role of neuraminidase-1 enzyme in heart failure. NEU1 interacts with GATA4 transcription factor thereby producing Nppa and Nppb genes; it also promotes desialylation which leads to production of N-acetylneuraminic acid (Neu5Ac); NEU1 expression activates Drp1-dependent mitochondrial fission, apoptosis and mitophagy. This leads to hypertrophy, cardiac dysfunction, apoptosis and mitophagy. Zanamivir, oseltamivir and C-09 downregulate the expression of NEU1 enzyme. GATA4, GATA-binding protein 4; NEU1, neuraminidase-1; Nppa, natriuretic peptide A; Nppb, natriuretic peptide B; Drp1, dynamin-related protein 1; ATG5, autophagy-related 5; PINK1, PTEN-induced kinase 1; Ub, ubiquitin-activating enzyme; P62, ubiquitin-binding protein p62; LC3, microtuble-associated protein light chain 3. This figure was created with
Role of urotensin receptor in heart failure. UTR interacts with UT and promotes hypertrophy via MAPK signalling pathway and RhoA/Rock signalling pathway; it also upregulates fibrotic response by promoting TGF-β/Smads signalling pathway. KR-36996 and KR36676 inhibit the MAPK signalling and the hypertrophic response, Urantide inhibits fibrosis and SB710411 and SB-706375 inhibit apoptosis and hypertrophic response. MAPK, mitogen-activated protein kinase; ERK, serine/threonine protein kinase; TGF-β, transforming growth factor beta; Smad, suppressors of mother against decapentaplegic; α-SMA, alpha smooth muscle actin; RhoA, Ras homolog family member A; Rock, Rho-associated protein kinase; Akt, serine/threonine protein kinase. This figure was created with
Role of milk fat globule-EGF factor 8 in heart failure. MFGE8 inhibits Akt/mTOR/Gsk-3β signaling pathway and thereby apoptosis induced hypertrophy; it also inhibits TGF-β1/Smad2/3 pathway directly or indirectly via integrin β3 receptor which leads to EndMT-induced cardiac fibrosis. In vivo administration of rhMFGE8 downregulates both of these signaling pathway. Gsk-3β, glycogen synthase kinase-3β; mTOR, mammalian target of rapamycin; Smad, Smad-signaling pathway; α-SMA, smooth muscle alpha-actin; CD31, cluster of differentiation 31; Snail, snail family transcriptional repressor 1; EndMT, endothelial to mesenchymal transition. This figure was created with
Purpose of Review Heart failure is a global epidemic that affects at least 26 million individuals globally and is becoming more prevalent. Despite advances in treatment strategies, survival and symptom management in individuals with heart failure remain exceptionally low. This review discusses emerging targets for the treatment of heart failure. Recent Findings Recently, a number of targets are being investigated as prospective treatment possibilities for heart failure. These include targets like Runx1 transcription factor (RUNX1), milk fact globule-EFG factor 8 (MFGE8) protein and enzymes such as neuraminidase 1 (NEU1), G protein–coupled receptor kinase 5 (GRK5), G protein–coupled oestrogen receptor 1 (GPER1), urotensin-II receptor (UTR), cluster of differentiation 47 (CD47) and relaxin receptor 1 (RXFP1). Summary On a worldwide level, heart failure is a developing epidemic with substantial morbidity and death. The number of individuals diagnosed with chronic heart failure is rising, and it is anticipated to surge by 46% by 2030. Appropriate heart failure treatment can have the greatest influence on prolonging patients’ lives in the coming year. Targets discussed in this review may provide new therapeutic approaches for the treatment of heart failure.
Purpose of Review Vascular rings are congenital malformations resulting from abnormal development of the great vessels, with the consequent encircling and compression of the trachea, esophagus, or both. We conducted a review of the current literature to identify the different management strategies that can be implemented based on the prognosis of each of these anomalies. Recent Findings Although most vascular rings occur in isolation, they can also be associated with other congenital cardiac and/or respiratory diseases; therefore, thorough investigation is necessary before definitive surgical repair. Clinical presentation varies from asymptomatic to severe, with both respiratory and digestive symptoms. Although early surgical results are acceptable, the long-term outcome is variable; therefore, there is still controversy regarding the appropriate timing of treatment. This is especially true with regard to the Kommerell diverticulum (KD) and in patients without symptoms at the time of initial surgical evaluation. Summary As more sophisticated diagnostic tools have become available and more studies on adults affected by this condition have been published, understanding of this condition and its additional clinical implications has grown and appears to be tilting management toward earlier intervention.
