Fungal infective endocarditis is a rare but highly lethal condition. Its diagnosis is often delayed due to nonspecific symptoms, inconclusive medical imaging, and negative blood cultures. Recent reviews of cases and series over the last 5 years indicate that the condition remains rare and lethal. If fungi are identified as the causative agents in more than 5% of patient cases with infective endocarditis, it is likely that risk factors such as immune suppression or cardiac implants are probably involved. A series derived from recent case reports indicates that Candida and Aspergillus are still the main causative infectious agents, with. C parapsilosis on the rise. From these cases, diagnostic clues (frequent embolisms, ophthalmic involvement, large, mobile and friable vegetation, non-valvular cardiac manifestations) are pointing towards fungal IE. These reports, however, are not standardized and a publication bias towards rare microorganisms or towards a favorable outcome might exist. Complications might be underreported, and important data such as diagnostic delay are absent or difficult to retrieve. Pharmacologic treatment is not fully standardized. Knowledge of resistant strains in this respect is important. Statistical analysis for the effect of complications and treatment modalities on outcome shows that any result should be treated cautiously. The current series is by no means a valid substitute for a well-designed series of fungal endocarditis. However, the better outcome with Candida and patients treated with surgery confirm earlier results. An international multicentric standardized registry of cases with fungal endocarditis in order to improve the outcome of this disease is highly needed. The effect of diagnostic delay on outcome remains elusive and should be resolved.
Aim: Recent studies demonstrate that sodium-glucose cotransporter 2 inhibitors (SGLT2i) and dipeptidyl peptidase-4 inhibitors (DPP4i), two classes of antidiabetic drugs, are cardioprotective. However, the mechanisms of these benefits and their comparative efficacy remain unclear. We aimed to compare the effects of these antidiabetic agents on cardiac function, perfusion, and microvascular density using a swine model of chronic myocardial ischemia.
Methods: Chronic myocardial ischemia was induced in Yorkshire swine by ameroid constrictor placement to the left circumflex artery. Two weeks later, pigs were administered vehicle (“CON”, 8 pigs), 300 mg SGLT2i canagliflozin, (“CANA”, 8 pigs), or 100 mg DPP4i sitagliptin (“SIT”, 5 pigs) daily. Five weeks later, pigs were euthanized. Cardiac function, perfusion, collateralization, and protein expression were determined by pressure-volume catheter, microsphere analysis, immunofluorescence, and immunoblotting, respectively.
Results: Compared with SIT, CANA was associated with improved stroke volume and cardiac output, with a trend towards reduced left ventricular stiffness. Both CANA and SIT trended towards improved perfusion compared to CON, but there were no differences between the two treatment groups. SIT was associated with improved capillary density with a trend towards improved arteriolar density compared to CANA. Both CANA and SIT were associated with increased expression of vascular endothelial cadherin compared to CON, without differences in treatment groups. SIT pigs had decreased 5′ adenosine monophosphate-activated protein kinase activation compared to CON and CANA. There was a trend towards increased endothelial nitric oxide synthase activation in the SIT group compared to CON. There were no differences in activation of extracellular signal-regulated kinase 1/2 across groups.
Conclusions: In the setting of chronic myocardial ischemia, canagliflozin is associated with improved cardiac function compared to sitagliptin, with similar effects on perfusion despite differences in microvascular collateralization.
This review outlines the development of less invasive treatments for coronary artery disease, focusing primarily on minimally invasive coronary artery bypass grafting (MICS CABG). We compare conventional coronary artery bypass grafting (CABG) and MICS CABG indications and contraindications, surgical techniques, early and long-term outcomes, and the process of implementation of MICS CABG to cardiac surgery programs. The invasiveness of cardiopulmonary bypass and the sternotomy incision used in conventional CABG are appreciably mitigated by the MICS CABG procedure, which is generally performed off-pump and through a left mini-thoracotomy. In the literature, MICS CABG is a feasible alternative to sternotomy CABG with safe, reproducible, efficient, and durable outcomes.
Thoracic aortic dissection is a feared, highly lethal condition most commonly developing from aneurysmal dilation of the thoracic aorta. Elective prophylactic replacement of thoracic aortic aneurysms dramatically mitigates this risk. However, diagnosis of a thoracic aortic aneurysm can be challenging. Thoracic aortic disease - horacic aortic aneurysm and dissection (TAAD) - can be sporadic or heritable. Patients with syndromic heritable TAAD present with classic phenotype and clinical features correlating to their disease. In contrast, patients with non-syndromic heritable disease are harder to diagnose due to their lack of defining uniform phenotypes. Recent advances in genomics have begun to elucidate the genetic underpinnings of non-syndromic TAAD (ns-TAAD) for better understanding this complex disease and improve diagnosis and management. Herein, we review the foundation of knowledge in ns-TAAD heritability and key research studies identifying gene mutations in vascular smooth muscle cells, the extracellular matrix, and TGF-beta signaling present in ns-TAAD. We summarize the current guidelines for the diagnosis, screening, and surgical management of ns-TAAD including recommendations for genetic testing of high-risk individuals. Finally, we highlight areas of future research that will continue to advance our understanding of the complex genetic and epigenetic factors in TAAD.
