Hearts

Background/Objectives: Heart failure (HF) often develops from a prolonged asymptomatic phase where early detection could prevent progression. Pre-heart failure (pre-HF) populations—those with risk factors (Stage A) or subclinical myocardial changes (Stage B)—are critical for intervention. Cardiac magnetic resonance (CMR) with T1 and extracellular volume (ECV) mapping offers a non-invasive approach to detect early myocardial changes in these groups. This systematic review evaluates the role of T1 and ECV mapping in pre-HF populations, focusing on their diagnostic and prognostic utility. Methods: A systematic search of PubMed, EMBASE, and Cochrane was conducted up to April 2025, identifying 17 studies that met inclusion criteria. Data was extracted directly into Excel, and methodological quality was assessed using the Newcastle–Ottawa Scale (NOS) for cohort and cross-sectional studies and AMSTAR-2 for systematic reviews and meta-analyses. A meta-analysis was performed using Review Manager (RevMan) to compare T1 and ECV values between pre-HF and control groups. Results: Studies consistently reported elevated T1 (989.6–1415.41 milliseconds) and ECV (25.7–42.81%) in pre-HF groups compared to controls (T1: 967–1310.63 ms, ECV: 23.5–29.9%). Meta-analysis showed a significant increase in T1 (MD: 27.62 ms, 95% CI: 8.04–47.19, p < 0.006) and ECV (MD: 2.97%, 95% CI: 1.88–4.06, p < 0.00001) in pre-HF groups. RQS scores ranged from 17.2% to 77.8% (mean: 37.9%), and NOS scores ranged from 5 to 8 (mean: 6.2), reflecting variability in study quality. The AMSTAR-2 rating for the systematic review was moderate. Conclusions: T1 and ECV mapping enhance CMR-based detection of early myocardial changes in pre-HF, offering a promising non-invasive approach to predict HF risk. However, variability in study quality, small sample sizes, and methodological inconsistencies limit generalisability. Future research should focus on standardised protocols, prospective designs, and multi-center studies to integrate these techniques into clinical practice, potentially guiding preventive therapies such as SGLT2is and tafamidis. Full article

Background/Objectives: Invasive coronary angiography (ICA) is the gold standard for the diagnosis of coronary artery disease (CAD), with various non-invasive imaging modalities also available. Machine learning (ML) methods are increasingly applied to overcome the limitations of diagnostic imaging by improving accuracy and observer independent performance. Methods: This meta-analysis (PRISMA method) summarizes the evidence for ML-based analyses of coronary imaging data from ICA, coronary computed tomography angiography (CT), and nuclear stress perfusion imaging (SPECT) to predict clinical outcomes and performance for precise diagnosis. We searched for studies from Jan 2012–March 2023. Study-reported c index values and 95% confidence intervals were used. Subgroup analyses separated models by outcome. Combined effect sizes using a random-effects model, test for heterogeneity, and Egger’s test to assess publication bias were considered. Results: In total, 46 studies were included (total subjects = 192,561; events = 31,353), of which 27 had sufficient data. Imaging modalities used were CT (n = 34), ICA (n = 7) and SPECT (n = 5). The most frequent study outcome was detection of stenosis (n = 11). Classic deep neural networks (n = 12) and convolutional neural networks (n = 7) were the most used ML models. Studies aiming to diagnose CAD performed best (0.85; 95% CI: 82, 89); models aiming to predict clinical outcomes performed slightly lower (0.81; 95% CI: 78, 84). The combined c-index was 0.84 (95% CI: 0.81–0.86). Test of heterogeneity showed a high variation among studies (I² = 97.2%). Egger’s test did not indicate publication bias (p = 0.485). Conclusions: The application of ML methods to diagnose CAD and predict clinical outcomes appears promising, although there is lack of standardization across studies. Full article

