Coronary arteriovenous fistulas (CAFs) are abnormal communications between coronary arteries and cardiac chambers or great vessels. They are usually congenital but may be acquired after trauma, surgery, or percutaneous p...Coronary arteriovenous fistulas (CAFs) are abnormal communications between coronary arteries and cardiac chambers or great vessels. They are usually congenital but may be acquired after trauma, surgery, or percutaneous procedures. Although often incidental in childhood, hemodynamically significant CAFs in adults can cause myocardial ischemia, arrhythmia, heart failure, or endarteritis. Evidence to guide management is limited, and multidisciplinary evaluation at centers experienced in both percutaneous and surgical approaches is recommended. A 60-year-old man with hypertension and prior left anterior descending coronary artery stenting presented with worsening chest pain that progressed to unstable angina. A coronary angiogram showed a new middle right coronary artery stenosis that was treated with a stent. Coronary angiography identified a high-flow fistula from the proximal right coronary artery draining into the superior vena cava. Persistent symptoms, right-sided chamber enlargement, and a Qp:Qs of 1.5 indicated a significant shunt and functional ischemia from coronary steal. Initial attempts to deploy a 6-mm Amplatzer Vascular Plug II failed due to inadequate catheter support across a tortuous tract. An anchoring balloon technique aid, permitting delivery and successful deployment of the AVP II at the arterial origin with complete angiographic occlusion. CAFs are a rare but treatable cause of angina and myocardial ischemia. Management should be individualized and planned by a multidisciplinary Heart Team. Transcatheter closure is effective in suitable anatomies, and balloon-assisted anchoring is a useful technique to facilitate device delivery in elongated or tortuous fistulas.
Hypertension is the most prevalent risk factor for heart failure (HF) and a primary driver of HF with preserved ejection fraction (HFpEF). Chronic pressure overload in hypertensive heart disease leads to left ventricular...Hypertension is the most prevalent risk factor for heart failure (HF) and a primary driver of HF with preserved ejection fraction (HFpEF). Chronic pressure overload in hypertensive heart disease leads to left ventricular hypertrophy, myocardial fibrosis, and diastolic dysfunction, which eventually cause elevated filling pressures and HF symptoms despite preserved systolic function. Over the past decade, HFpEF has increasingly been recognized as a multi-system syndrome influenced by systemic inflammation, comorbidities, and metabolic factors. In hypertensive HFpEF, myocardial remodeling is further promoted by neurohormonal activation, endothelial dysfunction, and cardiometabolic stress. Blood pressure control also influences prognosis. Observational studies suggest a reverse J-curve relationship, and uncontrolled blood pressure is associated with adverse outcomes. Hypertensive HFpEF reflects the interaction of chronic pressure overload and cardiometabolic inflammation and requires integrated management that targets blood pressure, comorbidities, and myocardial remodeling.
Congenitally corrected transposition of great arteries (cc-TGA) is often accompanied by associated lesions with a wide spectrum of presentations. Traditionally, ventricular septal defects (VSDs) in such patients have bee...Congenitally corrected transposition of great arteries (cc-TGA) is often accompanied by associated lesions with a wide spectrum of presentations. Traditionally, ventricular septal defects (VSDs) in such patients have been managed surgically with either physiologic repair or, more recently, there is a paradigm shift towards anatomical repair, such as the double switch operation. Percutaneous VSD device closure in cc-TGA physiology is extremely rare, with only isolated case reports in the literature. The present case report highlights a 15-year-old female, previously diagnosed with cc-TGA with moderate right atrio-ventricular valve regurgitation (AVVR), who presented to us with a history of shortness of breath for the last 1 year. The presence of perimembranous VSD with VSD jet directed towards the right atrioventricular (AV) valve, leading to moderate right AVVR, was identified during detailed evaluation. Cardiac catheterization was undertaken for better visualization and hemodynamic assessment, which revealed sub-systemic morphological left ventricle pressures and a device suitable VSD anatomy. Considering physiologic repair, VSD device closure was done in the same setting. The procedure was adapted to account for the altered cardiac anatomy by adjusting the fluoroscopic angles and wire-torquing manoeuvres. A KONAR-Multifunctional Occluder device (MFO) 10 × 8 mm was successfully deployed via an antegrade approach without complications utilizing hemodynamic and echocardiographic guidance, with good follow-up outcomes. Our case underscores the unique challenges of this complex cardiac anatomy and suggests technical modifications for successful percutaneous VSD closure. In conclusion, VSD device closure in atypical scenarios like cc-TGA can be a safe and feasible option for physiologic repair in selected cases.