Significant coronary artery disease (CAD) and severe aortic stenosis (AS) are frequent findings in patients who undergo transcatheter aortic valve implantation (TAVI). With the extension of TAVI in patients who have intermediate and even low surgical risk, the optimal evaluation and management of concomitant CAD needs to be determined. Both pre-TAVI evaluation of CAD and indications for revascularization remain a matter of debate. In this review, we provide an updated overview of the prevailing landscape of CAD in patients undergoing TAVI with a focus on its prognostic impact, diagnostic evaluation pre-procedure, indications for revascularization, optimal timing of revascularization, and future directions.
The recommendation to employ a heart team to guide revascularization has persisted for over a decade. Despite evidence for improved adherence to guidelines, widespread adoption of the heart team approach has been limited. This review delves into the history of the guidelines endorsing the use of a heart team and the supporting data. Additionally, it outlines some attributes of a successful heart team, and how the heart team has been run at several large academic centers. Finally, it reviews some of the barriers to a heart team and future considerations.
The clinical use of irreversible electroporation in invasive cardiac laboratories, termed pulsed field ablation (PFA), is gaining early enthusiasm among electrophysiologists for the management of both atrial and ventricular arrhythmogenic substrates. Though electroporation is regularly employed in other branches of science and medicine, concerns regarding the acute and permanent vascular effects of PFA remain. This comprehensive review aims to summarize the preclinical and adult clinical data published to date on PFA’s effects on pulmonary veins and coronary arteries. These data will be contrasted with the incidences of iatrogenic pulmonary vein stenosis and coronary artery injury secondary to thermal cardiac ablation modalities, namely radiofrequency energy, laser energy, and liquid nitrogen-based cryoablation.
Antimalarial agents have been used to treat various autoimmune rheumatic diseases for over a century. Hydroxychloroquine is a safe, effective and inexpensive antimalarial drug with additional antithrombotic, cardioprotective, antimicrobial, and anti-neoplastic benefits. It has been used extensively in various diseases, especially systemic lupus erythematosus and rheumatoid arthritis; however, it has not been used in anti-neutrophil cytoplasmic antibody associated vasculitides (AAVs). There exists a significant unmet need for safe and inexpensive treatments for non-severe AAV or those with low-grade “grumbling” disease activity who do not warrant significant escalation of therapy but who remain at risk of disease flares and damage accumulation. Hydroxychloroquine may be an option to help fill this void. Although the mechanisms of action of Hydroxychloroquine are not fully understood, it interacts with various inflammatory mediators involved in the pathogenesis of AAV. Based on these benefits, along with the unmet need in AAV, we present evidence to support the use of Hydroxychloroquine as a potential therapy for AAV.
Coronary artery calcifications (CAC) affect more than 90% of men and more than 67% of women older than 70; the spread is mainly due to the high occurrence of major cardiovascular risk factors. The presence of CAC can be detected by several noninvasive and invasive methods like computed tomography (CT), coronary angiography (CA), Intravascular Ultrasound (IVUS), and Optical Coherence Tomography (OCT), with each system providing different information that can be used in the treatment strategy of CAC. Several devices can modify calcium during PCI: high-pressure non-compliant balloons, cutting/scoring balloons, atheroablative technologies, and intravascular Lithotripsy (IVL). Each technique has advantages and disadvantages that every interventional cardiologist should know to perform an optimal PCI and to achieve the best result and clinical outcome. This is a narrative review that aims to illustrate the contemporary management of CAC, focusing on the available techniques to assess calcifications and their novel advancements and explaining the existing tools to treat CAC with a focus on their significant challenges and pitfalls.
Thoracoabdominal aortic aneurysm (TAAA) is a severe and complex condition with multifactorial etiology that can lead to life-threatening complications. Its treatment is genuinely complex irrespective of the chosen technique, open or endovascular repair. Fenestrated-branched endovascular aneurysm repair (F/B-EVAR) has been increasingly accepted in patients with suitable anatomy, resulting in outcomes compared to or superior to open repair. The selection of patients, judicious surgical planning, and device selection are paramount to achieving successful treatment. The field of TAAA repair is continuously evolving with ongoing research and the development of new techniques and devices to further improve patient outcomes. This paper aims to present a review of endovascular TAAA treatment, summarizing anatomical and clinical features relevant to technical performance and treatment indications.
Acute type A aortic dissection (ATAAD) is a surgical emergency with a nonoperative mortality rate of up to 1% per hour and an operative mortality rate as high as 24%. Therefore, evaluation of comorbidities and patient presentation characteristics prompts a pause for risk stratification before proceeding to the operating room, as emergent surgery may not always be the optimal approach. This comprehensive review explores key considerations in ATAAD management, emphasizing the need for nuanced decision making, by considering medical management and delayed surgery as an alternative management approach for high-risk populations such as the frail or patients who have a history of cardiac surgery. Beyond the immediate threat of aortic rupture, organ malperfusion stands out as the most feared complication of ATAAD, also elevating perioperative risk significantly. In such cases, careful assessment of patient’s hemodynamic status is paramount. For stable patients, a thorough preoperative strategy and multidisciplinary discussions are encouraged. Notably, the advent of endovascular techniques provides viable lower-risk alternatives to the traditional open approach. The consequences of ATAAD surgical intervention extend beyond the immediate procedural concerns, with a substantial impact on the patient’s overall function. Prioritizing patient-centered care becomes imperative in aligning management with individual goals of care. This review seeks to provide insights into these considerations by offering a stepwise approach to patient-centered decision-making in ATAAD management.
