Journal of Cardiovascular Development and Disease

Heart failure with preserved or mildly reduced ejection fraction (HFpEF/HFmrEF) accounts for approximately half of the global heart failure burden and remains a syndrome with limited device-based therapeutic options. It is often characterized by a disproportionate rise in left-sided filling pressure during exercise. Interatrial shunt devices (IASDs) aim to reduce left atrial pressure through controlled left-to-right atrial communication. We performed a structured narrative review of mechanistic studies, early feasibility cohorts, randomized trials, meta-analyses, and ongoing studies indexed through to August 2026. Early proof-of-concept studies consistently demonstrated technical feasibility, durable patency, and favorable hemodynamic effects, particularly through reductions in pulmonary capillary wedge pressure (PCWP), often accompanied by improved functional status. However, larger sham-controlled randomized trials failed to show consistent overall benefit in unselected populations. Recent mechanistic and observational data indicate that pulmonary vascular reserve, right ventricular–pulmonary arterial coupling, rhythm-device status, and device design may affect benefits and harms. Latent pulmonary vascular disease and impaired right-heart reserve may identify patients poorly suited for shunt implantation, whereas carefully selected, promising phenotypes remain under prospective study. IASDs should therefore remain investigational. Future trials should use exercise hemodynamics and validated noninvasive markers to prospectively define responders, assess device-specific effects, and reconcile physiological unloading with clinical outcomes.

Background and Purpose: Abnormality in the motion of the inferior papillary muscle was found in an early study of mitral valve prolapse (MVP). We visually observed an abnormal movement not only in the inferior wall but also in the anterolateral and inferolateral basal walls in several patients with MVP. Therefore, the aim of this work was to analyze these findings using strain (Speckle Tracking—STE). Methods: A total of 60 MVP patients having a superior systolic displacement of the posterior leaflet, in whole or in part of the scallops, of at least 2 mm, and 20 normal subjects as controls were included. Longitudinal strain was calculated in the three apical views (Philips iE 33 Matrix—implemented strain software). The strain in the three abovementioned basal segments was measured at 160 ms from the beginning of systole (mid-systole), and then we averaged their values to form a “triad” of averaged values that could be subsequently compared among the groups for statistical calculations. The Global Longitudinal Strain (GLS) was also calculated for all subjects. The Mann–Whitney U-test was used for comparisons. A “p” value ≤ 0.05 was considered significant. Results: According to the strain patterns, we were able to identify two distinct groups in MVP patients: Group 1 had a “paradoxical” strain at 160 ms (=positive, that means “mechanical stretching”) in at least a single segment of the aforementioned “triad” of basal segments (n = 35), and Group 2 had not a “paradoxical” strain (n = 25) in any of the aforementioned “triad” segments at the same mid-systolic point. Statistical significance was found between Group 1 and Group 2 at 160 ms and at the peak (p < 0.0001 for both) and the same was found for GLS (p < 0.01). Group 1 vs. controls, as expected, displayed a significant difference in the strain at 160 ms (p < 0.0001) while Group 2 vs. controls did not differ significantly, even at the peak. Conclusions: According to our results, we found in our MVP population (more than half of the patients) that some MVP patients have a “paradoxical” strain (=mechanical stretching) in at least a single segment of the basal inferior-to-lateral segments (that we have named the “triad”) in mid-systole, whereas others do not. The passive continuous stretching of myocardial cells is known to lead, with time, to the replacement of cells by fibrosis (and fibrosis is a condition that is well known to be a source of arrhythmias, and even malignant). Previous Cardiac Magnetic Resonance (CMR) studies already reported the presence of fibrosis in the same basal wall segments in some MVP patients. Thus, considering our strain results, in MVP patients, but only in those with ventricular arrhythmias, it is indicated, in our opinion the strain should be analyzed, as it is an inexpensive tool. If the strain is found to be “paradoxical” even in a single segment of what we have named the “triad”, a further evaluation with CMR (even if expensive) is recommended to look for the presence of fibrosis. Strain analysis is indicated because these findings may have implications for prognosis, further evaluation of arrhythmias and the selection of appropriate therapy.

Background: Atrial fibrillation (AF) is the most common sustained arrhythmia in hypertrophic cardiomyopathy (HCM), occurring in 20–25% of patients and associated with increased morbidity, stroke risk, and symptom burden. Despite this substantial clinical impact, the understanding of the short-term natural history of AF, including recurrence and the effectiveness of treatment strategies in HCM, remains poorly characterized. Methods: We assessed 2016 patients referred to Lahey Hospital and Medical Center for the diagnosis and subspecialty management of HCM, of whom 341 (17%) had a remote history of AF (≥5 years), and 149 (7%) had AF episodes initially detected between January 2020 and June 2025. These 149 patients were included in this retrospective analysis to allow comprehensive short-term assessment of AF recurrence, treatment interventions, and clinical outcomes from first detected AF utilizing contemporary treatments. Results: AF was first detected at a median age of 63 years (IQR 54–70); 63% were male. Most AF episodes (87%) were symptomatic at presentation. Among 146 patients who converted to sinus rhythm, AF recurred in 80 (54%) at a median of 171 days (IQR 53–278; 29% at 6 months, 43% at 12 months). In patients not undergoing rhythm control after first detected AF episode, 60% had spontaneous recurrence (29% at 6 months, 48% at 1 year), while recurrence rates after antiarrhythmic drug (AAD) initiation were 44% (28% at 6 months, 37.5% at 1 year), and after catheter ablation were 27% (9.8% at 6 months, 18% at 1 year). At last follow-up, 1.9 years (IQR 1.2–2.6 years) from first detected AF episode, 133 of 149 patients (89%) were in sinus rhythm. Seven patients (4.7%) died at a median of 1.16 years (IQR 0.74–1.62) after their first detected AF; estimated survival was 98.6% at 1 year and 96.0% at 3 years. Conclusions: AF recurrence occurs at high rates after the initial detected AF episode in HCM regardless of rhythm-control strategy or AAD use. Catheter ablation was associated with lower recurrence rates. These findings characterize the relapsing natural history of HCM-associated AF and underscore the need for further studies to optimize rhythm-control strategies in this population.