Cardiology in Review

George Reed, MD: Cardiac Surgical Pioneer and Visionary No abstract available

Vulnerable Plaque: A Review of Current Concepts in Pathophysiology and Imaging Advances in our understanding of the natural history and biology of atherosclerotic vascular disease led to the concept of a vulnerable plaque (VP), which is predisposed toward more rapid progression and acute coronary events. With newer technologies, we now have at our disposal high-quality imaging studies, both invasive and noninvasive, which promise in identifying plaque characteristics that make it more vulnerable. Upcoming trials aim to evaluate the utility of imaging VP in predicting clinical events. We discuss the role of VP imaging in managing atherosclerotic vascular disease.

Cardiovascular Sequelae of Sickle Cell Disease Sickle cell disease (SCD) is one of the most common hereditary hemoglobinopathies worldwide. It is a multisystem disease that causes considerable patient morbidity. Despite advances in medical treatment, cardiopulmonary complications remain the most common cause of death in individuals with SCD. A growing body of evidence has shown that SCD results in a spectrum of cardiovascular complications through a variety of mechanisms, including chronic hemolysis, local tissue hypoxia, increased oxidative stress, and autonomic instability. Herein, we will examine the pathophysiology of sickle cell vasculopathy and discuss the spectrum of cardiovascular sequelae of the disease, while highlighting the impact of SCD on the cardiovascular health of the patients.

Pregnancy Complications as a Window to Future Cardiovascular Disease Pregnancy is a time of significant hemodynamic, metabolic, and hormonal stress that can unmask underlying subclinical cardiovascular abnormalities, and pregnancy-related complications may serve as early warning signs for future risk of cardiovascular disease. The increased recognition of these sex-specific risk factors could identify women who may benefit from more intensive risk factor modification to reduce morbidity and mortality later in life. In this review, we describe several pregnancy-related complications that have been associated with the risk of cardiovascular disease, including hypertensive disorders of pregnancy, gestational diabetes mellitus, preterm delivery, and pregnancy loss. Pregnancy-associated risk factors must be identified to fully assess a woman’s future cardiovascular risk and may influence strategies for risk reduction.

Beta Adrenergic Blocker Use in Patients With Chronic Obstructive Pulmonary Disease and Concurrent Chronic Heart Failure With a Low Ejection Fraction Chronic heart failure (CHF) and chronic obstructive pulmonary disease (COPD) often coexist and present clinicians with diagnostic and therapeutic challenges. Beta-blockers are a cornerstone of CHF treatment, in patients with a low ejection fraction, while beta-agonists are utilized for COPD. These 2 therapies exert opposing pharmacological effects. COPD patients are at an increased risk of mortality from cardiovascular events. In addition to CHF, beta-blockers are used in a number of cardiovascular conditions because of their cardioprotective properties as well as their mortality benefit. However, there is reluctance among physicians to use beta-blockers in patients with COPD because of fear of inducing bronchospasms, despite increasing evidence of their safety and mortality benefits. The majority of this evidence comes from observational studies showing that beta-blockers are safe and well tolerated, with minimal effect on respiratory function. Furthermore, beta-blockers have been shown to lower the mortality risk in patients with COPD alone, as well as in those with COPD and CHF. Large clinical trials are needed in order to dispel the mistrust of beta-blocker use in COPD patients. The current evidence supports the use of cardioselective beta-blockers in patients with COPD. As the population continues to live longer, comorbidities become ever more present, and cardioselective beta-blockers should not be withheld from patients with COPD and coexistent CHF, because the benefits outweigh the risks.

Care of the Post-CABG Patient An estimated 400,000 coronary artery bypass graft operations are performed annually in the United States. Saphenous vein grafts are the most commonly used conduits; however, graft failure is common. In contrast, left internal mammary artery grafts have more favorable long-term patency rates. Guidelines recommend aggressive secondary prevention. In the 2 decades following surgery, 16% of patients require repeat revascularization, and percutaneous coronary intervention accounts for 98% of procedures performed. Post-coronary artery bypass graft patients presenting with symptoms of acute coronary syndrome or progressive heart failure should undergo early coronary angiography given the high likelihood that such a presentation represents graft failure. Percutaneous coronary intervention in degenerated saphenous vein grafts is associated with embolization that may cause the “no-reflow phenomenon,” which can be avoided with the use of embolic protection devices. Hybrid revascularization procedures are a promising emerging strategy to avoid the placement of vein grafts.

Right Heart Catheterization-Related Complications: A Review of the Literature and Best Practices Right heart catheterization (RHC) is considered to be the gold standard for the measurement of pulmonary artery pressure and has a class 1 indication to confirm the diagnosis of pulmonary arterial hypertension and to guide treatment decisions. Associated complications with RHC in contemporary practice are uncommon. In this review, we aim to summarize the complications that have been published in case reports or case series with updated management and techniques to prevent and mitigate complications. We searched the PubMed database for the following reports: “right heart catheterization,” “Swan-Ganz catheter,” “pulmonary artery catheter,” “balloon-tip catheter,” and “complication” or “adverse event.” Complications reported in 46 manuscripts were included in the final analysis. After evaluation of all reports, complications were grouped categorically. We found that the most commonly reported access site-related issues were either carotid artery injury or arteriovenous fistula formation, and injury to the tricuspid valve was the most commonly reported catheter-related complication. Our findings suggest that infrequent complications can occur with RHC and can be fatal. The optimal technique should be used to minimize complications. Operators should always be cautious during the procedure and monitor the patient closely.

Left Atrial Appendage Occlusion in the Management of Stroke in Patients With Atrial Fibrillation Atrial fibrillation (AF) is associated with a substantially higher risk of thromboembolism, particularly stroke events, resulting in significant morbidity and mortality. Oral anticoagulation (OAC), while effective in reducing embolic events in AF patients, is associated with an increased bleeding risk. Thus, not all patients with AF are candidates for OAC and some are only candidates for OAC in the short term. Of the available nonpharmacologic strategies for the management of AF, left atrial appendage occlusion (LAAO) has emerged as a potential approach for reducing the risk of systemic thromboembolism in AF patients eligible for OAC. LAAO can be achieved either surgically or percutaneously using an epicardial, endocardial, or a combined approach. Although available data are limited, currently available LAAO devices, and those being developed, have shown promise in reducing bleeding risk in AF patients because of the reduced overall need for anticoagulation, while maintaining efficacy in preventing thromboembolism. The optimal device will reduce both embolic and hemorrhagic strokes, and other bleeds, with a high implant success rate and a low complication rate. Until that time, anticoagulation remains the gold standard that these devices strive to surpass, and thus LAAO devices are currently indicated in patients with relative contraindication to OAC therapy.

Functional Mitral Regurgitation in Heart Failure. Erratum. No abstract available