Artificial intelligence (AI) is changing our clinical practice. This is particularly true in cardiology where the clinician is often required to handle a large amount of clinical, biological, and imaging data during decision making. In this context, AI can address the need for fast and accurate tools while reducing the burden on clinicians and improving the efficiency of healthcare systems. With this inevitable shift towards more automated and efficient systems, patients may benefit from a more accurate diagnosis and more tailored treatment. A multitude of clinical applications have already been made available and implemented in several fields of cardiology. The aim of this narrative review is to provide an overall picture of the most recent evidence in the literature about AI implementations, highlighting their potential impact on clinical practice.
Coronary artery aneurysms and coronary ectasia are defined as focal or diffuse dilation of the coronary arteries, respectively. Although frequently silent and detected as incidental findings at coronary angiography or computed tomography, coronary aneurysms have been associated with different clinical conditions, including silent ischemia and acute coronary syndromes, and with poor clinical outcomes. The optimal management still remains unsettled, as randomized data are lacking and treatment with either surgical or percutaneous procedures faces significant challenges. This review aims to provide an update on the classification, etiopathogenesis, diagnostic workup, and treatment of aneurysmal coronary disease.
Polymyalgia rheumatica (PMR) is the most common inflammatory rheumatic disease in those over the age of
Aim: Optimal cannulation strategy for acute type A aortic dissection (ATAAD) surgery remains debated. Recent guidelines have advocated antegrade systemic perfusion through right axillary artery (RAX) cannulation, instead of femoral artery (FA) cannulation. However, RAX cannulation can be technically challenging and time-consuming. On the other hand, direct (ascending) aorta (DA) cannulation is a swift procedure that also ensures downstream antegrade flow. In this regard, we assessed whether DA cannulation is a safe alternative to FA cannulation.
Methods: Records of all patients undergoing ATAAD surgery between 2006-2022 at the Radboud University Medical Center were retrospectively reviewed.
Results: In total, 281 patients underwent surgery for ATAAD during the investigated period. Three patients were excluded due to death before the start of extracorporeal circulation and four because of RAX cannulation. Of the remaining 274 patients, 53% (N = 145) received primary FA and 47% (N = 129) DA cannulation, with a success rate of 98% for both approaches. Surgical mortality (combined in-hospital and 30-day) was 9.9%
Conclusion: DA cannulation offers a safe and fast alternative to FA cannulation in ATAAD surgery. There were no significant differences in mortality and neurological complications. Future studies should focus on the differences between RAX and DA cannulation strategies on postoperative outcomes in ATAAD surgery.
Aim: Fenestrated/branched endografting (F/B-EVAR) is an established technique to treat thoracoabdominal aortic aneurysms (TAAAs) in high-risk patients. Spinal cord ischemia/infarction (SCI) is a possible postoperative complication leading to deterioration in quality of life and decreased survival. Several strategies have been suggested in order to minimize its occurrence. The aim of this study was to report the outcomes of a dedicated multidisciplinary SCI prevention protocol for elective F/B-EVAR in Crawford’s extent I-III TAAAs.
Methods: All consecutive Crawford’s I-III TAAAs undergoing elective F/B-EVAR from 2010 to 2022 (March) in a single center were prospectively collected and retrospectively analyzed. A dedicated SCI prevention protocol was always adopted. The protocol included several surgical precautions, such as the collateral arterial network optimization, the adoption of a staged repair, and the early limbs reperfusion. Routine use of cerebral spinal fluid drainage (CSFD) was embraced. More anesthesiological measures were the maintenance of perioperative mean arterial pressure > 80 mm Hg, and blood hemoglobin levels > 10 mg/dL. Neurological measures were constituted by intraoperative monitoring with motor-evoked (MEPs) and somatosensory-evoked potentials (SSEPs) plus hourly bedside neurological evaluation during ICU stay. Preoperative comorbidity and postoperative complications were classified according to the Society of Vascular Surgery Reporting Standards. SCI, cardiac/pulmonary morbidities, postoperative hemodialysis, and 30-day/in-hospital mortality were assessed as early outcomes. Survival was evaluated during follow-up.