Background/Objectives: While elevated Lp(a) levels are associated with incident heart failure development, the role of Lp(a) in established heart failure with reduced ejection fraction (HFrEF) versus heart failure with preserved ejection fraction (HFpEF) remains unexplored. Methods: We conducted a retrospective analysis of 387 heart failure patients from our institutional database (January 2018–June 2024). Patients were categorized as HFrEF (n = 201) or HFpEF (n = 186) using ICD-10 codes. Categorical variables were compared between heart failure types using the Chi-square test or Fisher’s Exact test, and continuous variables were compared using the two-sample t-test or Wilcoxon rank-sum test, as appropriate. Logistic regression was utilized to assess heart failure type as a function of Lp(a) levels, adjusting for covariates. Spearman correlation assessed relationships between Lp(a) and pro-BNP levels. Results: Despite significant demographic and clinical differences between HFrEF and HFpEF patients, Lp(a) concentrations showed no significant variation between groups. Median Lp(a) levels were 60.9 nmol/dL (IQR: 21.9–136.7) in HFrEF versus 45.0 nmol/dL (IQR: 20.1–109.9) in HFpEF (p = 0.19). After adjusting for demographic and clinical covariates, Lp(a) showed no association with heart failure subtype (OR: 1.001, 95% CI: 0.99–1.004; p = 0.59). Conclusions: Lp(a) levels do not differ significantly between HFrEF and HFpEF phenotypes, suggesting possible shared pathophysiological mechanisms rather than phenotype-specific biomarker properties. These preliminary findings may support unified screening and treatment strategies for elevated Lp(a) across heart failure, pending confirmation in larger studies. Full article

Background: Large Language Models (LLMs) such as ChatGPT, Claude, and Gemini are being increasingly adopted in medicine; however, their reliability in cardiology remains underexplored. Purpose of the study: To compare the performance of three general-purpose LLMs in response to cardiology-related clinical queries. Study design: Seventy clinical prompts stratified by diagnostic phase (pre or post) and user profile (patient or physician) were submitted to ChatGPT, Claude, and Gemini. Three expert cardiologists, who were blinded to the model’s identity, rated each response on scientific accuracy, completeness, clarity, and coherence using a 5-point Likert scale. Statistical analysis included Kruskal–Wallis tests, Dunn’s post hoc comparisons, Kendall’s W, weighted kappa, and sensitivity analyses. Results: ChatGPT outperformed both Claude and Gemini across all criteria (mean scores: 3.7–4.2 vs. 3.4–4.0 and 2.9–3.7, respectively; p < 0.001). The inter-rater agreement was substantial (Kendall’s W: 0.61–0.71). Pre-diagnostic and patient-framed prompts received higher scores than post-diagnostic and physician-framed ones. Results remained robust across sensitivity analyses. Conclusions: Among the evaluated LLMs, ChatGPT demonstrated superior performance in generating clinically relevant cardiology responses. However, none of the models achieved maximal ratings, and the performance varied by context. These findings highlight the need for domain-specific fine-tuning and human oversight to ensure a safe clinical deployment. Full article

Hypertensive left ventricular hypertrophy (LVH) is an ominous cardiovascular sequel to chronic hypertension, marked by structural and functional alterations in the heart. Identified as a significant risk factor for adverse cardiovascular outcomes, LVH is typically detected through echocardiography and is characterized by pathological thickening of the left ventricular wall. This hypertrophy results from chronic pressure overload (increased afterload), leading to concentric remodelling, or from increased diastolic filling (preload), contributing to eccentric changes. Apoptosis, a regulated process of cell death, plays a critical role in the pathogenesis of LVH by contributing to cardiomyocyte loss and subsequent cardiac dysfunction. Given the substantial clinical implications of LVH for cardiovascular health, this review critically examines the role of cardiomyocyte apoptosis in its disease progression, evaluates the impact of pharmacological interventions, and highlights the necessity of a comprehensive, multifaceted treatment approach for the prevention and management of hypertensive LVH. Finally, we address the health disparities associated with LVH, with particular attention to the disproportionate burden faced by African Americans and other Black communities, as this remains a key priority in advancing equity in cardiovascular care. Full article

Cardiac iron overload is a rare but important adverse consequence of systemic iron overload, marked by the abnormal accumulation of iron in the myocardium. It is most typically caused by hereditary hemochromatosis (mutations in the HFE gene) or secondary iron overload conditions, such as transfusion-dependent anemias. Excess iron in the myocardium causes oxidative stress, cardiomyocyte damage, and progressive fibrosis, ultimately leading to cardiomyopathy. Clinical manifestations are diverse and may include heart failure, arrhythmias, and restrictive or dilated cardiomyopathy. Given the worsened prognosis with cardiac involvement, timely diagnosis and management are essential to improve clinical outcomes. This review provides a contemporary overview of the cardiovascular complications associated with iron overload, including clinical manifestations, diagnostic approaches, and treatment options. Full article

