Myocardial infarction with nonobstructive coronary arteries (MINOCA) refers to a clinical syndrome where a patient meets the criteria for acute MI, but coronary angiography shows no obstructive coronary artery disease. M...Myocardial infarction with nonobstructive coronary arteries (MINOCA) refers to a clinical syndrome where a patient meets the criteria for acute MI, but coronary angiography shows no obstructive coronary artery disease. MINOCA accounts for 6% to 8% of all myocardial infarctions and is more common in non-ST-elevation MI than ST-elevation MI. Up to 60% of cases of MINOCA are seen in women, which disproportionately affects younger and middle-aged women. Patients are typically younger than those with obstructive MI and have fewer traditional risk factors. Formal recognition aids the development of targeted research, standardized care, and improved outcomes.
Transthoracic echocardiography (TTE) plays the primary role in the assessment of patients with aortic stenosis (AS). Alternative imaging modalities are important for the confirmation of AS severity in patients with disco...Transthoracic echocardiography (TTE) plays the primary role in the assessment of patients with aortic stenosis (AS). Alternative imaging modalities are important for the confirmation of AS severity in patients with discordant AS or inadequate assessment by TTE. Multimodality imaging can inform prognosis in patients with AS. In this article, we discuss the role of multimodality imaging for accurate diagnosis of AS severity and assessment of prognosis to inform patient management. We provide an overview of the use of computed tomography for procedural planning for transcatheter aortic valve replacement.
In this article, the authors review the approach to infections associated with surgically placed leads, leads placed in unusual locations such as azygous veins, extraction of active fixation coronary sinus leads, and the...In this article, the authors review the approach to infections associated with surgically placed leads, leads placed in unusual locations such as azygous veins, extraction of active fixation coronary sinus leads, and the role of hybrid extractions in difficult cases. The authors also review strategies to mitigate the risk of paradoxic embolism among patients undergoing transvenous lead extraction.
Cardiac implantable electronic devices (CIEDs) can be lifesaving but complications associated with CIEDs can lead to significant morbidity and mortality. Effective techniques to remove these devices are critical to reduc...Cardiac implantable electronic devices (CIEDs) can be lifesaving but complications associated with CIEDs can lead to significant morbidity and mortality. Effective techniques to remove these devices are critical to reducing complications and improving quality of life. Percutaneous extraction techniques are effective for removing the majority of CIEDs but surgical lead extraction is still required in certain situations. Surgical lead extraction volumes are generally low at most centers but familiarity with the techniques and principles is important for maintaining a comprehensive lead management program. This review discusses indications and techniques for surgical lead extraction and considerations for device reimplantation.
Transvenous lead extraction is performed for device infection, lead failure, or to provide access for additional leads/device upgrade. A patient-centered risk assessment for transvenous lead extraction can be determined...Transvenous lead extraction is performed for device infection, lead failure, or to provide access for additional leads/device upgrade. A patient-centered risk assessment for transvenous lead extraction can be determined using a combination of clinical factors and several imaging modalities. Predicting a complex lead extraction, for example, one that will require powered tools or the use of a femoral approach, is aided by pre-procedural imaging and clinical assessment. Procedural imaging utilizing fluoroscopy, transesophageal echocardiography, and intracardiac echocardiography during an extraction can improve safety and identify complications rapidly.
With increasing volume of cardiac implantable electronic devices in the last decade, the indications for device extraction have increased. Multidisciplinary collaboration between cardiothoracic surgeons, cardiac anesthes...With increasing volume of cardiac implantable electronic devices in the last decade, the indications for device extraction have increased. Multidisciplinary collaboration between cardiothoracic surgeons, cardiac anesthesiologists, and cardiac electrophysiologists has been recognized as an essential pre-requisite in pre-procedural planning to limit complications from this inherently risky procedure. Fortunately, the tools and techniques have continued to evolve to make extraction safer and more effective. This article discusses traditional and non-traditional techniques for transvenous lead extraction in addition to retrieval of leadless pacemakers.