Results: Out of 104 patients, there were 6 (6%), 51 (49%), and 47 (45%) Crawford’s extent I, II, and III TAAAs, respectively. A staged TAAA repair, according to endograft design, anatomical and clinical characteristics, was performed in 83 (80%) cases. The mean hospital stay was 25 ± 22 days. Eight (8%) patients developed SCI, 2 (2%) transitory, and 6 (6%) permanent. Among those with permanent deficits, only 3 (3%) patients had permanent paraplegia with inability to walk. Out of 104 patients, 5 (5%) had cerebral hemorrhage, two among SCI patients. Postoperative cardiac and pulmonary morbidity was reported in 6 (6%) and 6 (6%) cases, respectively. Hemodialysis was necessary in 3 (3%) patients. Three patients died within 30 postoperative days and other 4 during a prolonged/complicated hospitalization, for an overall in-hospital mortality of 7%. The mean follow-up was 30 ± 18 months. The overall estimated 3-year survival was 62%, with a significant difference in survival at 2 years between patients with and without postoperative SCI (SCI: 18% vs. no-SCI: 69%; P < 0.001).
Conclusions: A dedicated multidisciplinary SCI prevention protocol in elective F/B-EVAR for Crawford’s
Systemic vasculitides can cause a wide variety of gastrointestinal manifestations (GI) ranging from mild and frequently nonspecific abdominal pains to potentially life-threatening bowel perforations. Vascular involvement in systemic vasculitides can affect any GI blood vessel, most commonly mesenteric, hepatic, or splenic arteries. Inflammatory changes affecting different layers of arterial vessel walls can lead to aneurysmatic dilatation or blood vessel occlusion with subsequent organ ischemia leading to mucosal ulcerations, GI bleeding, perforations, or bowel obstruction. While the presence of extraintestinal manifestations may aid in diagnosis, delays in making appropriate diagnoses and rapid initiation of glucocorticoid and immunosuppressive treatment can have detrimental consequences. Awareness of isolated gastrointestinal vasculitis is of particular importance as it frequently remains undiagnosed until end-stage organ damage becomes apparent. Vasculitis mimics such as vascular Ehlers-Danlos syndrome or fibromuscular dysplasia add another lay of complexity in approaching patients with suspected GI vasculitis and should always be carefully considered.
Cardiovascular disease is the leading cause of death worldwide. Over past decades, multiple clinical trials have provided substantial evidence supporting the advantages of managing plasma lipids in individuals with coronary artery disease (CAD). A primary focus in reducing clinical atherosclerotic cardiovascular disease (ASCVD) in patients who have undergone percutaneous coronary intervention (PCI) is the regulation of blood lipids, with an emphasis on low-density lipoprotein (LDL) cholesterol. Statins represent the cornerstone of lipid-lowering therapy (LLT), with high-intensity statins consistently associated with beneficial outcomes in patients at high risk of ASCVD. Nevertheless, a notable portion of patients do not achieve their target cholesterol levels through statin monotherapy, necessitating the inclusion of complementary LLT strategies. Among these therapies are ezetimibe and proprotein convertase subtilisin/kexin type 9 inhibitors, which have also demonstrated clinical advantages by further reducing cholesterol levels. Existing guidelines recommend using these agents when maximally tolerated statin doses fall short of achieving target LDL levels. Additionally, recently introduced ATP-citrate lyase inhibitors, such as bempedoic acid, have gained approval as adjunctive treatments. Furthermore, icosapent ethyl, a purified derivative of eicosapentaenoic acid, targets hypertriglyceridemia and has shown cardiovascular benefits compared to placebo. In this article, we delve into the mechanisms of blood lipids and molecular targets in connection with CAD undergoing PCI. We also explore the current landscape of available LLT options, guidelines in practice, and the subtleties of therapy.
This narrative review summarizes the angiographic and clinical outcome results of the most common coronary artery bypass grafting (CABG) conduits. The left internal mammary artery is the preferred first conduit to bypass the left anterior descending artery due to superior long-term survival and graft patency. Recent studies suggest the radial artery may be the preferred second conduit for the circumflex or right coronary artery territories, challenging the belief that the right internal mammary artery is the best choice. Despite their historical high failure rates, saphenous vein grafts continue to be widely used as secondary conduits. Several recent studies report suboptimal rates of right internal mammary artery graft failure, with clinical outcomes comparable to or worse than saphenous veins. The suboptimal rates of RIMA graft failure may be attributed to several factors such as improvements in vein graft failure rates, the use of in situ and non-left anterior descending artery grafting configurations, and skeletonized harvesting techniques. While observational studies favor multiple over single arterial grafting, randomized studies are needed for confirmation. The ongoing Randomized comparison of the clinical Outcome of single vs. Multiple Arterial grafts (ROMA) trial aims to determine if multiple arterial grafting reduces major adverse cardiovascular events and mortality and how secondary conduit selection influences these outcomes. Greater adoption of arterial grafting strategies is likely to come from high-quality evidence of benefit and safety from ongoing and future large pragmatic trials.
Coronary stent thrombosis (ST) is a rare but severe complication of percutaneous coronary interventions (PCIs) with significant implications for patient outcomes. Despite advancements in antiplatelet medications and drug-eluting stent (DES) technology, ST remains associated with considerable morbidity and mortality. Notably, ST is an adverse event arising from various factors, including patient characteristics, stent-related issues, and procedural complications. In such a context, intravascular imaging (IVI) plays a pivotal role in assessing the underlying mechanisms and guiding treatment decisions. The use of thrombus aspiration and intracoronary antithrombotic therapies have been debated in the context of de novo acute myocardial infarction, but they could have a remarkable role for ST. However, the optimal management of ST requires individualized approaches tailored to patient-specific factors. This review provides a comprehensive analysis of the current understanding of ST, encompassing its incidence, outcomes, and risk factors, focusing on procedural acute management.