During hospitalization, patients with acute heart failure (AHF) may progress to low cardiac output syndrome (LCOS) or cardiogenic shock (CS). However, the predictive factors for this evolution are not clearly defined. To...During hospitalization, patients with acute heart failure (AHF) may progress to low cardiac output syndrome (LCOS) or cardiogenic shock (CS). However, the predictive factors for this evolution are not clearly defined. To evaluate the frequency of progression to LCOS or CS in patients hospitalized for AHF and to identify predictive factors of this progression among clinical, echocardiographic, and laboratory parameters obtained at admission. A single-center cohort study was conducted, performing a retrospective analysis of prospectively collected data from consecutive patients admitted for AHF between 2015 and 2020. The primary endpoint was the occurrence of LCOS or SCAI (Society for Cardiovascular Angiography and Interventions) stage C to E CS during the index hospitalization. Logistic regression models adjusted for age and sex were used to determine the association between predictive factors and the occurrence of the primary endpoint. A total of 748 patients were included, with a mean age of 76 ± 11.7 years, 63.6% of whom were men. Coronary artery disease accounted for 34.5% of the etiology of heart failure (HF), and 36.9% of the patients had a previous hospitalization for HF. The median left ventricular ejection fraction (LVEF) was 46% (interquartile range 41, 60), and reduced LVEF <40% accounted for 40.5% of cases. The primary endpoint occurred in 22.33% of the cohort (n = 167). In-hospital mortality was 38.9% in patients who developed LCOS or CS, compared to 4.5% in those who did not (p < 0.001). Systolic blood pressure at admission for every 10 mmHg decrease (odds ratio [OR] 1.25, 95% confidence intervals [CI] 1.12-1.40, p < 0.001), estimated creatinine clearance <60 ml/min/m (OR 1.99, 95% CI 1.27-3.13, p = 0.003), LVEF <40% (OR 1.65, 95% CI 1.11-2.45, p = 0.013), and TAPSE (tricuspid annular plane systolic excursion) <18 mm (OR 2.05, 95% CI 1.39-3.02, p < 0.001) were significant predictors of progression to LCOS or CS. In a cohort of patients hospitalized for AHF, systolic blood pressure, estimated creatinine clearance <60 ml/min/m, LVEF <40%, and TAPSE <18 mm were identified as predictive factors for progression to CS or LCOS. These simple, widely available parameters obtained at the time of admission may allow for early identification of at-risk patients and could impact management and treatment strategies. However, additional prospective studies are needed to validate these findings and confirm their clinical utility in routine practice.
Resistance exercise in hypertrophic cardiomyopathy (HCM) remains underexplored. Yet, it has traditionally been restricted due to hypothesized deleterious effects. This single-center pilot study evaluated the acute effect...Resistance exercise in hypertrophic cardiomyopathy (HCM) remains underexplored. Yet, it has traditionally been restricted due to hypothesized deleterious effects. This single-center pilot study evaluated the acute effects of resistance exercise on left ventricular outflow tract (LVOT) gradient. One-repetition maximum (1RM) was determined for upright chest press and leg press exercises. In a subsequent session, patients completed 8 to 12 repetitions at 40%1RM and 2 repetitions at 80%1RM under 3 breathing conditions: no instructions, with Valsalva, and without Valsalva. LVOT gradients were measured at baseline, during, and immediately after exercise. Medication regimens were not altered. 24 patients (18 obstructive) were included. No individual with nonobstructive HCM developed obstruction during or immediately after resistance activity, even at higher intensities. Patients with obstructive HCM and baseline gradients <50 mmHg while on medical therapy exhibited only modest and likely clinically irrelevant increases in gradients during and after resistance efforts. Among those with higher resting gradients (≥50 mmHg), responses were variable depending on the type and intensity of exercise, but most did not experience significant increase in gradients. Importantly, no patient developed symptoms, drop in blood pressure, or arrhythmias during or after the exercises. There was also no consistent difference in gradient magnitude during versus immediately postexercise. Higher-intensity exercise with fewer repetitions did not produce larger increases in gradients. Different breathing instructions during lifting did not produce consistent changes in gradients. In conclusion, resistance exercise was not associated with clinically significant acute increases in LVOT gradient in patients with nonobstructive HCM and in most treated patients with obstructive HCM, including those with high resting gradients. Variability in individual responses supports the need for personalized exercise prescriptions.
