Myocardial Revascularization in Patients With Ischemic Cardiomyopathy: For Whom and How

Novel diagnostic biomarkers regulating macrophages autophagy in ischemic cardiomyopathy: An analysis integrating bulk RNA sequencing with single-cell RNA sequencing

Macrophage autophagy plays a pivotal role in ischemia cardiomyopathy (ICM). However, the underlying mechanisms and macrophage autophagy-related biomarkers in ICM have not been elucidated. Therefore, this study was designed to explore novel macrophage autophagy-related biomarkers for ICM. The autophagy-related genes were downloaded from the Human Autophagy Modulator and intersected with the differentially expressed genes (DEGs) of GSE46224 identified with "limma" package in R to obtain the autophagy-related DEGs. Immune infiltration analysis showed that macrophages were the dominant immune cells in ICM tissue. Then the macrophage autophagy-related DEGs were identified using the weighted gene co-expression network analysis (WGCNA). A total of six hub genes were obtained from the PPI network. All of the hub genes showed specific diagnostic significance with AUCs higher than 0.7, as also validated in the external dataset GSE116250. RT-qPCR was conducted to detect the mRNA expression levels of hub genes in vivo ICM rat model. Single-cell RNA sequencing analysis was also performed to investigate gene expression profiles. Our study explored the macrophage autophagy-related biomarkers and their relative pathways in ICM, provided novel diagnostic biomarkers for ICM, and gave new insight into the progression mechanism of ICM.

Characterization of ischemic etiology in heart failure with reduced ejection fraction randomized clinical trials: A systematic review and meta-analysis

AIMS

We investigated how ischemic etiology has been assigned in heart failure with a reduced ejection fraction (HFrEF) randomized controlled trials (RCTs).

METHODS AND RESULTS

We performed a systematic review and meta-analysis of definitions, rates of ischemic etiology and of each ischemic definition component: i) coronary artery disease (CAD), ii) myocardial infarction (MI), iii) coronary revascularization, and iv) prior/current angina. A total of 145 HFrEF RCTs were selected, of which 133 (91.7 %) enrolling both ischemic and non-ischemic patients (629 patients/study on average, median age 64.8 years and ejection fraction 28.2 %). The majority of these RCTs (84.2 %) lacked of clear ischemic etiology definition. Rate of ischemic etiology was 57.8 % (122 RCTs, 169,855 patients), of CAD 53.8 % (25 RCTs, 18,756 patients), of prior MI 46.7 % (57 RCTs, 80,582 patients), of prior revascularization 39.9 % (32 RCTs, 30,730 patients), and of prior/current angina 25.5 % (22 RCTs, 25,572 patients). In studies presenting both variables, prior MI showed the strongest correlations with assigned ischemic etiology (β = 0.84, p < 0.0001, 49 RCTs), followed by prior/current angina (β = 0.84, p < 0.0001, 20 RCTs), prior revascularization (β = 0.30, p = 0.006, 28 RCTs), whereas CAD had no significant correlation (β = 0.29, p = 0.162, from 17 RCTs). Rate of prior MI decreased over time (1986-2007: 51.4 ± 11.6 %; 2008-2016: 48.2 ± 8.8 %; 2017-2023: 41.4 ± 16.6 %; p = 0.057), whereas the one of prior revascularization increased (28.3 ± 11.2 %; 40.7 ± 19.6 %; 49.3 ± 19.4 %; p = 0.048).

CONCLUSIONS

An accurate definition of ischemic etiology is mostly lacking in HFrEF RCTs, and primarily assigned based on investigators clinical judgment, sometimes in the presence of a prior MI, although the rate of this component showed a decline over time.

Optimizing Revascularization in Ischemic Cardiomyopathy: Comparative Evidence on the Benefits and Indications of CABG and PCI