This review paper delves into the acute aortic syndromes, with a particular focus on those affecting the descending thoracic aorta, including acute type B aortic dissection (aTBAD), intramural hematoma (IMH), penetrating aortic ulcer (PAU), blunt traumatic thoracic aortic injury (bTAI), and ruptured aneurysm of the descending thoracic aorta (rDTA). These conditions present with sudden-onset symptoms such as severe chest or back pain, necessitating immediate medical attention. While traditional open surgical repair was historically the mainstay of treatment, advancements in endovascular techniques have revolutionized management approaches. Endovascular treatment offers advantages such as reduced operative time, blood loss, and hospital stay, making it a safer option for high-risk patients. However, it is crucial to carefully evaluate patients for endovascular suitability, considering the potential complications and risks associated with these techniques. This paper aims to provide an updated overview of acute aortic syndromes involving the descending thoracic aorta, analyze available therapeutic options, and review contemporary treatment modalities, shedding light on the technical aspects and considerations guiding clinical decision-making in this complex and life-threatening scenario.
Aims: There are currently no evidence-based guidelines for exercise after thoracic aortic dissection (TAD), leading to highly variable recommendations that frequently lead patients to restrict their physical activities. This multicenter randomized controlled trial was intended to evaluate the safety and efficacy of a moderate intensity guided exercise program for TAD survivors.
Methods: Participants were eligible if they had a Type A or Type B dissection at least 90 days before enrollment and could attend two in-person study visits. The guided exercise circuit consisted of six aerobic, isotonic, or isometric exercises that participants continued at home with virtual follow-up sessions. The primary endpoint is the change in the composite anxiety and depression PROMIS-29 T-score at 12 months. Secondary endpoints include changes in grip strength, weight, 24-h ambulatory blood pressure, and arterial biomechanical properties measured by central arterial waveform analysis.
Results: Preliminary analysis of the first 81 enrolled participants demonstrated that the guided exercise circuit was completed safely and was not associated with severe hypertension, injury, or adverse cardiovascular events. At enrollment, adverse central waveform or ABPM characteristics were prevalent and were significantly associated with exertional hypertension.
Conclusions: Guided exercise is safe for aortic dissection survivors. Follow-up of enrolled participants will conclude in October 2024.
(clinicaltrials.gov Identifier: NCT05610462)
The following is a brief review and commentary covering the content of the Special Issue of Vessel Plus entitled Current state of knowledge: Atrial Fibrillation and Cardiac Surgery. All articles in this issue are highlighted with a brief comment for the busy reader, the idea being to facilitate and encourage reading of the original work.
Patients who present with acute myocardial infarction (AMI) often suffer from coronary multivessel disease (MVD). This condition is associated with an increased mortality rate; it is, therefore, important to improve clinical outcomes through appropriate treatment strategies. Over the past decades, extensive research in AMI and MVD patients has consistently shown that complete revascularization is superior to treatment of the only culprit lesion. Another controversial issue concerns the most appropriate timing for percutaneous coronary intervention in non-culprit lesions. Fractional flow reserve (FFR) is considered the best method for identifying ischemic coronary lesions in the context of acute coronary syndromes, but the detection of vulnerable plaques in non-culprit vessels could further improve clinical outcomes. Intravascular imaging goes beyond physiology and it is potentially useful to recognize patients who are vulnerable, despite negative FFR. Therefore, we analyzed the most relevant studies that have investigated the relationship between physiological indexes and plaque vulnerability. However, ongoing trials aim to clarify how coronary physiology can be combined with the benefits of intracoronary imaging.
Angiogenesis, the formation of new blood vessels, plays a crucial role in the progression and metastasis of various cancers, including head and neck squamous cell carcinoma (HNSCC). HNSCCs are characterized by altered levels of angiogenesis-related factors, including the overexpression of pro-angiogenic factors such as vascular endothelial growth factor (VEGF) and platelet-derived growth factor (PDGF), as well as the dysregulation of angiogenesis inhibitors. Together, these factors drive the formation of new blood vessels within the tumor microenvironment and are considered therapeutic targets in HNSCC. Although preclinical studies are promising, challenges have emerged in the clinical use of anti-angiogenic agents in the clinic, including treatment-related toxicities and the development of resistance to therapy. There is an unmet need for further research to elucidate the molecular pathways involved in HNSCC angiogenesis, identify novel therapeutic targets, and discover predictive biomarkers to improve patient selection.
The use of intravascular ultrasound (IVUS) to guide and optimize percutaneous coronary intervention (PCI) has been subject to robust clinical investigation for the last three decades. In this narrative review, we summarize the major clinical outcomes of the randomized controlled trials evaluating the potential benefit of IVUS-guided PCI, compared with either angiography alone or other coronary imaging and physiology technologies. These studies, spanning decades and continents, provide the most rigorous evidence base that clinicians can use to guide real-world decision making regarding the utility of IVUS guidance during PCI in contemporary clinical practice.