Background/Objectives: Cangrelor, an intravenous P2Y12 inhibitor, is increasingly used during percutaneous coronary intervention (PCI) for rapid and reversible platelet inhibition in patients unable to take oral antiplatelet agents, particularly in emergencies such as ST-elevation myocardial infarction (STEMI), cardiac arrest, or cardiogenic shock. This single-centre study evaluates cangrelor and outcomes in a non-surgical centre. Methods: Between June 2017 and December 2021, all the patients for whom cangrelor was used at a district general hospital (DGH) in the UK were included in this study. Data collection included baseline characteristics, admission, procedural details, and patient outcomes. The primary outcome was a composite of all-cause mortality, bleeding, and cardiovascular events, including myocardial infarction, stent thrombosis, and stroke, within 48 h. Secondary outcomes included predictors of the composite outcome at 48 h. Results: During the study period, cangrelor was administered peri-procedurally to 93 patients. Males comprised 85% of the patients; the mean age was 65.5 ± 10.6 years. A total of 1 patient (1.1%) had a cardiovascular event within 48 h of cangrelor administration, whereas all-cause mortality occurred in 17 patients (18%) within 48 h. No major bleeding events were noted at 48 h following cangrelor administration. Regression analysis did not find predictors of composite outcomes at 48 h. Conclusions: Cangrelor offers a potential alternative to oral P2Y12 inhibitors in specific high-risk scenarios. Further research is needed to validate its role in broader populations. Full article

Background: This study aims to evaluate the impact of critical illness, defined as the need for preoperative intensive care unit (ICU) admission for invasive monitoring or organ support, on cardiac surgery outcomes for patients with acute infective endocarditis (IE). Methods: A retrospective analysis of prospectively collected data from patients treated between 1 January 2017 and 30 May 2024 at a single Australian tertiary cardiothoracic centre was performed. Data were collected from the Australian and New Zealand Cardiothoracic Society (ANZCTS) database and the Australian and New Zealand Intensive Care Adult Patients Database (ANZICS-APD). Results: Among 342 patients who underwent cardiac surgery for IE, 32 (9.4%) were critically ill. The critically ill patients were admitted to the ICU before surgery with a diagnosis of septic or cardiogenic shock, with 86% (n = 30) requiring mechanical ventilation. Compared to the non-critically ill cohort, critically ill patients were more likely to have a history of intravenous drug use (IVDU) (41% vs. 14%, p = 0.03) and a younger age (median age 49 years [42–56] vs. 61 years [44–70], p = 0.03), and although methicillin-sensitive Staphylococcus aureus (MSSA) was the most common causative organism in both groups, it was found significantly more often in the critically ill cohort (66% and 27%, p = 0.001). The median EuroSCORE II was comparable between the groups (2.1 [1.3–10] vs. 2.8 [1.3–5.7], p = 0.69); however, the APACHE III (57 [49–78] vs. 52 [39–67], p = 0.03) and ANZROD scores (0.04 [0.02–0.09] vs. 0.013 [0.004–0.038], p = 0.00002) were significantly higher in the critically ill patients. The overall 30-day mortality rates were similar between the groups (13% vs. 5%, p = 0.60). The median ICU length of stay (LOS) was significantly longer for the critically ill patients (5 days [IQR 2–10 days] vs. 2 days [1–4 days], p = 0.0004), with a similar hospital LOS (23 days [IQR 14–36] vs. 21 days [12–34], p = 0.46). Renal replacement therapy was three times higher in the critically ill (34% vs. 11%, p = 0.0001). Reoperations for bleeding were similar between the groups (16% vs. 11%, p = 0.74). Conclusions: Despite being associated with higher ANZROD and APACHE III scores, a longer ICU length of stay, and higher use of renal replacement therapy, critical illness did not have an impact on the EuroSCORE II, hospital length of stay, or reoperation rates for bleeding or 30-day mortality among patients with IE undergoing cardiac surgery. The lessons from this study will guide and inform the development of better infective endocarditis databases and registries. Full article