Ischemic cardiomyopathy remains a leading cause of heart failure, yet the optimal revascularization approach for patients with reduced left ventricular function remains uncertain. This review synthesizes current evidence on coronary revascularization strategies, emphasizing real-world applicability and individualized treatment. It critically evaluates the benefits and limitations of coronary artery bypass grafting [CABG] and percutaneous coronary intervention [PCI], highlighting key knowledge gaps. Findings from the STICH trial demonstrate that CABG improves long-term survival despite an elevated early procedural risk, particularly in patients with extensive multivessel disease. In contrast, the REVIVED-BCIS2 trial suggests that PCI enhances quality of life but does not significantly reduce mortality compared to optimal medical therapy, making it a viable alternative for high-risk patients ineligible for surgery. This review underscores the role of advanced imaging techniques in myocardial viability assessment and emphasizes the importance of comprehensive risk stratification in guiding revascularization decisions. Special attention is given to managing high-risk patients unsuitable for CABG and the potential benefits of PCI in symptom relief despite uncertain survival benefits. A stepwise algorithm is proposed to assist clinicians in tailoring revascularization strategies, reinforcing the need for a multidisciplinary Heart Team approach to optimize outcomes.

Myocardial Viability: Evolving Insights and Challenges in Revascularization and Functional Recovery

The prevalence of heart failure, driven significantly by ischemic heart disease, continues to rise globally. Myocardial viability-the potential ability of dysfunctional myocardium to recover contractile function after revascularization-remains an ongoing key area of research in managing ischemic cardiomyopathy. Advances in imaging modalities, including PET/SPECT, cardiac MRI, and dobutamine stress echocardiography, have enabled identification of viable myocardium that can potentially predict their functional recovery following revascularization. Despite these advances, recent evidence from major trials questions the routine reliance on viability testing for revascularization guidance. These studies found a limited correlation between myocardial viability and improved outcomes in key metrics including mortality. Furthermore, they highlighted the effectiveness of guideline-directed medical therapy in improving left ventricular function independent of revascularization. This narrative review explores the concept of myocardial viability, its assessment through contemporary imaging techniques, its clinical utility in decision making for revascularization, and future directions.

Mechanical Circulatory Support With Impella in High-Risk Patients With Chronic Total Occlusion and Complex Multivessel Disease

BACKGROUND

The therapeutic management of patients with multivessel disease and severe left ventricular dysfunction is complex and controversial.

AIMS

The aim of this study was to analyze the clinical outcomes and the changes in left ventricular ejection fraction (LVEF) in patients with severe left ventricular dysfunction and at least one chronic total occlusion (CTO) undergoing percutaneous coronary intervention (PCI) with hemodynamic support provided by Impella.

METHODS

Retrospective, multicenter study enrolling patients with severe left ventricular dysfunction and severe coronary artery disease with at least one CTO who required percutaneous mechanical circulatory support with Impella, from January 2019 to December 2023. The primary endpoints were the incidence of MACE (composite of cardiovascular death, acute myocardial infarct, and target lesion revascularization) at 90 days. The secondary endpoint was changes in LVEF and functional class during the same period.

RESULTS

A total of 27 patients (34 CTOs) were included in the study. The mean SYNTAX score was 35 ± 11. The median J-CTO score of 2 (1-3). At 90 day of follow-up, there were three MACE (11%), two cardiovascular deaths and one TLR; three vascular complications were related to access for the Impella device (only one required invasive treatment); and LVEF improved significantly after revascularization (delta LVEF: 10% [CI 95% 6, 15]). A total of 81% of patients improved their angina or dyspnea status at 90 days.

CONCLUSIONS

In high-risk patients with severe left ventricular dysfunction with complex coronary disease including CTO, PCI with mechanical circulatory support using the Impella device is associated with favorable safety and efficacy outcomes at short-term follow-up.

Lower Sphingomyelin SM 42:1 Plasma Level in Coronary Artery Disease-Preliminary Study