The study is focused on the connection between cognitive dysfunction, inflammatory processes, oxidative stress, and various associated biological factors. Postoperative cognitive dysfunction is a condition where a patient exhibits a temporary deterioration in cognitive function after surgery, which may include problems with memory, concentration, and overall cognitive performance. While most common among elderly patients, it can occur in individuals of any age. The causes are not fully elucidated, but it is assumed that peripheral trauma during long-term surgical interventions is behind the development of inflammation and the creation of conditions of oxidative stress, which leads to the disruption of the blood-brain barrier and the subsequent development of cognitive impairment. This review aims to describe the detected changes at the level of selected markers of inflammation and oxidative damage in patients, primarily in connection with cardiac surgery.
Diabetic kidney disease (DKD) is a global health burden and the leading cause of end-stage renal disease. Its clinical management focuses on controlling hyperglycemia, hypertension, and hyperlipidemia. While the progression of DKD can be slowed with intervention, it cannot be stopped or reversed yet. The pathogenesis of DKD is complex, with an interplay of numerous signaling pathways, and research continues to decipher the players and their role, be it beneficial or pathogenic. Inflammation is an essential defense of our bodies against internal or external insults. The injuries that trigger inflammation range from pathogenic infections and wounds to dysregulated metabolism. Inflammation is helpful only if it is controlled and subsides after it has helped defend the individual against the insult. Uncontrolled or chronic inflammation is recognized as a contributor to numerous chronic diseases. Dysregulated inflammation plays a role in multiple aspects of DKD: glomerular hyperfiltration, mesangial expansion, podocyte injury, tubular injury, basement membrane thickening, fibrosis, and scarring. Since inflammation plays an integral role in the progression of DKD, targeting it for therapy is also reasonable. There is a growing trend of targeting inflammation as a therapeutic approach, with new targets being discovered and drugs evaluated every year. The exponential increase in literature necessitates a comprehensive summary of current information, hence this review.
Aim: A significant medical diagnostic tool for monitoring cardiovascular health and function is 2D electrocardiograms. For computerized echocardiogram (echo) analysis, recognizing how this device performs is essential. This paper primarily focuses on detecting the transducer's viewpoint in cardiac echo videos using spatiotemporal data. It distinguishes between different viewpoints by monitoring the heart's function and rate throughout the cycle of heartbeats. Computer-aided diagnosis (CAD) examination sizes are the first steps toward computerized classification of cardiac imaging tests. Since clinical analysis frequently starts with automatic classification, the current view can enhance the detection of Cardiac Vascular Disease (CVD).
Methods: This research article uses a Machine Learning (ML) algorithm called the Integrated Metaheuristic Technique (IMT), which is the Whale Optimization Algorithm with Weighted Support Vector Machine (WOA-WSVM).
Results: The parameters in the classification are optimized with the assistance of WOA, and the echo is classified using WSVM. The WOA-WSVM classifies the images effectively and achieves an accuracy of 98.4%.
Conclusion: The numerical analysis states that the WOA-WSVM technique outperforms the existing state-of-the-art algorithms.
This review explores the pivotal role of the blood-brain barrier (BBB) in maintaining central nervous system (CNS) homeostasis and its dynamic involvement in the pathogenesis of cerebral small vessel disease (CSVD), i.e., the major precursor of age-related neurodegenerative diseases such as vascular dementia and Alzheimer’s disease. It underscores the BBB as a critical physiological boundary that regulates the exchange between the bloodstream and the cerebral milieu through a complex and dynamic interface composed of endothelial cells, astrocyte endfeet, and pericytes. The integrity of this barrier is paramount for neural function, shielding the brain from toxicants and pathogens while facilitating the transport of essential nutrients. Nevertheless, BBB dysfunction is recognized as a lead in the pathogenesis of neurodegeneration including CSVD, emphasizing the need for focused research on maintaining or restoring BBB function. This review highlights recent advancements in our understanding of BBB dynamics in both health and disease states, its involvement in CSVD pathomechanisms, and the challenges and future directions of translational research and emerging technologies. The review advocates for a multidisciplinary approach to uncover the complexity of BBB dysfunction in CSVD, as well as insights into potential therapeutic targets aimed at preserving BBB integrity, thereby minimizing its impact given the notable world’s aging demographics.