Cardiovascular disease (CVD) is the leading cause of death in the United States and a major driver of healthcare spending. Combined direct costs, such as hospitalizations, procedures, and medications, with indirect costs...Cardiovascular disease (CVD) is the leading cause of death in the United States and a major driver of healthcare spending. Combined direct costs, such as hospitalizations, procedures, and medications, with indirect costs from lost productivity and caregiving, exceed $500 billion each year and are expected to surpass $1 trillion by 2035. Wide cost variation across health systems underscores inefficiencies and inequities. Women, older adults, and racial and ethnic minorities bear a disproportionate financial burden, which worsens existing health disparities. In conclusion, addressing this crisis requires a comprehensive approach that emphasizes prevention, equitable access, value-based care, and the reduction of waste through streamlined administration and fair pricing. Sustainable strategies are essential to improve outcomes, contain costs, and narrow disparities as the prevalence of cardiovascular disease continues to rise.
Tremendous progress has been made in the knowledge of the pathophysiology of atrial fibrillation (AF). However, the evolution of antiarrhythmic drug (AAD) use has stagnated. Many healthcare professionals (HCPs) have limi...Tremendous progress has been made in the knowledge of the pathophysiology of atrial fibrillation (AF). However, the evolution of antiarrhythmic drug (AAD) use has stagnated. Many healthcare professionals (HCPs) have limited familiarity with these agents and remain unsure when to initiate and use AADs, partially driven by misunderstandings regarding the effectiveness and safety profiles of AADs. In this review, we focus on the unmet needs of AAD use, including the requirement for a patient-centered approach to AF management, how lifestyle and risk factor modifications can complement pharmacological intervention with AADs, and the benefits of shared decision-making between patients and HCPs. Additionally, the populations of people with AF for whom AADs may be most beneficial are discussed along with the role of AADs as an adjunctive component to other medical strategies for AF management. Lastly, we explore what future data are needed to better guide the use of AADs in managing AF.
Long COVID refers to persistent sequelae following SARS-CoV-2 infection, and sex-specific cardiovascular outcomes among hospitalized patients remain incompletely characterized. We queried the 2022 National Inpatient Samp...Long COVID refers to persistent sequelae following SARS-CoV-2 infection, and sex-specific cardiovascular outcomes among hospitalized patients remain incompletely characterized. We queried the 2022 National Inpatient Sample (NIS) to identify adult hospitalizations with a diagnosis of long COVID (ICD-10 U09.9), excluding patients younger than 18 years or with missing outcome data. Analyses incorporated NIS discharge weights to generate national estimates. Multivariable (survey-weighted) logistic regression was used to estimate adjusted odds ratios (aORs) for cardiovascular diagnoses and in-hospital mortality. Among 87,415 weighted hospitalizations for long COVID, 49.4% were male, and 50.6% were female. Males had more complicated hypertension, coagulopathy, and alcohol use disorder, whereas females had higher rates of obesity, depression, and hypothyroidism (all p <0.05). Males had a higher in-hospital mortality rate (5.9% vs 4.7%, p <0.001). In adjusted analyses, females had lower odds of in-hospital mortality (aOR: 0.874 [95% CI 0.819-0.932]), cardiac arrhythmias (aOR: 0.652 [0.629-0.677]), venous thromboembolism (aOR: 0.846 [0.807-0.887]), and myocardial infarction (aOR: 0.767 [0.720-0.817]). Adjusted odds of ischemic cerebrovascular accident were not significantly different (aOR: 0.955 [0.795-1.146]). Females had higher odds of transient ischemic attack (aOR: 1.441 [1.067-1.945]). Median length of stay (5 vs 4 days) and total hospital charges ($50,447 vs $43,839) were lower in females (all p <0.001). In conclusion, in this nationally representative analysis of long COVID hospitalizations, sex-based differences were observed in cardiovascular diagnoses, mortality, and healthcare utilization, and these findings support sex-sensitive risk stratification and hypothesis generation for post-COVID care.
