Cardiology

Editorial introductions No abstract available

Diagnosis and management of low-flow, low-gradient aortic stenosis Purpose of review The severity of low-flow, low-gradient aortic stenosis cases continue to be misunderstood because of challenging diagnosis, and treatment remains complex. We discuss current diagnostic and treatment modalities for low-flow, low-gradient aortic stenosis. Recent findings This article summarizes current guidelines and best practices for the management of low-flow, low-gradient aortic stenosis. Summary Low-flow, low-gradient aortic stenosis is a difficult entity to diagnose and treat. Various diagnostic modalities are needed to accurately determine the severity of aortic stenosis and potential treatment benefit. True-severe classical and paradoxical low-flow, low-gradient aortic stenosis can be distinguished from pseudo-severe aortic stenosis by dobutamine stress echocardiography and/or multidetector computed tomography. Once the distinction is made, aortic valve replacement results in better outcomes compared with conservative management. Although both surgical and transcatheter aortic valve replacement result in adequate outcomes, the decision between the two treatment strategies is based on patient characteristics, valve morphology, and other risk factors.

Valve sparing root replacement: an update Purpose of review Until the year 2000, the publications concerning aortic valve sparing (AVS) did not exceed 20 articles; in the following years almost 300 publications have appeared. Over 35 years from the introduction of valve sparing techniques and 500 years after the death of Leonardo da Vinci, this review highlights the significant steps in modern imaging techniques and the excellent clinical results in the field of reconstructive aortic root surgery. Recent findings AVS operations underwent significant modifications over the last few years making it reproducible with satisfactory outcomes. The extraordinary potential of imaging opens new boundless horizons in the perspective of an increasingly patient-tailored surgical planning. The basic surgical concepts include the preservation and resuspension of the aortic valve in a near-normal environment (with the creation of functionally suited neo-aortic sinuses) and the re-establishment of a normal relationship of the aortic root components. Summary Today is possible to perform a reimplantation procedure with the creation of neo-sinuses or a remodeling procedure with the addition of annular support. Both procedures can now guarantee an anatomical root reconstruction and an increased long-term durability. AVS operations have become established alternatives to Bentall procedures for patients with aortic root pathology, especially in young patients.

Is there a problem with respect? Risk of neochordal rupture Purpose of review In this review, we summarize the history of mitral valve repair, discuss the broad principles of neochord preparation and implantation, and highlight comparative outcomes between mitral valve repair strategies while focusing on the risk of neochordal rupture. Recent findings There have been several recent studies comparing outcomes been leaflet-resection and nonresection, neochord-based mitral valve repair. Operative mortality was very low regardless of repair strategy; however, the rate of mitral valve reoperation is lower in those that undergo a neochord-based repair with overall lower mean mitral gradients postrepair. The introduction of minimally invasive approaches to mitral valve repair has preferentially favored an increase in neochord-based repair, given the technical simplicity compared with resection-based approaches. In very rare cases, neochord rupture can occur, likely secondary to a combination of chordal calcification and mechanical stress. Summary The method of performing mitral valve repair with neochord implantation has demonstrated superior durability over leaflet resection approaches with equivalent operative outcomes. Although the risk of neochord rupture exists, it is exceedingly rare, and should not be considered a limitation to a neochord-based mitral valve repair. Recurrent mitral regurgitation secondary to neochord rupture is incredibly rare; however, regular echocardiographic evaluation of these patients appears warranted, especially when follow-up extends over 10 years.

Surgical management of mitral annular calcification Purpose of review The aim of the article is to discuss different therapeutic options for patients with severe mitral valve dysfunction because of mitral annular calcification (MAC), including mitral valve repair, conventional mitral valve replacement, percutaneous transcatheter mitral valve replacement (TMVR), and hybrid procedures. Recent findings Optimal management of severe mitral valve disease because of MAC remains challenging. Various ‘resect’ or ‘respect’ repair strategies have been standardized and are applicable in eligible patients. Mitral valve replacement with a standard surgical bioprosthesis is often possible in nonrepair candidates, especially with noncircumferential MAC. TMVR has evolved as a feasible option for anatomically and/or clinically prohibitive open-surgery cases, with the caveat of strict anatomic eligibility criteria. Hybrid TMVR provides the advantages of both open-surgery and TMVR and has emerged as a promising alternative in select patients. Summary Surgical management of MAC and severe mitral valve disease continues to evolve. The addition of transcatheter valve options may benefit many patients previously considered inoperable and are now candidates for intervention. This review will summarize state-of-the-art management options for patients with MAC.