Inflammation is an intrinsic part of the body’s immune response, significantly influencing a myriad of physiological and pathological processes. There is now clinical and experimental evidence suggesting that inflammation accelerates atherosclerosis and its associated complications. The presence of macrophages, T and B cells inside the atherosclerotic plaque fueled this concept and steered subsequent research endeavors toward understanding the pathophysiology of atherosclerosis including plaque formation and destabilization leading to plaque rupture resulting in myocardial injury and remodeling. Understanding the mechanism behind atherosclerosis will aid in developing appropriate treatment interventions. Shifting research and drug development from a singular focus on cholesterol-lowering agents to include adjunctive anti-inflammatory therapies is crucial. Targeting a root cause, i.e., inflammation, will help decrease the incidence and progression of atherosclerosis and improve patient outcomes. In this review, we aim to discuss the current understanding of the intricate role of inflammation in the pathogenesis of atherosclerosis, myocardial infarction, and cardiac remodeling. This synthesis will encompass an exploration of the various inflammatory cells involved, the intricate network of chemokines orchestrating inflammatory responses, and the pathways that underpin these cardiovascular conditions. Furthermore, we will explore promising diagnostic and therapeutic strategies aimed at addressing inflammation in cardiovascular diseases. These include interventions such as colchicine, monoclonal antibodies, and nanoparticles designed to deliver and accumulate drugs at the molecular level within cells.
Aim: Emergency coronary artery bypass grafting (CABG) is a critical intervention for patients with acute coronary syndrome (ACS), particularly in high-risk cases where rapid revascularization is necessary. Despite advancements in surgical techniques, early mortality rates remain high. This study aims to identify predictors of short-term mortality in patients undergoing emergency CABG for ACS through a comprehensive systematic review and meta-analysis.
Methods: A PRISMA-based systematic review was performed using major databases up to May 2024. Inclusion criteria focused on studies reporting short-term mortality outcomes and associated predictors in patients undergoing emergency CABG for ACS. Data extraction and quality assessment were performed independently by multiple reviewers. Statistical analysis included pooled odds ratios (OR) and confidence intervals (CI) for identified predictors using random-effects models.
Results: A total of 20 studies encompassing 4,777 patients met the inclusion criteria. Key predictors of short-term mortality include advanced age (OR 1.40, 95%CI: 1.07-1.82), cardiogenic shock (OR 5.35, 95%CI: 3.27-8.74), chronic kidney disease (OR 3.55, 95%CI: 1.30-9.71), and preoperative use of an intra-aortic balloon pump (OR 2.46, 95%CI: 1.00-6.04). Timing of surgery within the first 48 h post-ACS was also associated with higher mortality rates.
Conclusion: This systematic review and meta-analysis highlight important predictors of short-term mortality in patients undergoing emergency CABG for ACS. These findings underscore the importance of tailored perioperative management strategies to improve outcomes in this high-risk patient population.
Dual antiplatelet therapy (DAPT), combining aspirin and a P2Y12 receptor inhibitor, is the basis of acute coronary syndrome (ACS) treatment, demonstrating efficacy in reducing ischemic complications while being linked to increased bleeding. Recent interest has emerged in bleeding reduction strategies, specifically de-escalation strategies involving P2Y12 inhibitor potency and dosage modulation that can be achieved in two different ways: the unguided de-escalation, where P2Y12 inhibitors are adjusted based on clinical judgment, and the guided de-escalation, incorporating genetic or platelet function tests to tailor the therapy. Several randomized controlled trials (RCTs) demonstrated that both unguided and guided de-escalation strategies can reduce bleeding without compromising ischemic outcomes. However, some gaps in evidence are still present and further investigation is needed. Ongoing and upcoming RCTs aim to address uncertainties, including direct comparisons between de-escalation strategies, optimal timing for intervention, and personalized approaches guided by genetic testing. Furthermore, the review emphasizes the need for standardization in implementing de-escalation strategies in routine clinical practice.
Giant cell arteritis (GCA) is the most common primary systemic vasculitis in the elderly. Although the diagnosis of GCA has improved, monitoring its disease activity remains challenging due to the lack of validated tools and biomarkers. The current reliance on assessing symptoms, physical signs, and inflammatory markers during disease follow-up presents limitations, notably the nonspecific nature of GCA-related symptoms and the suppressive impact of IL-6 inhibitors on inflammatory markers. Therefore, recent attention has shifted toward acknowledging imaging as a monitoring tool, particularly ultrasound, given its widespread accessibility, cost-effectiveness, and well-established role in GCA diagnosis. Research on this topic has found that ultrasound characteristics, including the number of affected arterial segments and halo size, are associated with laboratory markers and treatment response, underscoring the ultrasound’s potential as a monitoring tool for GCA. It has also been demonstrated that ultrasound abnormalities progress differently throughout the disease course, depending on the type of arterial involvement, with vessel wall changes in the axillary arteries resolving more slowly than those in the temporal arteries. Nevertheless, there are still no studies comparing the added value of regular ultrasounds for monitoring disease activity to clinical and laboratory monitoring alone; hence, this imaging modality is not yet recommended for patients with GCA in clinical and biochemical remission. This narrative review aims to synthesize the main research findings of key studies addressing the role of ultrasound for monitoring disease activity in GCA, with a focus on the pattern of arterial involvement. It highlights the potential of ultrasound, particularly halo sign assessment, for evaluating disease progression but notes that further validation and standardization of protocols are needed to improve accuracy and enable routine use.