Coronary artery atherosclerosis is a common condition characterized by different symptomatology and incidences of risk factors. The disease manifestation may differ; therefore, proper diagnosis is essential. The preventive, diagnostic, and therapeutic arms are still developing to improve patient outcomes. Among diagnostic steps, the non-invasive tools for evaluating non-classical factors related to metabolomic profiles are gaining attention. The aim of this study was to investigate possible metabolic profiling differences between patients with chronic coronary artery disease (CAD) and a control group based on plasma sphingomyelin levels. The study group consisted of 23 patients (72% male, median age of 69 (63-72) years) presenting with chronic coronary syndrome and confirmed epicardial disease in coronary angiography and 15 patients (33% male, median age of 70 (64-72) years) with normal angiographic results. Clinical data were recorded, and blood samples were collected for standard biochemical laboratory assessment and metabolomic profiling. The plasma sphingomyelin levels were evaluated in patients with different degrees of coronary artery atherosclerosis involvement. In addition, the severity of the epicardial disease was estimated by the Gensini Score. The study subgroups did not differ in terms of age (p = 0.765) and co-morbidities, though the male sex was more common in the CAD group (p = 0.007). The analysis revealed significant differences regarding neutrophil count (p = 0.014), neutrophil-to-lymphocyte ratio (NLR) (p = 0.016), and high-density lipoprotein (HDL) (p = 0.003). Among different plasma sphingomyelin species, there was a significant difference in plasma SM42:1 level (16.2 (14.2-19.1) vs. 20.8 (18.9-21.7) (p = 0.044) between the CAD and control groups, respectively. The SM 42:1 plasma level was independent of the number of involved epicardial arteries (p = 0.109). However, Spearman correlations tests were performed between the SM 42:1 plasma level and the number of coronary arteries diagnosed with atherosclerosis disease (rho = -0.356, p = 0.014) and the severity of the disease measured by the Gensini Score (rho = -0.403, p = 0.006). There was no correlation between plasma sphingomyelin levels and NLR (Spearman's rho = -0.135, p = 0.420), suggesting a lack of inflammatory associations. Further, sphingomyelins showed no relationship with coronary artery disease risk factors such as dyslipidemia and diabetes. Lower plasma SM 42:1 levels were revealed in the CAD group compared with the control group, indicating a possible significance of sphingomyelin 42:1 in coronary artery disease progression.

Identification of novel ferroptosis-related biomarkers associated with the oxidative stress pathways in ischemic cardiomyopathy

Background

Ferroptosis is a cell death process that depends on iron and reactive oxygen species. It significantly contributes to cardiovascular diseases. However, its exact role in ischemic cardiomyopathy (ICM) is still unclear.

Methods

Using bioinformatics methods, we identified new molecular targets associated with ferroptosis in ICM and conducted various analyses-including correlation analysis, pathway enrichment analysis, protein interaction network construction, and analysis of transcription factor and drug interactions, to reveal the potential mechanisms behind these genes.

Results

We evaluated two independent training sets of ICM, GSE57338 and GSE5406, comprising 203 ICM samples, and validation sets GSE76701 to examine differentially expressed genes (DEGs) related to ferroptosis. After extracting the intersection of the gene sets and ferroptosis-related genes, 53 DEGs were identified. Enrichment analyses showed that the alterations in ferroptosis-related DEGs were mainly enriched in oxidative stress response, and immune-related pathways. Furthermore, 11 hub genes were identified using protein-protein interaction network analysis. The key interactions between 11 hub genes were more pronounced in protein localization during ICM development. In addition, we construct a hub gene and transcription factor interaction network and a small molecule drug-gene interaction network. We found that among these hub genes, the N-acetylneuraminate outer membrane channel(NANC) gene is positively correlated with most of the small-molecule drugs used to treat ICM, and its high expression might increase resistance.

Conclusions

Ferroptosis exists in ICM and and is associated with oxidative stress. This association suggests that ferroptosis may facilitate the progression of ICM.

Outcomes after percutaneous coronary intervention or bypass surgery for ischemic cardiomyopathy

INTRODUCTION AND OBJECTIVES

There are 2 options to achieve revascularization in ischemic cardiomyopathy: percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG). While the benefits of PCI for ischemic cardiomyopathy are unclear, achieving complete revascularization with PCI could improve outcomes comparable to CABG.

METHODS

A total of 1496 patients with left ventricular ejection fraction (LVEF) <50% and multivessel disease who underwent either PCI or CABG were selected from a single-center cohort registry. They were divided into the PCI with complete revascularization (n=188), the PCI with incomplete revascularization (n=263), and the CABG group (n=1045), and then compared. The primary outcome was a 5-year composite of cardiac death or myocardial infarction.

RESULTS

A total of 1496 patients treated for ischemic cardiomyopathy was stratified into CABG (n=1045) and PCI (n=451) groups, the latter subdivided into complete (n=188) or incomplete revascularization (n=263). PCI showed a higher incidence of the primary outcome compared with CABG (PCI vs CABG, 27.8% vs 22.2%, adjusted HR, 1.35; 95%CI, 1.05-1.73, P=.019). However, PCI with complete revascularization and CABG had similar incidences of the primary outcome (20.5% vs 22.2%, adjusted HR, 1.07; 95%CI, 0.73-1.57; P=.718).