Background: Patients with chronic kidney disease (CKD) face an elevated risk of cardiovascular disease (CVD), particularly those with estimated glomerular filtration rate (eGFR) <30 mL/min/1.73 m². Aims: To assess low-density lipoprotein cholesterol (LDL-C) values and the proportion of pre-dialysis patients achieving national and international targets. Methods: This was a retrospective audit (May–October 2024) of 272 patients aged >18 years attending pre-dialysis clinic (estimated glomerular filtration rate <30 mL/min/1.73 m²) at the Renal Unit, Birmingham Heartlands Hospital. Data on age, sex, ethnicity, body mass index, smoking status, CVD status, hypertension, diabetes, lipids (including LDL-C using the Friedewald and Sampson algorithms) and lipid-lowering therapy were collected from the hospital electronic records. Statistical analyses evaluated factors that were associated with LDL-C (linear/multiple regression) and statin therapy (Chi square). Results: The median (interquartile range) calculated LDL-C values were 2.2 (1.7–2.8) mmol/L and 2.3 (1.7–2.9) mmol/L using the Friedewald and Sampson algorithms respectively. Age and statin therapy were independently associated with LDL-C. Using the Friedewald algorithm, 83.8%, 70.6% and 60.3% did not achieve LDL-C targets of 1.4 mmol/L, 1.8 mmol/L and 2.0 mmol/L respectively, these figures were higher when the Sampson algorithm was applied. Only 18 and 3 of the patients were on ezetimibe and inclisiran respectively, whilst not a single patient was on bempedoic acid or proprotein convertase subtilisin/kexin type 9 inhibitors. Conclusion: Our data highlight deficiencies in the management of LDL-C in advanced CKD. We would recommend greater awareness of LDL-C targets and the use of combination lipid-lowering therapy following optimisation of statin therapy. Full article

Background: Infected aortic aneurysms pose significant therapeutic challenges, given the fragility of infected aneurysmal tissue. Mycotic aneurysms caused by Streptococcus agalactiae are rare and may progress in the absence of classical systemic infection signs. Here, we discuss the surgical management of an unusual presentation of a mycotic aneurysm and its rapid progression with no incremental changes in the patient’s symptoms. Case: A 72-year-old woman presented with subacute general deterioration and back pain. A general workup revealed a mycotic aneurysm of the aortic arch, at the level of the brachiocephalic artery. Initial CT showed a 7 × 5.5 mm pseudoaneurysm that enlarged to 41 × 26 mm within three weeks, despite clinical improvement of her presenting symptoms on antibiotics. Given that the lesion progressed, a staged procedure, consisting of a left carotid–subclavian bypass followed by proximal arch repair, was undertaken with success. Intra-operatively, a completely thrombosed innominate vein was found compressing—and likely tamponading—the pseudoaneurysm, a phenomenon that may have prevented catastrophic rupture. A Dacron graft was sewn end-to-end to the distal ascending aorta; the posterior half of this distal anastomosis incorporated the rim of the innominate artery defect to create a single hemostatic suture line. Conclusions: This case demonstrates a benign initial presentation can degenerate into a catastrophic pseudoaneurysm and how rapidly progressive thoracic infected aneurysms can develop. Heightened clinical acumen is required for accurate diagnosis. Close follow-up is also suggested based on the rapid progression experienced by our patient. Serial imaging, rather than symptomatic or laboratory response alone, should guide the timing of intervention. Full article

Catheter ablation (CA) was found to outperform antiarrhythmic drug therapy (AAD), and it is a key treatment for rhythm control for patients with symptomatic atrial fibrillation (AF). Nevertheless, the procedure’s effectiveness is limited by recurrence rates. Identifying determinants of effective ablation is critical for optimizing patient selection, operative results, and long-term rhythm management strategies. In this state-of-the-art review, we have comprehensively discussed the various factors that can determine the recurrence of AF after a successful CA. Full article