Speckle tracking echocardiography: imaging insights into the aorta Purpose of review Pathophysiologic changes of aortic tissue may not always manifest as aneurysms, nor does the size of an aneurysm necessarily represent the severity of tissue abnormality – approximately 40% of patients who present with dissection have aortic diameters below criteria recommended for surgical resection. Noninvasive imaging-based quantification of aortic biomechanics has the potential to improve our knowledge of the pathophysiology of aortic disease, including patient-specific risk-stratification and intraoperative surgical decision-making. Recent findings We summarize the current state of clinical utilization of two-dimensional speckle tracking echocardiography (2D-STE) aortic strain to better understand the pathophysiology, clinical implications, and risk stratification of aortic disease. Summary 2D-STE has demonstrated promising early results as an imaging modality to determine clinically relevant measures of aortic tissue mechanical properties. Further large multinational, multiethnic, age-stratified, and sex-stratified measures of normal aortic strain measurements, as well as comparison studies with alternative imaging techniques, will be needed to properly elucidate the role echocardiography will play in the clinical management of aortic disease.

Modes of bioprosthetic valve failure: a narrative review Purpose of review A thorough understanding of the modes of bioprosthetic valve failure is critical as clinicians will be facing an increasing number of patients presenting with failed bioprostheses in coming years. The purpose of this article is to review modes of bioprosthestic valve degeneration, their management, and identify gaps for future research. Recent findings Guidelines recommend monitoring hemodynamic performance of prosthetic valves using serial echocardiograms to determine valve function and presence of valve degeneration. Modes of bioprosthetic valve failure may be categorized as structural degeneration (calcification, tears, fibrosis, flail), nonstructural degeneration (pannus), thrombosis, and endocarditis. Calcification is the most common form of structural valve degeneration. Predictors of bioprosthetic valve failure include valves implanted in the mitral position, younger age, and type of valve (porcine versus bovine pericardial). Failed bioprosthetic valves are managed with either redo surgical replacement or transcatheter valve-in-valve implantation. Summary Several modes of bioprosthetic valve failure exist, which vary based on patient, implant position, and valve characteristics. Further research is required to characterize factors associated with early failure to delay structural valve degeneration and improve patient prognosis.

Iron deficiency in heart failure: getting to the guidelines Purpose of review Iron deficiency is a common condition affecting approximately 50% of patients with heart failure. The purpose of this review is to explore the impact of iron deficiency on patients’ quality of life and outcomes. Moreover, how intravenous replacement, even in the absence of anemia, can improve these outcomes. Recent findings The role of iron deficiency anemia has long been a part of assessing reversible and treatable contributors to patients’ symptoms in heart failure. Recent studies have demonstrated how vital identifying not only anemic patients but those who are iron deficient without anemia, may allow us to impact their quality of life by several different measures. The latter appears to be the case not only for reduced ejection fraction but also impacts patients with preserved ejection fraction who have very few other modalities which improve symptoms. Summary Iron deficiency in heart failure is common, and with improvements in diagnosis and management, it has led to a better understanding of the importance of iron deficiency in cardiac failure and function.

The risk and prevention of sudden death in patients with heart failure with reduced ejection fraction Purpose of review Patients with heart failure are at increased risk of sudden cardiac death. The methods to predict patients at high risk of sudden cardiac death in heart failure are neither sensitive nor specific; both overestimating risk in those with ejection fractions less than 35% and not identifying those at risk with ejection fractions greater than 35%. Recent findings The absolute risk of sudden cardiac death in patients with heart failure have decreased over the past 20 years. New novel tools are being developed and tested to identify those at higher risk of sudden cardiac death. Reduction in the risk of sudden cardiac death has been achieved with the use of beta-blockers, spironolactone, sacubitril–valsartan, cardiac resynchronization and implantable cardioverter defibrillators. Summary The use of contemporary treatments for patients with heart failure can reduce the risk of sudden cardiac death, but research is required to identify those at highest risk.

Mechanical circulatory support in cardiogenic shock Purpose of review Cardiogenic shock remains a complex clinical syndrome with high morbidity and mortality. The purpose of this article is to review important landmark trials as well as the relevant recent literature for percutaneous mechanical circulatory support following acute myocardial infarction. Recent findings The sole use of intraaortic balloon pumps for cardiogenic shock following acute myocardial infarction continues to be questioned with downgrading of its recommendation in recent years, there however may remain a role in patients with mechanical complications of their myocardial infarction. The combined use of extracorporeal circulatory support and a ventricular unloading device appears to be promising with increasing data supporting this strategy. Summary Given the complex and heterogeneous nature of cardiogenic shock there remains somewhat limited robust data to guide clinical practice. Ongoing research is needed to help guide improvements in patient outcomes.