CONCLUSIONS

CABG is associated with more favorable clinical outcomes than PCI in patients with ischemic cardiomyopathy. However, achieving complete revascularization with PCI could improve outcomes comparable to CABG.

Introducing sequential partial aortic clamp technique for proximal anastomoses and its advantages in myocardial protection in coronary artery bypass grafting

Ischemic heart disease (IHD) is a common and potentially lethal cardiovascular disorder. Coronary artery bypass grafting (CABG) is a standard procedure for treating IHD. This study aims to introduce a novel technique for proximal anastomoses in CABG. This clinical trial studied 29 cases and 29 matched controls. Data were gathered from June 2014 to June 2023. Regarding proximal anastomoses, the sequential partial aortic clamp was performed in cases, and the partial aortic clamp was done for controls. In the sequential partial aortic clamp technique, a relatively small or medium vascular clamp was used instead of one clamp for all proximal anastomoses, which closed a small amount of the aortic wall at each stage. At each stage, only one hole in the aortic wall and only one anastomosis between the conduit and the aorta was performed. After the end of each anastomosis, the clamp was opened and placed on another part of the aorta, and the next anastomosis was performed. CK-MB (p < 0.001, Eta Squared = 0.255) level was significantly lower in cases that underwent sequential partial ascending aorta clamping. However, cTnI level was not statistically different among cases and controls(p = 0.05). Of all patients, 3 (10.3%) cases and 12 (41.4%) controls developed with postoperative atrial fibrillation (p = 0.007). The sequential partial aortic clamp technique leads to less myocardial injury than the partial aortic clamp technique. Also, patients undergoing sequential partial aortic clamp technique are less likely to develop postoperative atrial fibrillation.

Coronary bypass surgery for multivessel disease after percutaneous coronary intervention in acute coronary syndromes: why, for whom, how early?

Multivessel coronary artery disease is present in ∼50% of patients with acute coronary syndrome and, compared with single-vessel disease, entails a higher risk of new ischaemic events and a worse prognosis. Randomized controlled trials have shown the superiority of 'complete revascularization' over culprit lesion-only treatment. Trials, however, only included patients treated with percutaneous coronary intervention (PCI), and evidence regarding complete revascularization with coronary artery bypass graft (CABG) surgery after culprit lesion-only PCI ('hybrid revascularization') is lacking. The CABG after PCI is an open, non-negligible therapeutic option, for patients with non-culprit left main and/or left anterior descending coronary artery disease where evidence in chronic coronary syndrome patients points in several cases to a preference of CABG over PCI. This valuable but poorly studied 'PCI first-CABG later' option presents, however, relevant challenges, mostly in the need of interrupting post-stenting dual antiplatelet therapy (DAPT) for surgery to prevent excess bleeding. Depending on patients' clinical characteristics and coronary anatomical features, either deferring surgery after a safe interruption of DAPT or bridging DAPT interruption with intravenous short-acting antithrombotic agents appears to be a suitable option. Off-pump minimally invasive surgical revascularization, associated with less operative bleeding than open-chest surgery, may be an adjunctive strategy when revascularization cannot be safely deferred and DAPT is not interrupted. Here, the rationale, patient selection, optimal timing, and adjunctive strategies are reviewed for an ideal approach to hybrid revascularization in post-acute coronary syndrome patients to support physicians' choices in a case-by-case patient-tailored approach.

Molecular Imaging of Heart Failure: An Update and Future Trends

Molecular imaging can detect and quantify pathophysiological processes underlying heart failure, complementing evaluation of cardiac structure and function with other imaging modalities. Targeted tracers have enabled assessment of various cellular and subcellular mechanisms of heart failure aiming for improved phenotyping, risk stratification, and personalized therapy. This review outlines the current status of molecular imaging in heart failure, accompanied with discussion on novel developments. The focus is on radionuclide methods with data from clinical studies. Imaging of myocardial metabolism can identify left ventricle dysfunction caused by myocardial ischemia that may be reversible after revascularization in the presence of viable myocardium. In vivo imaging of active inflammation and amyloid deposition have an established role in the detection of cardiac sarcoidosis and transthyretin amyloidosis. Innervation imaging has well documented prognostic value in predicting heart failure progression and arrhythmias. Tracers specific for inflammation, angiogenesis and myocardial fibrotic activity are in earlier stages of development, but have demonstrated potential value in early characterization of the response to myocardial injury and prediction of cardiac function over time. Early detection of disease activity is a key for transition from medical treatment of clinically overt heart failure towards a personalized approach aimed at supporting repair and preventing progressive cardiac dysfunction.