Background/Objectives: The complexity of Minimally Invasive Mitral Valve Surgery (MIMVS) could cause a slow learning curve and potentially patient harm. We thus investigated if a novice mitral valve center encountered difficulties implementing MIMVS. Methods: We investigated seven hundred and forty-eight mitral valve surgery patients, two years before and after MIMVS introduction. Results: We propensity score matched two hundred and sixty elective mitral valve patients for comparison, with one hundred and thirty patients in each group. Surgical- (5.5 vs. 4.3 h), Cardiopulmonary bypass- (180 vs. 102 min) and aortic cross-clamp times (98 vs. 81 min) became longer after MIMVS introduction. One-year mortality and in-hospital outcomes remained unaffected. Hospital length of stay shortened significantly after MIMVS (5 d vs. 7 d; p < 0.001). Conclusions: Adopting MIMVS in a mitral valve center without prior experience in the procedure showed feasibility, equally good outcome and shorter hospital stay when compared to conventional sternotomy. Full article

Adult congenital heart disease (ACHD) represents a significant portion of congenital anomalies, and with improved treatments leading to an increased life expectancy, its prevalence has been increasing over the past few decades. Nonetheless, a considerable number of patients with ACHD require cardiac rhythm management devices during their lifetime. Traditionally, transvenous pacemaker placement has been the standard mode of treatment for these patients. However, some patients with ACHD have anatomical barriers that obscure this mode of treatment. Leadless pacing systems (LPSs) have changed the field of pacing. Currently, two different LPSs are available. In a real-world setting, implanting an LPS in patients after tricuspid valve (TV) surgery seems to be a straightforward procedure with a low risk of complications, with patients showing no valvular dysfunction after the intervention. LPS implantation is an option to avoid device-related complications in patients with previous TV surgery. Moreover, it has been demonstrated that even the jugular approach seems as safe as the femoral approach and could be considered an alternative implantation method for LPSs. The Aveir VR leadless pacemaker is a helix LPS with unique features, such as its capacity as a dual-chamber leadless pacemaker, the ability to map electrical parameters before releasing the device, and its possibility of being retrievable. Hereby, we present the case of Ebstein’s anomaly, atrial septal defect closure, and previous TV surgery with symptomatic intermittent advanced atrioventricular block. This case illustrates that a transjugular approach for LPSs is also feasible in patients with ACHD. Full article

Right heart failure (RHF) is a common manifestation after left ventricular assist device (LVAD) placement and is associated with a high mortality rate. Historically, RV failure requiring an RVAD at the time of LVAD implantation has been associated with an especially high mortality. However, more recently, some studies have shown reasonable outcomes after LVAD implantation even when an RVAD is required, especially if RV failure is recognized early and treated with RV mechanical support. This article analyzes the current trends and studies investigating the use of RVAD placement post-LVAD implantation with an emphasis on the newest devices and treatment paradigms. Full article

Cardiac arrest remains a leading cause of death worldwide and is a global health crisis. First described in the medical literature in the 18th century, modern cardiopulmonary resuscitation (CPR) with closed chest compressions has remained the standard of care since 1960. Despite exponential advances in basic science research and technological innovations, cardiac arrest survival remains a dismal 10%. The standard of care closed chest compressions provide only 20–30% of baseline cardiac output to the body. Have modern therapies plateaued in effectiveness? This article reviews the history of cardiac arrest, its therapies, and opportunities for future treatments. Through an exploration into the history of CPR and breakthroughs in its treatment paradigms, modern-day researchers and providers may find further inspiration to combat the cardiac arrest public health crisis. Full article

Background: The increased hospital morbidity and mortality associated with hyponatremia is well recognized in the critically ill pediatric population. Neonates and infants exposed to vasopressin following cardiopulmonary bypass (CPB) may be at increased risk for hyponatremia. We aimed to determine the associated effect and potential risk factors leading to hyponatremia and sodium variability in the immediate postoperative period in neonates and infants up to 90 days of age exposed to vasopressin following surgery for congenital heart disease. Methods: This was a retrospective review of 75 consecutive patients at a single tertiary cardiac intensive care unit (CICU) from 2018 to 2020. Using mixed-effects linear regression, we compared sodium trends and variability between the groups who did and did not receive vasopressin. Results: While sodium levels fell in both groups, beyond the first postoperative day, the group exposed to vasopressin had a significantly increased fall in sodium relative to the control (p < 0.001). Vasopressin exposure was associated with increased within-day sodium variability on postoperative days one and two (p < 0.05). Total incidents of moderate to severe hyponatremia (sodium < 130 mmol/L) were higher in the vasopressin group but did not reach statistical significance. Age, volume of modified ultrafiltration, and total diuretic dose were not risk factors for either effect in this study. Conclusions: While all patients in this study appeared to be at risk of postoperative hyponatremia, cumulative vasopressin dose appeared to increase the risk for absolute hyponatremia as well as greater sodium variability within the early postoperative period. Full article