The cytokine storm involved in COVID-19 infections is a source of oxidative stress. Viruses and traumas (mental or physical) in general may lead to oxidative stress, which may lead to parasympathetic or sympathetic dysfunction(s), known as dysautonomias (adapted from Rasa et al. [21••])
Classification of Long-COVID (reprinted from Raveendran AV et al. Diabetes Metab Syndr. 2021 May to Jun;15(3):869–875, with permission from Elsevier) [51]
Purpose of Review Long-COVID syndrome is a multi-organ disorder that persists beyond 12 weeks post-acute SARS-CoV-2 infection (COVID-19). Here, we provide a definition for this syndrome and discuss neuro-cardiology involvement due to the effects of (1) angiotensin-converting enzyme 2 receptors (the entry points for the virus), (2) inflammation, and (3) oxidative stress (the resultant effects of the virus). Recent Findings These effects may produce a spectrum of cardio-neuro effects (e.g., myocardial injury, primary arrhythmia, and cardiac symptoms due to autonomic dysfunction) which may affect all systems of the body. We discuss the symptoms and suggest therapies that target the underlying autonomic dysfunction to relieve the symptoms rather than merely treating symptoms. In addition to treating the autonomic dysfunction, the therapy also treats chronic inflammation and oxidative stress. Together with a full noninvasive cardiac workup, a full assessment of the autonomic nervous system, specifying parasympathetic and sympathetic (P&S) activity, both at rest and in response to challenges, is recommended. Cardiac symptoms must be treated directly. Cardiac treatment is often facilitated by treating the P&S dysfunction. Cardiac symptoms of dyspnea, chest pain, and palpitations, for example, need to be assessed objectively to differentiate cardiac from neural (autonomic) etiology. Summary Long-term myocardial injury commonly involves P&S dysfunction. P&S assessment usually connects symptoms of Long-COVID to the documented autonomic dysfunction(s).
Purpose of Review Paravalvular leak (PVL) is a relatively uncommon complication associated with prosthetic valve implantation. PVL can occasionally lead to serious adverse consequences such as congestive heart failure, infective endocarditis, and hemolytic anemia. Surgical re-operation carries a high mortality risk. Recent Findings Transcatheter closure therapy provides a viable alternative for the treatment of this disorder with reasonable procedural and clinical success. The recent advent of hybrid imaging modalities has increased procedural success. Summary This article summarizes the pathophysiology, clinical characteristics, and treatment modalities surroundings prosthetic paravalvular leak.
Photoplethysmography (PPG)-based arrhythmia detection algorithm used in the A Apple Heart Study and B FitBit Heart Study. A The Apple Watch algorithm samples tachograms every 2 h at rest. After an irregular tachogram, sampling frequency is increased to every 15 min. If five of six sequential tachograms are found to be abnormal within a 48-h period, an irregular heart rate notification is provided to the user. B The FitBit algorithm analyzes overlapping 5-min tachograms while the wearer is stationary. If at least 11 consecutive intervals are irregular within a 24-h period, an irregular heart rhythm detection is generated (Fig. 1 adapted from Baman and Passman. J Cardiovasc Electrophysiol. 2022 Jan 20., with permission from John Wiley and Sons) [60]
Interaction between atrial fibrillation (AF) duration and risk of stroke and systemic embolism (SSE)
Purpose of Review Atrial fibrillation is associated with a significant increase in stroke and systemic embolism. This review explores the areas of stroke prevention. Recent Findings In the last decade, NOAC has overtaken warfarin as the anticoagulant of choice for stroke prevention in AF. For patients unable to take anticoagulation, LAA closure has proven to be a valid option. The use of digital devices has led to widespread consumer-directed AF screening. It remains to be determined if all device detect AF pose the same amount of risk as recent studies have shown that short and infrequent episodes of AF may not benefit from anticoagulation. Summary Stroke prevention is paramount in the management of AF. In this review we describe the risk factors contributing to stroke, recent advances in antithrombotic therapies, and the increasing role of digital health in guiding AF detection and stroke prevention.
