Showing papers in "Current Cardiology Reports in 2011"
TL;DR: The role of hypertriglyceridemia and its associated atherogenic lipoproteins in the pathogenesis of atherosclerosis, the relevance of a high TG level as a predictor of CVD, the cardiovascular outcomes from TG-lowering intervention trials, and the current guidelines for treating hypertrigonidemia are reviewed.
Abstract: Hypertriglyceridemia is a prevalent risk factor for cardiovascular disease (CVD) and increasingly important in the setting of current obesity and insulin resistance epidemics. High triglyceride (TG) levels are markers for several types of atherogenic lipoproteins. Patients who have hypertriglyceridemia may be at significant risk for CVD even if low-density lipoprotein cholesterol levels are at goal, and therefore warrant treatment that optimizes diet, reduces overweight, and promotes regular exercise. High-risk patients with hypertriglyceridemia, such as those with diabetes, CVD, or metabolic syndrome, may benefit from additional drug treatment aside from a statin to address other lipid abnormalities. In this discussion, we review the role of hypertriglyceridemia and its associated atherogenic lipoproteins in the pathogenesis of atherosclerosis, the relevance of a high TG level as a predictor of CVD, the cardiovascular outcomes from TG-lowering intervention trials, and the current guidelines for treating hypertriglyceridemia.
309 citations
207 citations
TL;DR: The purpose of this review is to present an update on the present state of knowledge with regard to diagnosis, prognosis, and prevention of PPM.
Abstract: Prosthesis-patient mismatch (PPM) is present when the effective orifice area of the inserted prosthetic valve is too small in relation to body size. Its main hemodynamic consequence is to generate higher than expected gradients through normally functioning prosthetic valves. The purpose of this review is to present an update on the present state of knowledge with regard to diagnosis, prognosis, and prevention of PPM. PPM is a frequent occurrence (20% to 70% of aortic valve replacements) that has been shown to be associated with worse hemodynamics, less regression of left ventricular hypertrophy, more cardiac events, and lower survival. Moreover, as opposed to most other risk factors, PPM can largely be prevented by using a prospective strategy at the time of operation.
73 citations
TL;DR: Risk scoring tools have been developed from clinical databases to predict expected patient mortality from cardiac surgical procedures and are effective models for predicting risk, with the STS-PROM being more accurate in high-risk patients.
Abstract: Risk scoring tools have been developed from clinical databases to predict expected patient mortality from cardiac surgical procedures. The risk algorithms have been developed and validated from variables that have been demonstrated to be predictive of mortality. At least six risk models have been developed from different databases measuring outcomes of cardiac surgery. These algorithms have then been used to select very high risk patients for conventional aortic valve replacement (AVR) who would be appropriate candidates for transcatheter aortic valve implantation (TAVI). The two most common risk models used for TAVI selection are the logistic EuroSCORE (LES) and the Society of Thoracic Surgeons Predicted Risk of Mortality (STS-PROM) algorithms. Although both models are accurate in predicting mortality in low-risk patients, the LES has been clearly demonstrated to overpredict expected mortality by a factor of three in high-risk candidates for AVR. Various factors that also impact mortality but are not included in either algorithm include liver disease, frailty, porcelain aorta, and previous radiation. Despite these shortcomings, risk algorithms are effective models for predicting risk, with the STS-PROM being more accurate in high-risk patients. Ultimately, a new risk algorithm specific for TAVI will need to be developed once sufficient databases are developed.
60 citations
TL;DR: The development of tissue-engineered mitral valves can build on knowledge derived from engineering semilunar valves, but the mitral valve will present its own unique challenges as investigators move toward a first-generation prototype.
Abstract: There are compelling reasons to develop a tissue-engineered mitral valve, but this endeavor has not received the same attention as tissue engineering strategies for the semilunar valves. Challenges in regenerating a mitral valve include recapitulating the complex heterogeneity in terms of anatomy (differently sized leaflets, numerous chordae), extracellular matrix composition, biomechanical behavior, valvular interstitial cell and endothelial cell phenotypes, and interior vasculature and innervation. It will also be essential to restore the functional relationships between the native mitral valve and left ventricle. A growing amount of information relevant to tissue engineering a mitral valve has been recently collected through investigations of cell mechanobiology and collagen organization. It is hoped that the development of tissue-engineered mitral valves can build on knowledge derived from engineering semilunar valves, but the mitral valve will present its own unique challenges as investigators move toward a first-generation prototype.