Cardiac implantable electronic devices (CIEDs) are being implanted at increasing rates. Patients with CIEDs require more lead management in contemporary clinical practice, given the increased survival of heart failure pa...Cardiac implantable electronic devices (CIEDs) are being implanted at increasing rates. Patients with CIEDs require more lead management in contemporary clinical practice, given the increased survival of heart failure patients. There are multiple indications for extraction with the strongest class I indications being in patients with CIED infections. Extraction with complete hardware removal is underutilized and often delayed when it is utilized in patients with CIED infections, resulting in higher mortality. Patient and provider preferences are critical to decision-making when considering extraction. Lead extraction referral and management care pathways are needed in order to optimize care for our patients with CIEDs.
Transvenous lead extraction (TLE) has evolved significantly since the introduction of cardiac pacing systems in the 1950s. The need for TLE has grown due to the increasing complexity of cardiac devices and patients, alon...Transvenous lead extraction (TLE) has evolved significantly since the introduction of cardiac pacing systems in the 1950s. The need for TLE has grown due to the increasing complexity of cardiac devices and patients, alongside rising infection rates and regulatory recalls. Despite its challenges, improved institutional support and advanced training programs have made TLE more accessible. Modern TLE indications are well-defined, evolving through scientific statements to include comprehensive lead management best practices and safety protocols. However, underutilization persists, particularly in infection management, highlighting the need for continued education and adherence to guidelines.
Cardiac implantable electronic device (CIED) infections are a highly morbid and potentially fatal complication of CIED implantation. Prompt diagnosis is paramount to the proper management of such infections. This review...Cardiac implantable electronic device (CIED) infections are a highly morbid and potentially fatal complication of CIED implantation. Prompt diagnosis is paramount to the proper management of such infections. This review seeks to highlight the pathophysiology, risk factors, diagnostic approach, and prevention strategies for CIED infection, with an emphasis on pocket infection. Management will be discussed in detail, with complete device removal representing the standard of case, but with conservative management representing a potential alternative for patients at high risk for extraction. The high prevalence of CIED in the cardiac population renders understanding of this subject essential for the practicing clinician.
The approach to a patient with a cardiac implantable electronic device (CIED) and bacteremia requires a high index of suspicion. The microorganism and duration of bacteremia affect the pretest probability of CIED infecti...The approach to a patient with a cardiac implantable electronic device (CIED) and bacteremia requires a high index of suspicion. The microorganism and duration of bacteremia affect the pretest probability of CIED infection. When transesophageal echocardiography findings are equivocal, fluorodeoxyglucose-PET/computed tomography can increase the sensitivity and specificity for CIED infection. Confirmed CIED infection warrants complete system extraction. In patients with persistent gram-positive bacteremia despite antimicrobial therapy and unclear involvement of the CIED, the device is sometimes empirically extracted. Long-term effects of extraction (such as risk of suboptimal/failed cardiac resynchronization therapy reimplant) should be factored into decisions regarding empiric CIED extraction.
Transvenous lead failure associated with cardiac pacing and defibrillation remains an important clinical problem, with an estimated incidence between 1 to 2%. Oversensing of non-physiological signals usually precede lead...Transvenous lead failure associated with cardiac pacing and defibrillation remains an important clinical problem, with an estimated incidence between 1 to 2%. Oversensing of non-physiological signals usually precede lead impedance changes and may result in clinical compliations such as pacing inhibition and inappropriate shocks. Device based algorithms that identify non-physiological signals can be used in conjunction with remote monitoring to facilitate early diagnosis and management of lead failure and avoid serious adverse outcomes. This review highlights mechanisms of lead failure and proposes a diagnostic approach to suspected lead failure.
Implantable cardioverter-defibrillators (ICDs) reduce sudden cardiac death (SCD) and improve survival in patients with a history of life-threatening arrhythmia or sudden cardiac arrest, and in select populations at high...Implantable cardioverter-defibrillators (ICDs) reduce sudden cardiac death (SCD) and improve survival in patients with a history of life-threatening arrhythmia or sudden cardiac arrest, and in select populations at high risk of SCD due to ventricular arrhythmias. However, patients with ICDs may receive inappropriate or unnecessary shocks, which have been associated with pro-arrhythmia, psychological sequelae, poor quality of life, and increased mortality. The benefits and risks of ICD therapy are therefore directly impacted on by physician operative and programming decisions. This article aims to provide a detailed review of transvenous ICD programming as guided by clinical trials.