Purpose of Review Clinical cardio-oncology considerations specific to women span across many areas and are particularly relevant for management of patients with sex-specific cancers, such as breast cancer. Recent Findings Major improvement in breast cancer survivorship over the last decade and the recognition of CV disease as the second leading cause of death among survivors point to the relevance of long-term cardiovascular (CV) safety. This review summarizes the CV effects associated with multimodality breast cancer treatments and contemporary approach to CV risk stratification, prevention, early detection, monitoring, and management at the time of cancer diagnosis, during and after completion of treatment. Summary We highlight the growing role of a multidisciplinary, team-based approach for comprehensive CV and oncology care through the entire cancer treatment continuum, from diagnosis through survivorship.
Purpose of Review Acute coronary syndromes (ACS) often occur in individuals with prior coronary artery bypass graft surgery (CABG). Our goal was to describe the prevalence, clinical characteristics, prognosis, and treatment strategies in this group of patients. Recent Findings Studies demonstrate that both acute and long-term major adverse cardiovascular outcomes are increased in patients with ACS and prior CABG compared to those without CABG. Much of this risk is attributed to the greater comorbid conditions present in patients with prior CABG. Data regarding optimal management of ACS in patients with prior CABG are limited, but most observational studies favor an early invasive approach for treatment. Native vessel percutaneous coronary intervention (PCI), if feasible, is generally preferred to bypass graft PCI. Summary Patients with ACS and prior CABG represent a high-risk group of individuals, and implementing optimal preventive and treatment strategies are critically important to reduce the risk.
PCSK9-targeted approach for prevention of atherosclerotic cardiovascular disease. A short graphical overview of the role of PCSK9 in lipoprotein metabolism (detailed description is provided in the maint text) and potential targets for marketed PCSK9 inhibitors. PCSK9, proprotein convertase subtilisin-kexin type 9; LDL-R, low-density protein receptor; siRNA, small interfering ribonucleic acid; mAbs, monoclonal antibodies; ER, endoplasmatic reticulum.
(Source: The icons in this image are reproduced from Servier Medical Art by Servier. Reproduced from Servier Medical Art by Servier under a Creative Commons [CC BY 4.0] licence.)
Purpose of Review Treatment of dyslipidemia represents one of the most crucial strategies to reduce risk of atherosclerotic cardiovascular (CV) disease (ASCVD). In this review, we critically summarize our knowledge on emerging cholesterol-lowering therapy, targeting PCSK9, paying particular attention on treatment allocation of two drug groups, currently available for clinical use, namely, anti-PCSK9 monoclonal antibodies (mAbs) and inclisiran, a first-in-class small interfering RNA against PCSK9. Recent Findings Although both drug classes show a pronounced, but fairly similar reduction in LDL-cholesterol, their long-term safety is still unknown. Compared to mAbs, inclisiran has a more favorable dosing regimen with biannual application that might improve therapeutic adherence significantly. However, a CV outcome trial (CVOT) for inclisiran is still missing. Summary If inclisiran will be safe and effective in ongoing/future CVOTs, it has a huge potential to overcome medication non-compliance, thereby providing a powerful therapeutic option to decrease the burden of ASCVD.
Make Early Diagnosis to Prevent Early Death (MedPed) Criteria [18]
Purpose of Review The current review discusses the importance and significance of differentiating monogenic familial hypercholesterolemia (FH) from polygenic hypercholesterolemia for clinical purpose. Recent Findings Consistent scientific evidence have demonstrated that, compared to polygenic hypercholesterolemia, monogenic FH patients are at significantly higher risk for premature coronary heart disease (CHD). This is despite both disease entities having a comparable low-density-lipoprotein cholesterol (LDLC) level. Monogenic FH also has poorer therapeutic response compared to its polygenic counterpart. However, there are no current available clinical management guidelines that stratify hypercholesterolemia patients based on genotype. Summary Monogenic FH patients are at higher risk for CHD with poorer therapeutic response. Thus, genotype testing should be performed when available. There is also an urgency to develop genotype-based clinical guideline that stratify patients on genotype and not only based on traditionally known cardiovascular risk factors.