57 citations
TL;DR: Physicians should be aware of the various elements that may influence a patient’s likelihood to take statin medications to improve adherence and provide the best possible patient outcomes.
Abstract: Statin therapy plays a central role in decreasing the morbidity and mortality associated with cardiovascular disease. However, prescribed statins are only effective if they are taken by patients on a regular basis, known as medication adherence. The factors that influence patient adherence to statin therapy can be categorized into patient factors, physician factors, and health system factors, often with interactions between the categories. Patient factors include demographics, socioeconomic status, comorbidities, and side effects. Physician factors include the physician's own adherence to applying guideline recommendations, office visits, and their interactions with patients. Health system factors include issues such as cost and access to care. Physicians should be aware of the various elements that may influence a patient's likelihood to take statin medications to improve adherence and provide the best possible patient outcomes.
54 citations
TL;DR: The current status of 3DE for the assessment of TV morphology and function, with its clinical applications and current limitations, as well as its potential implications for designing TV repair techniques are summarized.
Abstract: Tricuspid valve (TV) disease commonly occurs in combination with left-sided heart disease. Despite the growing enthusiasm for developing novel minimally invasive therapies for the mitral or aortic valve, the TV disease formerly received less attention and was frequently left untreated. Strong evidence has increased the awareness of the impact of severe TV regurgitation on patient survival, functional capacity, and surgical risk. Preoperative TV accurate description is challenging because, unlike left-sided valves, a complete visualization of tricuspid annulus and all three leaflets in one view is routinely impossible by two-dimensional transthoracic or transesophageal echocardiography. Three-dimensional echocardiography (3DE) with its unrestricted imaging capabilities has sparked significant research interest for a better understanding and improved treatment of valvular heart disease. This review summarizes the current status of 3DE for the assessment of TV morphology and function, with its clinical applications and current limitations, as well as its potential implications for designing TV repair techniques.
49 citations
TL;DR: Understanding of LDL metabolism has improved over the last years and an increasing number of potential novel targets for therapy have been recently identified and some of these emerging therapies have proven to be effective in lowering plasma LDL-C levels and are as such expected to have beneficial effects on CVD.
Abstract: Patients suffering from familial hypercholesterolemia (FH) are characterized by increased plasma levels of low-density lipoprotein cholesterol (LDL-C) levels and are at increased risk for premature cardiovascular disease (CVD). Current guidelines emphasize the need to aggressively lower LDL-C in FH patients, and statins are the cornerstone in the current regimen. However, additional therapies are eagerly awaited, especially for those patients not tolerating statin therapy or not reaching the goals for therapy. Our understanding of LDL metabolism has improved over the last years and an increasing number of potential novel targets for therapy have been recently identified. Apart from novel targets, we have also been confronted with novel modalities of treatment, such as mRNA antisense therapy. Some of these emerging therapies have proven to be effective in lowering plasma LDL-C levels and are as such expected to have beneficial effects on CVD. Hopefully, they will enrich our armamentarium against the severe dyslipidemia observed in FH patients in the not too distant future.
47 citations
TL;DR: Although imaging of coronary inflammation with FDG-PET holds tremendous promise, several hurdles remain to be surmounted prior to widespread clinical application.
Abstract: Conventional algorithms and noninvasive imaging tests for the identification of stable, hemodynamically significant coronary artery disease offer little insight into the detection of potentially vulnerable and inflamed coronary plaques, those most likely to rupture and cause acute coronary syndromes. Positron emission tomography (PET) with fluorodeoxyglucose (FDG) serves as a potential novel modality for the identification of plaque inflammation, as initial studies in animal and human studies have demonstrated that FDG uptake correlates with macrophage accumulation and inflammation. Therapy with anti-inflammatory agents has also been demonstrated in the arterial vasculature to reduce plaque FDG uptake. Although imaging of coronary inflammation with FDG-PET holds tremendous promise, several hurdles remain to be surmounted prior to widespread clinical application.