The last several years have witnessed an abundance of new and disruptive cardiac implantable electronic device innovations. These can be categorized in terms of cardiac pacing, noncardiac electrical stimulation, and lead...The last several years have witnessed an abundance of new and disruptive cardiac implantable electronic device innovations. These can be categorized in terms of cardiac pacing, noncardiac electrical stimulation, and leadless technology. A working knowledge of these new options for patients on the part of the clinical cardiology community is critical.
Transvenous leads continue to be the standard means to deliver bradyarrhythmia and tachyarrhythmia device therapy. Risk factors for cardiac implantable electronic devices (CIED) infection or complications of transvenous...Transvenous leads continue to be the standard means to deliver bradyarrhythmia and tachyarrhythmia device therapy. Risk factors for cardiac implantable electronic devices (CIED) infection or complications of transvenous lead extraction (TLE) and mortality represent a complex interplay between non-modifiable patient-related factors and actionable implant-related characteristics or adverse events. Careful attention to patient screening, infection mitigation, lead selection, and implant technique may enhance safety of the index procedure and subsequent clinical management.
Optimal blood pressure targets for patients with chronic kidney disease (CKD) remain a subject of ongoing debate. This review explores the evolution of evidence guiding blood pressure treatment thresholds in patients wit...Optimal blood pressure targets for patients with chronic kidney disease (CKD) remain a subject of ongoing debate. This review explores the evolution of evidence guiding blood pressure treatment thresholds in patients with CKD, highlighting shifts from kidney-focused outcomes to cardiovascular benefits. We examine landmark trials, historical and current guideline recommendations, and key controversies surrounding intensive blood pressure control. Additionally, we discuss challenges in applying existing data to underrepresented CKD populations. By synthesizing current evidence, this review aims to provide a comprehensive perspective on individualized blood pressure goals for patients with CKD.
Cardio-kidney metabolic (CKM) syndrome refers to the interconnected dysfunction of the cardiovascular, renal, and metabolic systems, leading to an increased risk of chronic conditions like hypertension, diabetes, and hea...Cardio-kidney metabolic (CKM) syndrome refers to the interconnected dysfunction of the cardiovascular, renal, and metabolic systems, leading to an increased risk of chronic conditions like hypertension, diabetes, and heart disease. In pediatrics, primordial prevention aims to prevent the development of risk factors for CKM syndrome by addressing the lifestyle factors such as diet and physical activity and reducing harmful exposures and behaviors from early childhood. Interventions focus on promoting healthy habits, managing obesity, and controlling conditions like high blood pressure. These interventions aim to mitigate long-term CKM syndrome complications and improve public health outcomes.
Cardiovascular-kidney-metabolic (CKM) syndrome is a complex disorder involving an interplay of metabolic risk factors such as obesity, type 2 diabetes mellitus, hyperlipidemia, hypertension, and chronic kidney disease. B...Cardiovascular-kidney-metabolic (CKM) syndrome is a complex disorder involving an interplay of metabolic risk factors such as obesity, type 2 diabetes mellitus, hyperlipidemia, hypertension, and chronic kidney disease. Because these risk factors augment the risk for cardiovascular complications, healthy nutrition in CKM syndrome is crucial. In particular, a healthy plant-based diet is effective in improving metabolic dysfunction through weight loss, enhancing glucose and blood pressure control, and promoting a more favorable gut microbiota composition, all of which may limit disease progression and cardiovascular complications in CKM syndrome.
Hypertensive disorders of pregnancy affect approximately 10% of all pregnancies where the prevalence is expected to rise. Post pregnancy, there are long-term health risks to mother and child. Mothers who experience hyper...Hypertensive disorders of pregnancy affect approximately 10% of all pregnancies where the prevalence is expected to rise. Post pregnancy, there are long-term health risks to mother and child. Mothers who experience hypertensive disorders during pregnancy are at a significantly higher risk of developing chronic diseases. Emerging evidence also indicates long-term adverse effects in children exposed to pre-eclampsia in utero. This article explores the latest theories on the pathogenesis and regional variations in the long-term consequences, where data is available. It also reviews current management, screening strategies, and identifies key areas for future research to enhance long-term care for affected individuals.