Transthyretin cardiac amyloidosis (TTR-CA) is a pathological condition characterized by the accumulation of misfolded transthyretin (TTR) protein in the heart, leading to restrictive cardiomyopathy. TTR-CA has gained increasing recognition in recent years due to its significant impact on morbidity and mortality. It is typically diagnosed when symptoms of heart failure appear. However, with advancements in non-invasive imaging, early and precise diagnosis of TTR-CA is now possible, enabling clinicians to take advantage of current therapeutic interventions that are more effective when initiated at an earlier stage of the disease. Moreover, genetic testing can now assist clinicians in identifying asymptomatic individuals who are at risk of developing the disease before clinical features manifest. In this review, we provide a general overview of TTR-CA and summarize expert opinions on pre-symptomatic testing and the management of asymptomatic patients, with a particular focus on the V122I mutation. This article aims to provide clinicians with a better understanding of TTR-CA and the current best practices for managing asymptomatic patients with this genetic predisposition. Full article

Background: Obesity presents a significant global health impact and is linked to cardiovascular diseases. While obesity often exacerbates the severity of cardiovascular conditions, an “obesity paradox” has previously been observed, where patients with higher body mass index (BMI) exhibit improved in-hospital and long-term outcomes in certain contexts. As minimally invasive procedures such as percutaneous coronary intervention (PCI) continue to become more relevant, understanding the impact of different patient characteristics on clinical outcomes becomes increasingly important. Methods: A comprehensive analysis was conducted using a large cohort of patients who underwent PCI. In this study, we identified patients who underwent PCI in the year 2020 using the International Classification of Disease (ICD) codes. Patients were categorized into five groups based on their Body Mass Index (BMI). This study aimed to examine the impact of BMI on inpatient outcomes among patients undergoing PCI, focusing on mortality, length of stay, and hospitalization costs across different BMI categories. Results: Our analysis revealed a U-shaped relationship between BMI and inpatient outcomes. Patients with a BMI ≥ 25 demonstrated significantly reduced inpatient mortality (adjusted odds ratio 0.31, 95% CI: 0.18 to 0.54 for BMI 25–29.9 group and adjusted odds ratio 0.32, 95% CI: 0.20 to 0.51 for the BMI 30–39.9 group, with p ≤ 0.001); shorter hospital stays (BMI of 25 or higher with mean reduction of −2.40 to −3.66 days, with p ≤ 0.001); and lower hospitalization costs with a cost reduction of −$40,881 (95% CI: −$64,540 to −$17,223) for the BMI 25–29.9 group, −$57,900 (95% CI: −$80,308 to −$35,492) for the BMI 30–39.9 group, and −$41,463 (95% CI: −$65,151 to −$17,775) for the BMI ≥40 group compared to those with normal BMI (20–24.9). However, these benefits diminished for patients with a BMI ≥ 40, where no significant differences in mortality or cost reductions were observed. Conclusions: These findings underscore the complexity of the obesity paradox and its limitations in extreme obesity. This study highlights the need for tailored management strategies in PCI patients with varying BMI profiles. Full article

The prevalence of cardiac amyloidosis (CA), especially as a cause of heart failure, has significantly increased in recent years. Early detection and accurate assessment of the disease burden are crucial for initiating timely treatment and ensuring precise prognosis. CA primarily results from the infiltration of the myocardium by either immunoglobulin light chain fibrils (AL) or transthyretin fibrils (ATTR), leading to restrictive cardiomyopathy and eventual death if untreated. Over the past decade, advancements in diagnostic imaging and heightened clinical awareness have revealed a substantial presence of CA, particularly ATTR, among the elderly. These diagnostic improvements encompass echocardiography, cardiac computerized tomography scans, magnetic resonance imaging, and radionuclide scintigraphy with bone-avid tracers. Concurrently, significant progress has been made in therapeutic options, with new disease-modifying treatments now available that can dramatically alter the disease trajectory and improve survival rates when administered early. However, despite these advancements, there remains an urgent need for the early and accurate detection of CA to ensure that patients can fully benefit from these emerging therapies. Full article