Cardiovascular biomarkers are established to guide diagnostic and prognostic evaluation in suspected coronary syndrome, but their role in cardiac stress testing remains debated. We evaluated their ability to discriminate...Cardiovascular biomarkers are established to guide diagnostic and prognostic evaluation in suspected coronary syndrome, but their role in cardiac stress testing remains debated. We evaluated their ability to discriminate positive and negative stress test results and predict major adverse cardiovascular events (MACE) in patients with suspected coronary artery disease (CAD). In a prospective cohort study patients undergoing cardiac stress testing for suspected CAD had baseline measurements of high-sensitivity cardiac troponin (hs-cTnI), high-sensitivity C-reactive protein, natriuretic peptides, and growth differentiation factor 15 (GDF-15). Hs-cTnI was remeasured 1 hour post-test. Diagnostic performance for predicting positive stress test results was evaluated using receiver operating characteristic curves and optimal cutoffs determined by Youden's index. Clinical outcomes were ascertained by phone/mail follow-up, hospital records, and verified through the local death registry, with a median follow-up of 2.8 years. Associations with MACE were examined using Cox regression models. Of 765 participants, 234 had positive stress and 531 had negative stress tests. Baseline hs-cTnI, natriuretic peptides, and GDF-15 were higher in pathological cases, but consistent with prior studies, all biomarkers showed poor discrimination for stress test results (area under a receiver-operating-curve < 0.65). Hs-cTnI concentrations slightly decreased after stress testing. During follow-up, 31% experienced MACE. Stress testing alone showed modest prediction of MACE, whereas the addition of hs-cTnI and GDF-15 demonstrated independent predictive value beyond conventional risk factors and stress test results. In conclusion, biomarkers poorly discriminated stress test results, but hs-cTnI and GDF-15 independently predicted incident MACE, suggesting their potential to improve risk stratification in high-risk patients with suspected CAD.
BACKGROUND: Early sodium glucose co-transporter 2 inhibitor initiation during acute heart failure (AHF) acutely improves measures of diuresis. Glucosuria from dapagliflozin decreases with declining estimated glomerular f...BACKGROUND: Early sodium glucose co-transporter 2 inhibitor initiation during acute heart failure (AHF) acutely improves measures of diuresis. Glucosuria from dapagliflozin decreases with declining estimated glomerular filtration rate (eGFR), and thus, the decongestive benefits may differ across eGFR. We investigated dapagliflozin's acute diuretic effects according to eGFR at randomization and the effects of dapagliflozin initiation on kidney function in AHF. METHODS: This pre-specified analysis of DICTATE-AHF evaluated 238 patients randomized within 24 hours of AHF hospital admission to dapagliflozin 10 mg daily or structured usual care, with protocolized IV diuretics in both groups. The role of eGFR at randomization as an effect modifier between weight loss, diuresis, and natriuresis per 40 mg IV furosemide and treatment assignment and changes in kidney function were assessed using proportional odds models. RESULTS: Median (IQR) eGFR at randomization was 53 (42 to 70) mL/min/1.73 m. eGFR at randomization did not modify dapagliflozin's treatment effect on diuretic efficiency assessed by weight loss (interaction p = 0.22), diuresis (interaction p = 0.23), or natriuresis (interaction p = 0.36). Dapagliflozin was not associated with a decrease in eGFR (p = 0.89), blood urea nitrogen (BUN) (p = 0.94), nor BUN/serum creatinine ratio (p = 0.41) from randomization to end-of-study. CONCLUSIONS: Early dapagliflozin initiation during AHF hospitalization is safe and similarly effective on acute diuretic measures across a wide range of eGFR. eGFR did not modify dapagliflozin's effects on weight loss, diuresis, and natriuresis. Dapagliflozin was not associated with worsening kidney function. TRIAL REGISTRATION: NCT04298229.