REVIVED BCIS-2: update and key learnings

PURPOSE OF REVIEW

This review summarises the shifting paradigms in the treatment of ischemic left ventricular dysfunction, spotlighting the revascularization for ischemic ventricular dysfunction-British cardiovascular intervention society-2 (REVIVED-BCIS2) trial results and its impact on key therapeutic goals: survival, left ventricular function, arrhythmia prevention, quality of life and viability testing.

RECENT FINDINGS

The REVIVED-BCIS2 trial, and its subsequent sub studies highlighted that (PCI) does not provide additional benefits to optimal medical therapy in terms of improving survival, left ventricular (LV) function, arrhythmic risk or quality of life. Additionally, viability testing did not differentiate patients who could benefit from PCI, although scar burden was found to be a significant predictor of outcome in these patients.

SUMMARY

The outcomes of REVIVED have challenged multiple existing beliefs in the field of ischaemic left ventricular dysfunction management, emphasising the importance of investigating evidence free areas in our practice. Future work, including the STICH3 international consortium of trials, aims to answer some of the remaining unanswered questions.

Current indications and surgical strategies for myocardial revascularization in patients with left ventricular dysfunction: a scoping review

BACKGROUND

Ischemic cardiomyopathy (ICM) accounts for more than 60% of congestive heart failure cases and is associated with high morbidity and mortality rates. Myocardial revascularization in patients with left ventricular dysfunction (LVD) and a left ventricular ejection fraction (LVEF) ≤35% aims to improve survival and quality of life and reduce complications associated with heart failure and coronary artery disease. The majority of randomized clinical trials have consistently excluded those patients, resulting in evidence primarily derived from observational studies.

MAIN BODY

We performed a scoping review using the Arksey and O'Malley methodology in five stages: 1) formulating the research question; 2) locating relevant studies; 3) choosing studies; 4) organizing and extracting data; and 5) compiling, summarizing, and presenting the findings. This literature review covers primary studies and systematic reviews focusing on surgical revascularization strategies in adult patients with ischemic left ventricular dysfunction (LVD) and a left ventricular ejection fraction (LVEF) of 35% or lower. Through an extensive search of Medline and the Cochrane Library, a systematic review was conducted to address three questions regarding myocardial revascularization in these patients. These questions outline the current knowledge on this topic, current surgical strategies (off-pump vs. on-pump), and graft options (including hybrid techniques) utilized for revascularization. Three independent reviewers (MAE, DP, and AM) applied the inclusion criteria to all the included studies, obtaining the full texts of the most relevant studies. The reviewers subsequently assessed these articles to make the final decision on their inclusion in the review. Out of the initial 385 references, 156 were chosen for a detailed review. After examining the full articles were examined, 134 were found suitable for scoping review.

CONCLUSION

The literature notes the scarcity of surgical revascularization in LVD patients in randomized studies, with observational data supporting coronary revascularization's benefits. ONCABG is recommended for multivessel disease in LVD with LVEF < 35%, while OPCAB is proposed for older, high-risk patients. Strategies like internal thoracic artery skeletonization harvesting and postoperative glycemic control mitigate risks with BITA in uncontrolled diabetes. Total arterial revascularization maximizes long-term survival, and hybrid revascularization offers advantages like shorter hospital stays and reduced costs for significant LAD lesions.

Assessment of Myocardial Viability in Ischemic Cardiomyopathy With Reduced Left Ventricular Function Undergoing Coronary Artery Bypass Grafting

BACKGROUND

We aim to provide a comprehensive review of the current state of knowledge of myocardial viability assessment in patients undergoing coronary artery bypass grafting (CABG), with a focus on the clinical markers of viability for each imaging modality. We also compare mortality between patients with viable myocardium and those without viability who undergo CABG.