37 citations
TL;DR: Assessment of RV function in the context of RV physiology is discussed, including physical examination, catheterization, conventional contrast and radionuclide angiography, nuclear perfusion scintigraphy, cardiac CT, MRI, echocardiography, and positron emission tomography.
Abstract: Right ventricular (RV) function is a powerful prognostic factor in congestive heart failure and pulmonary hypertension, but assessing RV function is a challenge because of the right ventricle's complex geometry, its extreme sensitivity to loading conditions, and a limited understanding of underlying mechanisms of right heart failure. At present, a single widely accepted and generally applicable index of RV function is not available. Current approaches to assessment of RV function include physical examination, catheterization, conventional contrast and radionuclide angiography, nuclear perfusion scintigraphy, cardiac CT, MRI, echocardiography, and positron emission tomography. This review will discuss assessment of RV function in the context of RV physiology.
33 citations
TL;DR: The LAA structure and its potential contribution to ischemic stroke is reviewed; the results of surgical and endovascular trials of LAA occlusion on risk of stroke and adverse events in AF patients are discussed; and early data on devices in development are presented.
Abstract: The left atrial appendage (LAA) is the primary nonvalvular cause of cardioembolic stroke in patients with atrial fibrillation (AF). Warfarin and direct thrombin inhibitors such as dabigatran are presumed to prevent formation of LAA thrombus, and are first-line treatments to prevent ischemic stroke in AF. However, these medications carry many contraindications such as hemorrhage, and can interact with many drugs and supplements. Epicardial and endovascular techniques for occlusion of LAA are being explored, whether to mitigate the need for anticoagulation in patients at risk of bleeding or as a first-line therapy to reduce the risk of thromboembolic stroke. The purposes of this article are to 1) review the LAA structure and its potential contribution to ischemic stroke; 2) discuss the results of surgical and endovascular trials of LAA occlusion on risk of stroke and adverse events in AF patients; and 3) present early data on devices in development.
TL;DR: Systemically reviews factors that can potentially affect H/M ratio, particularly the acquisition parameters, and proposes new approaches and/or procedures to standardize the imaging procedure and minimize the variation of H/m among institutions.
Abstract: Studies have repeatedly shown the utility of 123I-mIBG cardiac sympathetic imaging for identifying symptomatic heart failure patients most likely to experience adverse cardiac events. Delayed heart-to-mediastinal ratio (H/M) and washout rate derived from meta-iodobenzylguanidine (mIBG) scintigraphy have been used to monitor response to medical treatment. However, there is great variation of H/M ratio among publications from various institutions. The current article systemically reviews factors that can potentially affect H/M ratio, particularly the acquisition parameters, and proposes new approaches and/or procedures to standardize the imaging procedure and minimize the variation of H/M among institutions.
TL;DR: Positron emission tomography imaging of atherosclerosis using the metabolic marker fluorodeoxyglucose allows quantification of arterial inflammation across multiple vessels, and the rationale, utility, potential future applications, and limitations are discussed.
Abstract: The underlying pathologic mechanism of most acute coronary syndromes is atherosclerotic plaque rupture. One cause of rupture is plaque inflammation, leading to fibrous cap destabilization. Several imaging techniques, including x-ray coronary angiography and multislice CT, can be used for the detection of coronary atherosclerosis. However, these anatomical methods cannot measure arterial inflammation. Positron emission tomography imaging of atherosclerosis using the metabolic marker fluorodeoxyglucose allows quantification of arterial inflammation across multiple vessels. This review discusses the rationale, utility, potential future applications, and limitations of this emerging biomarker of cardiovascular risk.
TL;DR: The most current evidence supporting the different strategies to reduce thromboembolic risk before, during, and after catheter ablation for AF is reviewed.