Example electrocardiogram (ECG) of a precordial T wave inversions in a PKP2 variant carrier and right ventricular basal outpouching on MRI in (a) compared with lateral T wave inversions and circumferential late gadolinium enhancement (LGE) in a DSP variant carrier in (b)
Low voltage on electrocardiogram (ECG) in a PLN variant carrier (a) and conduction disease in a LMNA variant carrier (b)
Central illustration of gene presentation and overlap
Purpose of the Review The definition of arrhythmogenic cardiomyopathy (ACM) has expanded beyond desmosomal arrhythmogenic right ventricular cardiomyopathy (ARVC) to include other genetic cardiomyopathies with a significant arrhythmia burden. Emerging data on genotype–phenotype correlations has led recent consensus guidelines to urge genetic testing as a critical component of not only diagnosis but also management of ACM. Recent Findings Plakophilin-2 (PKP2) ARVC/ACM is most likely to meet ARVC Task Force Criteria with right sided involvement and ventricular arrhythmias, while desmoplakin (DSP) ACM may have a normal electrocardiogram (ECG) and has a subepicardial LV scar pattern. Extra-desmosomal ACM including ACM associated with transmembrane protein 43 and phospholamban variants may have characteristic ECG patterns and biventricular cardiomyopathy. Lamin A/C and SCN5A cardiomyopathy often have heart block on ECG with DCM, but are distinct from DCM in that they have significantly elevated arrhythmic risk. Newer genes, especially filamin-C (FLNC) also may have distinct imaging scar patterns, arrhythmia risk, and risk predictors. Summary Recognition of these key differences have implications for clinical management and reinforce the importance of genetic testing in the diagnosis and the emerging opportunities for genotype-specific management of ACM patients.
Purpose of Review Cardiovascular autonomic control is an intricately balanced dynamic process. Autonomic dysfunction, regardless of origin, promotes and sustains the disease processes, including in patients with heart failure (HF). Autonomic control is mediated through the two autonomic branches: parasympathetic and sympathetic (P&S). HF is arguably the disease that stands to most benefit from P&S manipulation to reduce mortality risk. This review article briefly summarizes some of the more common types of autonomic dysfunction (AD) that are found in heart failure, suggests a mechanism by which AD may contribute to HF, reviews AD involvement in common HF co-morbidities (e.g., ventricular arrhythmias, AFib, hypertension, and Cardiovascular Autonomic Neuropathy), and summarizes possible therapy options for treating AD in HF. Recent Findings Autonomic assessment is important in diagnosing and treating CHF, and its possible co-morbidities. Autonomic assessment may also have importance in predicting which patients may be susceptible to sudden cardiac death. This is important since most CHF patients with sudden cardiac death have preserved left ventricular ejection fraction and better discriminators are needed. Summary Many life-threatening cardiovascular disorders will require invasive testing for precise diagnoses and therapy planning when modulating the ANS is important. In cases of non-life-threatening disorders, non-invasive ANS testing techniques, especially those that individually assess both ANS branches simultaneously and independently, are sufficient to diagnose and treat serially.
Estimated prevalence of sarcomeric HCM and different phenocopies according to age groups. Estimated prevalence of sarcomeric HCM and main phenocopies in different age groups is reported in percentages. A) Age <1 year; B) Age 1-18 years; C) 18-40 years; D) 40-75 years; E) > 75 years. For details on each group of disorders see text. Malformation syndromes include RASopathies and other rarest conditions. Others include idiopathic cases and other rare genetic, infiltrative, and inflammatory cardiomyopathies not included in other groups. sHCM, sarcomeric hypertrophic cardiomyopathy
Imaging findings in adult patients with sarcomeric HCM and HCM phenocopies. A–E A 38-year-old female with sarcomeric HCM. A ECG shows high QRS voltages and diffuse repolarization abnormalities with diphasic-negative T waves in precordial leads and a “pseudo-ST-segment elevation myocardial infarction” in inferior leads. B Echocardiogram shows asymmetric septal hypertrophy with mild left atrial enlargement. C Reduced GLS velocities are measured in the basal-medium segments of anterior interventricular septum and anterior wall. D CMR shows a transmural area of LGE in the mid-anterior interventricular septum is present, while T1 mapping values are within the normal range in (E). F–J An 83-year-old male with wtATTR cardiac amyloidosis. F ECG presents sinus bradycardia