A significant proportion of patients referred to the cardiac catheterization laboratory for ischemia and/or angina do not have obstructive coronary arteries. This condition (INOCA and/or ANOCA, respectively) is frequentl...A significant proportion of patients referred to the cardiac catheterization laboratory for ischemia and/or angina do not have obstructive coronary arteries. This condition (INOCA and/or ANOCA, respectively) is frequently associated with coronary microvascular dysfunction (CMD). CMD causes myocardial ischemia, persistent symptoms, impaired quality of life, and increased healthcare utilization. Despite its clinical relevance, evidence-based therapeutic strategies remain limited, as prior studies regarding the treatment have been small and heterogeneous. Recently, an expert consensus proposed a standardized, stepwise management strategy for ANOCA/INOCA, built on the limited evidence currently available. However, the clinical effectiveness of this therapeutic algorithm has never been evaluated, either from a subjective perspective through patient-reported symptom burden or from an objective standpoint using invasive hemodynamic measurements. This prospective, single-center study aims to evaluate whether the state-of-the-art treatment recommended by the EAPCI Expert Consensus Document improves invasive measures of coronary microcirculation and symptoms in patients with ANOCA/INOCA. A total of 40 patients with angina, and objective evidence of ischemia on non-invasive testing, and CMD confirmed by continuous intracoronary thermodilution (coronary flow reserve ≤2.5) will be enrolled. Patients will receive sequential pharmacological therapy in 3 stages: (1) statins, beta-blockers, and ACE inhibitors; (2) conditional addition of a calcium channel blocker in case of persistent angina or pathological exercise treadmill test; and (3) conditional addition of ranolazine in case of persistent angina or pathological exercise treadmill test. At baseline and after each treatment stage, symptoms and quality of life will be assessed using the Seattle Angina Questionnaire (SAQ-19) and the EuroQol-5D (EQ-5D-5L). Invasive reassessment will be performed once patients report complete symptom resolution or once the complete therapeutic algorithm has been completed. This study will provide the first prospective evaluation of a sequential, guideline-based pharmacological strategy in CMD using both objective physiological measures and patient-centered outcomes. Findings may inform future guideline recommendations, improve clinical management of ANOCA/INOCA, and advance personalized treatment approaches in this understudied population.
Despite guideline recommendations, cardiac surveillance rates remain suboptimal for cancer patients exposed to potentially cardiotoxic treatments. The role of provider- and hospital-level factors in explaining suboptimal...Despite guideline recommendations, cardiac surveillance rates remain suboptimal for cancer patients exposed to potentially cardiotoxic treatments. The role of provider- and hospital-level factors in explaining suboptimal monitoring rates is understudied, while this information is necessary for a contextualized understanding. We quantified the relationship between hospital-level factors and cardiac screening and monitoring following the initiation of potentially cardiotoxic treatments. This study used Surveillance, Epidemiology, and End Results-Medicare patient-level data linked with hospital-level data. We included patients aged 66+ years who received potentially cardiotoxic treatments, including anthracycline, anti-human epidermal growth factor receptor 2 agents, and immune checkpoint inhibitors, between January 1, 2014 and December 31, 2018. The study outcome included the following: (1) receipt of cardiac screening within 30 days prior to or on the date of treatment initiation, and (2) routine cardiac monitoring within 1 year after treatment. A total of 2,143 patients were identified. Among those treated with anti-human epidermal growth factor receptor 2 therapy, anthracyclines, and immune checkpoint inhibitors, the proportions receiving cardiac screening at baseline were 54%, 58%, and 11%, respectively. Provider-level factors and hospital-level factors accounted for 12% and 3% of the variation in cardiac screening at baseline, respectively. Less than 1% of patients received routine monitoring following the initiation of potentially cardiotoxic treatments. In conclusion, these findings suggested that provider-level factors played a larger role in cardiac surveillance gaps than hospital-level factors. Interventions targeting clinician decision-making may be necessary to improve adherence to guideline-recommended cardiac monitoring.