Abstract: Periprocedural thromboembolic and hemorrhagic events are complications of percutaneous radiofrequency catheter ablation (RFA) of atrial fibrillation (AF). The management of anticoagulation before and after RFA could play an important role in the prevention of these complications. The incidence of thromboembolic events varies from 1% to 5%, depending on the ablation and the anticoagulation strategy used in the periprocedural period. The scientific evidence behind the management of anticoagulation in patients with AF undergoing RFA is scarce and is mostly based on small studies and experts' consensus. It remains unclear whether catheter ablation for AF reduces the risk of stroke and obviates the need for anticoagulation after the procedure. Limited data are available regarding the risk of thromboembolism with and without warfarin after AF ablation. In this review we will review the most current evidence supporting the different strategies to reduce thromboembolic risk before, during, and after catheter ablation for AF.
TL;DR: The current data regarding genotype-phenotype correlations and the role of clinical genetic testing in diagnosis, prognosis, and management of inheritable disorders leading to sudden cardiac death are reviewed.
Abstract: Advances in genetic testing technology have led to a proliferation of new genetic tests and accelerated developments in the field of cardiovascular genetic medicine. These advances enhance presymptomatic diagnosis and can establish a definitive molecular diagnosis for symptomatic patients at risk for sudden cardiac death. Most importantly, genotype-phenotype correlations can add important information for predicting outcome and selecting treatment for patients with inherited arrhythmic disorders. This paper reviews the current data regarding genotype-phenotype correlations and the role of clinical genetic testing in diagnosis, prognosis, and management of inheritable disorders leading to sudden cardiac death.
TL;DR: With the increasing numbers of cardiac implantable devices in use, lead extraction has become a critical procedure in remedying device-related infections and complications and patient preparation and in-place laboratory protocols are important for the prevention of complications.
Abstract: With the increasing numbers of cardiac implantable devices in use, lead extraction has become a critical procedure in remedying device-related infections and complications. Lead extraction technology has grown considerably over the past two decades from simple traction maneuvers to the use of powered, telescoping sheaths equipped with laser technology. Data from single center experiences and randomized control trials have continued to demonstrate the safety and efficacy of the most current lead extraction technology. Still, major complications occur in less than 1% of patients. Patient preparation and in-place laboratory protocols are important for the prevention of complications and the rapid diagnosis and treatment of life-threatening complications should they arise.
TL;DR: This review discusses common mechanisms and clues to diagnosis of the various VTs, and current advances in ablation options, which have been complemented by newer approaches such as percutaneous epicardial ablation.
Abstract: Catheter ablation for patients with recurrent ventricular arrhythmias has emerged as an important and effective treatment option. The approach to ablation, and the risks and likely efficacy are determined by the nature of the severity and type of underlying heart disease. Although implantable defibrillators remain the corner stone for prevention of sudden cardiac death, ablation successfully reduces tachycardia recurrences and storms of ventricular arrhythmias triggering defibrillator shocks in patients with structural heart disease. Our understanding of idiopathic ventricular tachycardia (VT) has grown substantially with several new sites of VT origin recognized in recent years. Ablation is often curative for idiopathic VT. This review discusses common mechanisms and clues to diagnosis of the various VTs, and current advances in ablation options. In particular, endocardial ablation techniques have been complemented by newer approaches such as percutaneous epicardial ablation. In rare cases, transcoronary alcohol ablation can be effective for life-threatening arrhythmia.
TL;DR: A framework for identifying adult congenital heart disease patients most likely to benefit from genetic testing is suggested, along with a summary of current techniques for genetic testing, and the clinical and ethical challenges associated with genetic counseling are highlighted.
Abstract: New discoveries using high-resolution methods for detecting genetic aberrations indicate that the genetic contribution to congenital heart disease has been significantly underestimated in the past. DNA diagnostics have become more accessible and genetic test results are increasingly being used to guide clinical management. Adult congenital heart disease specialists seeking to counsel adults with congenital heart disease about the genetic aspects of their condition face the challenge of keeping abreast of new genetic techniques and discoveries. The emphasis of this review is on the genetic basis of structural cardiovascular defects. A framework for identifying adult congenital heart disease patients most likely to benefit from genetic testing is suggested, along with a summary of current techniques for genetic testing. The clinical and ethical challenges associated with genetic counseling are highlighted. Finally, emerging technologies and future directions in genetics and adult congenital heart disease are discussed.
