Reviews & Analysis

In this educational Surgery Insight, Dearani and colleagues draw on the extensive experience with septal myectomy as a surgical option for patients with obstructive hypertrophic cardiomyopathy gained at the Mayo Clinic, Rochester, MN, USA.

The causes of progression from an asymptomatic fi broatheromatous lesion to a high-risk vulnerable plaque are not fully understood, but data suggest that intraplaque hemorrhage could be critical in this process. Here, Jainet al. focus on angiogenesis and intraplaque hemorrhage in atherosclerotic lesion progression. They discuss evidence for the role of antiangiogenic agents in normalizing the immature vasculature and examine the obstacles faced in testing their hypothesis both in preclinical models and in humans.

The number of elderly patients with cardiac conditions in the US is increasing, but these individuals receive fewer evidence-based therapies than their younger counterparts. Fibrinolytic therapy, in particular, is underused in the elderly and is commonly withheld on the basis of advanced age alone. In this Viewpoint, Cheuk-Kit Wong and Harvey D White seek to redress this situation by reviewing the evidence for fibrinolytic therapy in elderly patients and advocating that this treatment should not be denied unless there are clear contraindications.

The majority of strokes in patients with atrial fibrillation (AF) are caused by formation of thrombi in the left atrial appendage (LAA). Surgical closure the LAA orifice has emerged as a promising therapy for patients with AF at high risk of stroke, particularly those who are unable to tolerate oral anticoagulants. Here Tariqshah Syed and Jonathan Halperin discuss minimally invasive approaches to LAA occlusion and the future of these procedures in stroke prevention.

Myocardial changes associated with the obese state are increasingly recognized and, notably, are independent of hypertension, obstructive sleep apnea and coronary artery disease. In the first part of this two-part Review, Chiew Wong and Thomas Marwick examine the range of evidence supporting the existence of cardiomyopathy of obesity, and discuss the possible mechanisms.

Diagnosis and medical care of most aortic pathologies is frequently the responsibility of cardiologists. With the emergence of endovascular interventions, it is, therefore, increasingly important for cardiologists to gain confidence in managing at least the most-frequent presentations of aortic disease. Here, Hüseyin Ince and Christoph Nienaber review the etiology, pathophysiology and clinical management of patients with thoracic aortic aneurysm, in the context of the most recent literature.

Toll-like receptors are the primary innate immune receptors and could, therefore, be a key link between cardiovascular disease development and the immune system. Here, Stefan Frantz, Georg Ertl and Johann Bauersachs review this exciting field of research, and explore the evidence supporting a role for toll-like receptors in the pathophysiology of cardiovascular diseases.

Cigarette smoking contributes to 5 million deaths globally each year and up to 35% of tobacco-related deaths in developed countries have cardiovascular causes. In this Viewpoint, Professor of Psychiatry and Neuroscience, Robert Anthenelli, reviews the growing number of therapeutic options for treating tobacco dependence, and urges cardiologists to adopt a more proactive and persistent approach to motivating smoking cessation in their patients.

Suitable vein or artery tissue is not always available for revascularization procedures. A small-diameter conduit with patency equivalent to that of native tissue is, therefore, the holy grail of vascular surgery. In this Technology Insight, L'Heureux et al. examine the evolution of tissue-engineered vascular grafts and the key challenges we face in the transition from innovation to widespread clinical use.

The RALES and EPHESUS trials have provided data demonstrating survival benefits with spironolactone and eplerenone in chronic and postinfarction heart failure, leading to more frequent and sometimes unbridled use of these drugs. Here Kalidindi et al. describe the likely mechanisms of action of aldosterone-receptor antagonists, discuss the evidence supporting their use, and provide practical advice.

The differentiation between acute ischemic stroke and intracerebral hemorrhage following cardiac surgery is critical in making appropriate treatment decisions. In this Technology Insight, Leary and Caplan examine the role of multimodal brain MRI in identifying and delineating the size and location of acute ischemic strokes and intracerebral hemorrhages.

Although familial hypercholesterolemia is eminently treatable, the majority of cases go undetected, and this disorder remains a major challenge for preventive medicine. In this timely Viewpoint, Gerald Watts, Barry Lewis, and David Sullivan discuss how new genetic screening initiatives, together with a co-operative approach to treatment, could result in a quantum leap for coronary disease prevention.

In this Viewpoint, Michael Farkouh and colleagues question the evidence that C-reactive protein (CRP) is an independent predictor of future cardiovascular events. They suggest that failure to adjust for all components of the metabolic syndrome (MetS) in previous studies has bought into question the value of CRP over established traditional risk factors. The authors postulate that CRP is only a marker of the MetS and has limited incremental value in cardiovascular risk stratification.

Programmed ventricular stimulation has been proposed as a method of risk stratification in patients with repaired tetralogy of Fallot. In this Viewpoint, Paul Khairy reveals how Bayes' theorem can be used to identify patients most likely to benefit from programmed ventricular stimulation, and to demonstrate that routine electrophysiological testing is unnecessary.

The causes of transient ischemic attack (TIA) are identical to those for stroke; however, there are many unresolved issues regarding acute treatment for TIA. Here Mai Nguyen-Huynh and S Claiborne Johnston review the recent literature on stroke risk after TIA and the guidelines on evaluation and treatment.

Pulmonary arterial hypertension (PAH) was once a lethal condition. As the number of therapeutic options available has risen, however, the treatment of PAH has evolved considerably. In this Review, Aniket Puri, Michael McGoon and Sudhir Kushwaha consider the current knowledge of the pathogenesis of PAH in relation to presently available and novel emerging therapies, including combination therapy, that hold promise for treatment as well as disease modification.

In light of advances in imaging technology, awareness of the clinical significance of thoracic aortic aneurismal disease has increased in recent years and allowed earlier diagnosis. In this Surgery Insight, James Davies and Thoralf Sundt examine the indications for surgical intervention on the dilated aorta, particularly the ascending segment. They discuss the management options currently available and provide their clinical recommendations for follow-up.