with first-degree atrioventricular block, right bundle branch block, and low QRS voltages. G Echocardiography shows concentric LVH with granular-sparkling appearance of myocardium and thickening of atrioventricular valves and interatrial septum. Left atrium is significantly enlarged. H At strain rate imaging, GLS reduction with apical sparing is present. I CMR shows global diffuse myocardial LGE pronounced in the subendocardial layers, while T1 mapping values are significantly increased (J). K–O A 55-year-old male with classic Fabry disease. K ECG shows sinus rhythm with a 120-ms PQ interval, high QRS voltages, and diffuse repolarization abnormalities with negative T waves in V3–V6 and inferolateral leads. L Echocardiography shows concentric hypertrophy with thickened atrioventricular mitral leaflets and right ventricular free wall. M Reduced longitudinal strain velocities in the lateral mid-basal segments are present at strain rate imaging. N At CMR, a stria of midwall LGE is present in the lateral basal segments with reduced T1 mapping values of myocardial tissue that are pseudo-normalized in the lateral segments in correspondence of LGE area (O)
A red flag in transthyretin cardiac amyloidosis. Rupture of right arm distal biceps tendon (A) in a 83-year-old patient with intense radionuclide cardiac uptake (Perugini 3 grade) at 99mTc-3,3-diphosphono-1,2-propanodicarboxylic acid scan (B) ECG and imaging features of this patient are shown in Fig. 2F–J
A representative case of Danon disease. An 8-year-old child with initial mental retardation and muscle weakness. A ECG shows very high QRS voltages with marked repolarization abnormalities. A delta wave indicating atrioventricular pre-excitation is clearly visible. B and C Massive concentric LVH with associated right ventricular hypertrophy is evident in long-axis parasternal view (B) and apical view (C)
Diagnostic work-up for the differential diagnosis of HCM phenocopies. Most common red flags suggesting the diagnosis of main HCM phenocopies are reported for each diagnostic step. sHCM, sarcomeric hypertrophic cardiomyopathy; Mitoc-dis, mitochondrial disease; eGFR, estimated glomerular filtration rate; AL, light chain amyloidosis; CK, creatine kinase; PNS, peripheral nervous system; ATTR, transthyretin amyloidosis; LVH, left ventricular hypertrophy; LGE, late gadolinium enhancement
Purpose of Review We describe the most common phenocopies of hypertrophic cardiomyopathy, their pathogenesis, and clinical presentation highlighting similarities and differences. We also suggest a step-by-step diagnostic work-up that can guide in differential diagnosis and management. Recent Findings In the last years, a wider application of genetic testing and the advances in cardiac imaging have significantly changed the diagnostic approach to HCM phenocopies. Different prognosis and management, with an increasing availability of disease-specific therapies, make differential diagnosis mandatory. Summary The HCM phenotype can be the cardiac manifestation of different inherited and acquired disorders presenting different etiology, prognosis, and treatment. Differential diagnosis requires a cardiomyopathic mindset allowing to recognize red flags throughout the diagnostic work-up starting from clinical and family history and ending with advanced imaging and genetic testing. Different prognosis and management, with an increasing availability of disease-specific therapies make differential diagnosis mandatory.
Purpose of Review This review article provides an overview of the various roles of 3-dimensional (3D) echocardiography in the evaluation of the tricuspid valve (TV) with specific focus on tricuspid regurgitation (TR) and its treatment. Recent Findings The prognostic implications of TR and the advent of new transcatheter therapies have underscored the need of accurate assessment of the TV. Summary 3D echocardiography is key to assess the anatomy and function of TV and has provided new insights that have led to new classifications of the type of TR. Furthermore, 3D echocardiography is superior to 2-dimensional echocardiography to assess the right ventricle, an important parameter to select the patients with severe TR who may benefit from intervention. Finally, the use of 3D echocardiography during the guidance of transcatheter interventions is pivotal to ensure procedural success and minimize the complications. Three-dimensional echocardiography provides the soft tissue resolution that fluoroscopy does not provide.
Top-cited authors
Juan Simon Rico-Mesa
  • University of Texas Health Science Center at San Antonio
Nathan Wong
  • University of California, Irvine
June-Wha Rhee
  • Stanford University
Wenjun Fan
  • University of California, Irvine
Roland von Känel
  • University of Zurich