Prosthetic valve thrombosis (PVT) remains one of the most serious and potentially life-threatening complications of mechanical heart valves and continues to pose a major clinical challenge worldwide. Its incidence varies...Prosthetic valve thrombosis (PVT) remains one of the most serious and potentially life-threatening complications of mechanical heart valves and continues to pose a major clinical challenge worldwide. Its incidence varies widely depending on anticoagulation quality, valve type, and access to specialized care, with a higher burden in regions where rheumatic heart disease remains prevalent. Historically, urgent surgery was considered the standard therapy because it provides immediate restoration of valve function; however, operative mortality is significant, particularly in critically ill patients. Over the past decades, thrombolytic therapy has emerged as an effective alternative, with increasing evidence supporting carefully monitored regimens using recombinant tissue plasminogen activator. Advances in multimodal imaging, particularly transesophageal echocardiography (TEE), have improved diagnostic accuracy, patient selection, and treatment monitoring. Contemporary studies and randomized trials have demonstrated that slow and ultraslow low-dose alteplase protocols achieve high rates of valve function recovery with lower rates of embolic and hemorrhagic complications compared with historical regimens, challenging the traditional surgical-first paradigm in selected patients. Current guidelines increasingly recognize the role of thrombolysis as part of an individualized management strategy guided by thrombus characteristics, clinical status, and institutional expertise. In conclusion, contemporary evidence indicates that slow and ultraslow low-dose alteplase-based thrombolysis represents a safe and effective therapeutic option for many patients with PVT and has become an important component of modern management strategies.
Pulmonary artery intimal sarcomas are rare and very aggressive tumors, with variable presentation, and are often misdiagnosed as acute pulmonary embolisms or chronic thromboembolic pulmonary hypertension. We report a cas...Pulmonary artery intimal sarcomas are rare and very aggressive tumors, with variable presentation, and are often misdiagnosed as acute pulmonary embolisms or chronic thromboembolic pulmonary hypertension. We report a case of a 44-year-old man who presented after accidental smoke inhalation and was eventually diagnosed with PAIS, despite reporting no specific symptoms at the time of diagnosis.
Polygenic risk scores (PRS) summarize genetic variants associated with cardiovascular disease (CVD) risk. Socioeconomic status (SES) impacts CVD risk, but whether SES modifies genetic risk remains unclear. We investigate...Polygenic risk scores (PRS) summarize genetic variants associated with cardiovascular disease (CVD) risk. Socioeconomic status (SES) impacts CVD risk, but whether SES modifies genetic risk remains unclear. We investigated total and direct effects of the PRS for CVD on CVD events while accounting for SES and traditional risk factors. We followed UK Biobank participants recruited from 2006 to 2010 through 2022 with available PRS for CVD, SES (deprivation index, income, education), and cardiovascular risk factor data (diet, physical activity, smoking, sleep, body mass index, cholesterol, hbA1c, blood pressure). The primary outcome was first incident CVD event (myocardial infarction, heart failure, stroke, or CVD death). Competing-risk models were used to estimate total and direct effects of the PRS on CVD events after adjustment for age, sex, SES, and CVD risk factors. We additionally tested for interactions. Among 36,244 participants (mean age 55.3 ± 8.2 years; 53.6% female) with complete data, 1,900 (5.2%) experienced a CVD event. Each standard deviation increase in the PRS was associated with a higher risk of CVD events (HR 1.26, 95% CI 1.21 to 1.33), remaining significant after full adjustment (HR 1.23, 95% CI 1.18 to 1.29). Compared with the lowest-income group, participants with the highest income had 0.54 times the risk of a CVD event (HR 0.54, 95% CI 0.51 to 0.81). No significant interactions were observed. SES is independently associated with CVD events but does not modify genetic risk. CVD PRS remains directly associated with CVD after accounting for SES and traditional risk factors.