TL;DR: In patients with BAV, the decision to indicate surgical treatment in aortic diameters between 50 and 55 mm should be based on patient age, body size, comorbidities, type of surgery, and the presence of additional risk factors.
Abstract: Bicuspid aortic valve (BAV) is the most common form of congenital heart disease, with frequent and premature occurrence of cardiac events, dominated by significant valvular dysfunction. BAV has a high prevalence of aortic wall abnormalities such as ascending aortic dilatation. Because more rapid aortic dilatation can occur, once the ascending aorta reaches 40 mm, annual imaging with echocardiography or other imaging techniques is indicated. The most feared complication is aortic dissection. However, the actual incidence of this complication is low (4%). Although limited data exist regarding prophylactic intervention, it is suggested that elective surgical repair of BAV-associated aortic dilatation should be more aggressively recommended. In patients with BAV, the decision to indicate surgical treatment in aortic diameters between 50 and 55 mm should be based on patient age, body size, comorbidities, type of surgery, and the presence of additional risk factors.
TL;DR: The consequences of long-lived radioisotopes in myocardial PET and the potential role of absolute blood flow quantification to establish efficient clinical protocols are discussed.
Abstract: Myocardial perfusion imaging is a widely used approach to noninvasively identify myocardial ischemia and guide therapies. It is typically performed using single photon emission computed tomography. The competing technology positron emission tomography (PET) offers higher diagnostic accuracies but suffers from logistical limitations due to the use of short-lived radioisotopes. New (18)F-labeled perfusion markers were introduced in the past years and offer simplified supply approaches, as known from oncologic PET imaging. This review summarizes the available literature especially from preclinical studies, but also very recent findings from early clinical trials. We discuss the consequences of long-lived radioisotopes in myocardial PET and the potential role of absolute blood flow quantification to establish efficient clinical protocols.
TL;DR: The absence of detectable calcification determines excellent cardiovascular prognosis, with event rates lower than that of negative stress studies, probably due to the latter’s inability to detect nonobstructive coronary artery disease (CAD).
Abstract: Calcium score (CS) is a useful tool in evaluating the risk of cardiovascular events in asymptomatic patients. The absence of detectable calcification determines excellent cardiovascular prognosis, with event rates lower than that of negative stress studies, probably due to the latter’s inability to detect nonobstructive coronary artery disease (CAD). There are few primary prevention medications that would be cost-effective in such a low-risk patient population. The interval for retesting patients with zero CS is still open for debate but it should not be in less than 4 to 5 years. CS should not be used to rule out obstructive CAD in symptomatic patients, as its correlation with coronary stenosis is poor and obstructive CAD is commonly found among symptomatic zero CS patients. Most studies have found very low specificity values for CS to detect obstructive CAD in symptomatic patients, meaning it has limited ability to detect the true negative cases (ie, zero CS without obstructive CAD).
TL;DR: Whether initial β blockers newer than atenolol reduce cardiovascular risk to the same extent as other antihypertensive drugs should be answered with more clinical trials.
Abstract: Although most guidelines committees historically recommended initial diuretics and/or β blockers for uncomplicated hypertension, clinical trial outcomes analyzed in the last 5 to 7 years have been suboptimal with atenolol, the world’s most popular β blocker. Several meta-analyses have suggested that despite lowering blood pressure, any and all β blockers inadequately protect hypertensive patients from cardiovascular events. These phenomena have been attributed to ineffective lowering of central aortic or inter-visit blood pressures, or adverse metabolic effects (particularly when combined with diuretics). Although there has never been a head-to-head comparison of atenolol with any other β blocker in hypertensive patients, indirect comparisons can be done with network and Bayesian meta-analyses, which suggest that heterogeneity of β-blockers’ pharmacology also extends to outcomes. Although once-daily atenolol as initial antihypertensive therapy may be unwise, whether initial β blockers newer than atenolol reduce cardiovascular risk to the same extent as other antihypertensive drugs should be answered with more clinical trials.