The prevalence of insulin resistance (IR) is growing every year, which determines the risks of developing type 2 diabetes and cardiovascular diseases. Currently, IR is not recognized as a risk factor for the development of varicose veins (VVs), but the connection between the two is tacitly obvious because obesity and diabetes are risk factors for VVs. In this review, we have attempted to highlight the common nature of these two conditions in the context of mitochondrial dysfunction, inflammation, endothelial dysfunction, and tissue hypertrophy, and spotlight the role of IR in the development of VVs. We conclude that IR can contribute to the appearance of VVs.
Patent ductus arteriosus (PDA) is a congenital cardiac defect (CCD) and comprises 8% to 10% of all CCDs. Following the description of surgical closure by Gross and colleagues in the 1930s, it has become a standard mode of therapy and remained so until the description of transcatheter techniques to occlude PDA by Porstmann, Rashkind and their associates in the late 1960s. This review paper discusses transcatheter occlusion techniques with buttoned devices, Giantuco coils, and Amplatzer devices with particular attention to author’s contributions to these methods.
Patients undergoing hemodialysis (HD) are at high risk for both atherothrombosis and hemorrhage. Compared to healthy individuals, these patients show significant alterations in platelet dynamics, potentially contributing to cardiovascular complications and bleeding. This review presents a hypothesis-generating model to elucidate the mechanisms of platelet turnover, reactivity, and premature aging in HD patients. It also examines the roles of pulmonary thrombopoiesis, inflammation, and oxidative stress in platelet dysfunction. Furthermore, the review highlights the importance of platelet heterogeneity and proposes a strategy for developing personalized antiplatelet therapies for HD patients. Future research directions, such as single-cell analyses, are recommended to enhance understanding of platelet dynamics in HD and improve patient care.
Aim: This study aimed to evaluate the early and mid-term outcomes of minimally invasive direct coronary artery bypass (MIDCAB) surgery for isolated left anterior descending artery (LAD) disease, with a primary focus on revascularization-free survival.
Methods: A retrospective analysis was conducted on 155 consecutive patients who underwent MIDCAB at Santa Maria Hospital, Bari, Italy, between May 2017 and December 2023. All patients received a direct anastomosis of the left internal thoracic artery (LITA) to the LAD, with sequential grafting performed for those with concurrent diagonal artery disease. The primary endpoint was revascularization-free survival. The secondary endpoint was
Results: The median follow-up duration was 36 months [12-48]. No 30-day postoperative deaths occurred. The
Conclusion: MIDCAB for isolated LAD disease is safe, with satisfactory postoperative outcomes and excellent mid-term survival. These findings align with existing literature, underscoring the procedure’s reproducibility. Further multicenter studies are needed to validate these results and compare MIDCAB versus PCI in treating isolated LAD disease.
Multiple arterial grafting (MAG) has been evidenced to likely improve long-term mortality and morbidity outcomes compared with single arterial grafting during coronary artery bypass grafting (CABG), with current guidelines recommending its use. Notably, women make up less than 30% of the cohorts in the studies that inform these guidelines, and the use of MAG has not been well studied in the female population, despite the evidence that women present with more comorbidities and severe symptoms, and often perform worse after CABG compared with their male counterparts. Therefore, this comprehensive narrative review focuses on the currently available evidence examining MAG in women, and its use in on- and off-pump CABG.
Total arterial coronary artery bypass grafting (TAR) has emerged as a superior strategy in coronary revascularization due to its ability to enhance long-term graft patency and reduce postoperative adverse cardiac events compared to traditional saphenous vein graft (SVG)-based approaches. While coronary artery bypass grafting (CABG) remains the cornerstone for treating multivessel coronary artery disease, its historical reliance on SVG has been increasingly challenged by the recognized durability and superior clinical outcomes associated with arterial grafts, such as the internal mammary artery (IMA) and radial artery. This article highlights the advantages of TAR over both single arterial grafting (SAG) and multiple arterial grafting (MAG), emphasizing its potential to eliminate the long-term vulnerabilities associated with venous conduits. However, the adoption of TAR faces significant barriers, including perceived technical complexity, increased operative duration, and concerns over complications such as deep sternal wound infections, particularly when bilateral IMA grafts are used. In contrast, MAG represents a transitional approach that incorporates arterial grafts alongside SVG to mitigate these challenges, offering surgeons flexibility while advancing toward arterial revascularization. Despite growing evidence favoring TAR, its widespread implementation is limited by a lack of large-scale randomized trials and logistical challenges in training and execution. This article provides a balanced discussion of the benefits and limitations of TAR, exploring its role in contemporary CABG practice and its potential to redefine coronary revascularization strategies.
Primary percutaneous coronary intervention (PCI) is one of the most effective treatment modalities for acute life-threatening diseases. Although successful PCI provides a direct positive effect on patient survival, failure may be associated with the disappearance of this benefit and, beyond that, worsening of the prognosis. Disparities in the coronary anatomy, the pathologic nature of the culprit lesion, and the underlying mechanisms of acute coronary syndrome can complicate PCI. An invasive cardiologist must be aware of these challenging situations and how best to manage them. This review aims to summarize troublesome scenarios such as no-reflow, large thrombotic lesions, ectasia-associated myocardial infarction, and spontaneous coronary artery dissection in primary PCI and to provide practical information on how to manage these situations.