TL;DR: The CACS has been found to be a marker of vascular injury that correlates closely with overall atherosclerotic burden, whereas coronary CT angiography permits detection of noncalcified plaque coronary artery stenosis severity.
Abstract: Coronary heart disease is the leading cause of death worldwide, and has traditionally been assessed through a patient’s cardiovascular risk profile that is comprised of a combination of genetic, social, physiologic, and environmental factors. A growing discordance is being recognized in the ability of current risk estimation tools to predict outcomes versus that of actual measured outcomes. Exciting new improvements in technology have made noninvasive imaging modalities of the heart—in particular, coronary artery calcium score (CACS) and coronary computed tomography (CT) angiography—an increasingly important component in the diagnosis of ischemic heart disease. The CACS has been found to be a marker of vascular injury that correlates closely with overall atherosclerotic burden, whereas coronary CT angiography permits detection of noncalcified plaque coronary artery stenosis severity. A growing body of literature has developed detailing the valuable prognostic utility of these tests in the management of patients and how they may 1 day be used to complement current risk prediction models.
TL;DR: Patients exhibiting reduced clopidogrel metabolism and/or low clopIDogrel responsiveness have an increased rate of thrombotic events after percutaneous coronary intervention, and several trials are underway to demonstrate the potential utility of platelet reactivity testing with P2Y12-ADP receptor antagonists.
Abstract: P2Y12-ADP receptor antagonist use has been critical in the development of percutaneous coronary intervention, dramatically reducing the rate of early stent thrombosis. However, it recently was observed that a significant proportion of patients do not achieve optimal platelet reactivity inhibition after clopidogrel loading dose. The large interindividual variability in clopidogrel responsiveness is related to several factors, including the genetic polymorphism of hepatic cytochrome P450 2C19 (CYP2C19*2), which recently has been highlighted by a warning from the U.S. Food and Drug Administration. Of importance, patients exhibiting reduced clopidogrel metabolism and/or low clopidogrel responsiveness (ie, high on-treatment platelet reactivity) have an increased rate of thrombotic events after percutaneous coronary intervention. This review summarizes the current knowledge on this important clinical issue. While the future of genetic testing remains undetermined, several trials are underway to demonstrate the potential utility of platelet reactivity testing with P2Y12-ADP receptor antagonists.
TL;DR: This brief article aims to provide a conceptual framework for evaluating the premise, promise, and potential limitations of both invasive antihypertensive therapies.
Abstract: Invasive device-based therapies for drug-resistant hypertension are undergoing active clinical investigation The two approaches are 1) permanent implantation of a carotid baroreceptor pacemaker and 2) radiofrequency catheter ablation of the renal nerves Both are designed to reduce the sympathetic nervous system component of drug-resistant hypertension Several excellent comprehensive articles have reviewed each of these devices separately In contrast, this brief article aims to provide a conceptual framework for evaluating the premise, promise, and potential limitations of both invasive antihypertensive therapies
TL;DR: The role of CMR is discussed giving particular emphasis to recent developments and the additional information that can be obtained with this imaging modality, over and above standard echocardiography, in patients with suspected or known HF.
Abstract: Imaging has a central role in the evaluation of patients with heart failure (HF). Cardiovascular magnetic resonance (CMR) is rapidly evolving as a versatile imaging modality that often provides additional information to echocardiography in patients with suspected or known HF. CMR is the only imaging modality that has the ability to assess, without exposure to ionizing radiation, cardiac function, structure (tissue characterization), perfusion, and viability. Moreover, magnetic resonance spectroscopy techniques can assess the pathophysiologic role of deranged cardiac energetics in HF. In this review we discuss the role of CMR in the evaluation of patients with HF giving particular emphasis to recent developments and the additional information that can be obtained with this imaging modality, over and above standard echocardiography.
TL;DR: The emerging concepts of the patient-empowered risk/benefit tradeoff between PCI and CABG to help personalize the choice of revascularization modality are also explored.
Abstract: Percutaneous coronary intervention (PCI) of multivessel and/or left main stem disease have been shown to be potentially legitimate revascularization alternatives in appropriately selected patients. Risk stratification is an important component in guiding patients to identify the most appropriate revascularization modality (PCI or coronary artery bypass grafting [CABG]) in conjunction with the Heart Team. The aim of this paper is to give the clinician a concise overview of the important established and evolving contemporary risk models in aiding this decision-making process. Risk models, based on clinical and anatomical variables alone, the novel concept of functional anatomical risk scores, and risk models combining aspects from both clinical and anatomical scores, are all discussed. The emerging concepts of the patient-empowered risk/benefit tradeoff between PCI and CABG to help personalize the choice of revascularization modality are also explored.
TL;DR: Several lines of experimental and clinical evidence suggest an independent and causal pathway for bleeding-associated cardiovascular risk, and interventions that might reduce such complications are now a major emphasis in the current era of ACS treatment.
Abstract: Recent studies have highlighted the critical importance of bleeding complications on prognosis in patients with acute coronary syndromes (ACS). In fact, the hazard for an adverse cardiovascular event associated with bleeding is similar to that of a myocardial infarction. Several bleeding risk scores are now available that reliably quantify the probability of an ACS patient experiencing a bleeding complication. Consistent and strong correlates of bleeding include older age, female sex, renal impairment, and an invasive management approach. Although patients who tend to bleed are usually more morbid compared with their non-bleeding counterparts, several lines of experimental and clinical evidence suggest an independent and causal pathway for bleeding-associated cardiovascular risk. Given the frequency and adverse prognosis associated with bleeding, interventions that might reduce such complications are now a major emphasis in the current era of ACS treatment. Recent trials have shown that several novel antithrombotics, bivalirudin and fondaparinux, reduce bleeding risk while maintaining efficacy in reducing ischemic events during ACS. Other promising strategies that continue to be tested include the use of vascular closure devices and transradial arterial access during percutaneous coronary intervention.
TL;DR: The edge-to-edge repair using the MitraClip transcatheter mitral repair system, simulating the surgical Alfieri stitch via percutaneous approach proved to be a safe and feasible technique.
Abstract: Percutaneous heart valve therapies are rapidly changing our approach to valvular heart diseases. Currently, mitral valve surgery is the treatment of choice for patients suffering from severe symptomatic mitral regurgitation. However surgery, because of its inherent risks, is not applicable to all patients, particularly for the elderly with comorbidities. Catheter-based mitral repair systems offer a new option to those high-risk patients. The edge-to-edge repair using the MitraClip device (Evalve, Menlo Park, CA), simulating the surgical Alfieri stitch via percutaneous approach proved to be a safe and feasible technique. This article discusses the currently available data for the MitraClip transcatheter mitral repair system.
TL;DR: There is a growing body of literature on the utility of CMR for patient risk stratification, and its potential role in important management decisions such as for cardiac resynchronization therapy and defibrillator placement.
Abstract: In patients with heart failure, cardiovascular magnetic resonance imaging (CMR) allows a multifaceted approach to cardiac evaluation by enabling an assessment of morphology, function, perfusion, viability, tissue characterization, and blood flow during a single comprehensive examination. Given its accuracy and reproducibility, many believe CMR is the reference standard for the noninvasive assessment of ventricular volumes, mass, and function, and offers an ideal means for the serial assessment of disease progression or treatment response in individual patients. Delayed-enhancement (DE)-CMR provides a direct assessment of myopathic processes. This permits a fundamentally different approach than that traditionally taken to ascertaining the etiology of cardiomyopathy, which is vital in patients with nonischemic cardiomyopathy and incidental coronary artery disease and patients with mixed, ischemic and nonischemic cardiomyopathy. Precise tissue characterization with DE-CMR also improves the diagnosis of left ventricular thrombus, for which it is the emerging clinical reference standard. There is a growing body of literature on the utility of CMR for patient risk stratification, and its potential role in important management decisions such as for cardiac resynchronization therapy and defibrillator placement.