METHODS

A systematic database search with meta-analysis was conducted of comparative original articles (both observations and randomized controlled studies) of patients undergoing CABG with either viable or nonviable myocardium, in EMBASE, MEDLINE, Cochrane database, and Google Scholar, from inception to 2022. Imaging modalities included were dobutamine stress echocardiography (DSE), cardiac magnetic resonance (CMR), single-photon emission computed tomography (SPECT), and positron emission tomography (PET).

RESULTS

A total of 17 studies incorporating a total of 2317 patients were included. Across all imaging modalities, the relative risk of death post-CABG was reduced in patients with versus without viability (random-effects model: odds ratio: 0.42; 95% confidence interval: 0.29-0.61; p < 0.001). Imaging for myocardial viability has significant clinical implications as it can affect the accuracy of the diagnosis, guide treatment decisions, and predict patient outcomes. Generally, based on local availability and expertise, either SPECT or DSE should be considered as the first step in evaluating viability, while PET or CMR would provide further evaluation of transmurality, perfusion metabolism, and extent of scar tissue.

CONCLUSION

The assessment of myocardial viability is an essential component of preoperative evaluation in patients with ischemic heart disease undergoing surgical revascularization. Careful patient selection and individualized assessment of viability remain paramount.

Surgical Management of Ischemic Cardiomyopathy Patients with Severe Left Ventricular Dysfunction: Is It Time to Reconsider Revascularization Surgery?

Ischemic cardiomyopathy patients with severe left ventricular dysfunction are a specific group of patients with poor surgical outcomes. There are few surgical treatment options in practice for the treatment of these patients such as heart transplantation, coronary artery bypass surgery, surgical ventricular restoration, etc. Despite multiple treatment options, there are no explicit clinical guidelines available to guide surgeons in choosing the most appropriate option and ensuring that the specific patient can benefit from the selected surgical treatment. Heart transplantation is the gold standard treatment for ischemic cardiomyopathy patients with severe left ventricular dysfunction, but it is limited to very few highly equipped centers around the world due to donor shortages, complex perioperative and surgical management, and limited technological and human resources. It is evident from some studies that heart transplant-eligible candidates can benefit from alternative surgical options such as coronary artery bypass surgery alone or combined with surgical ventricular restoration. Therefore, alternative surgical options that are used for most of the population, especially in developing and underdeveloped countries, need to be discussed to improve their outcomes. A challenge in the recent era which has yet to find a solution is to determine which heart transplant candidate can benefit from simple revascularization compared to a complex heart transplantation procedure. Myocardial viability testing was one of the most important determinants in deciding whether a patient should undergo revascularization, but its role in guiding appropriate surgical options has been challenged. This review aims to discuss the available surgical management options and their long-term outcomes for patients with ischemic cardiomyopathy, which will eventually help surgeons when choosing a surgical procedure.

Comparative Efficacy of Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting in the Treatment of Ischemic Heart Disease: A Systematic Review and Meta-Analysis of Recent Randomized Controlled Trials

Background

Ischemic heart disease (IHD) is a major global health issue and a leading cause of death. This study compares the effectiveness of percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) in the management of IHD, focusing on their impact on revascularization, myocardial infarction (MI), and post-procedural stroke. This study aimed to evaluate and compare the effectiveness of PCI and CABG in treating IHD based on an exhaustive literature review of the past 5 years, emphasizing recent advancements and outcomes in IHD management.

Methods

A comprehensive literature review analyzed 32 randomized controlled trials (RCTs) retrieved from databases such as PubMed, Cochrane Library, and Google Scholar. The study specifically assessed the incidences of revascularization, stroke, and MI in patients treated with either PCI or CABG. The comparison between CABG and PCI exclusively focused on lesions with a SYNTAX score exceeding 32.

Results

Our findings highlight CABG's significant efficacy over PCI in reducing revascularization and MI. The aggregated Mantel-Haenszel (M-H) value for revascularization was 1.85 (95% confidence interval (CI): 1.65 - 2.07), signifying CABG's advantage. Additionally, CABG demonstrated superior performance in diminishing MI occurrences (M-H = 2.71, 95% CI: 1.13 - 6.53). In contrast, PCI was more effective in reducing stroke (M-H = 0.80, 95% CI: 0.60 - 1.10).

Conclusion

The study confirms CABG's superiority in reducing revascularization and MI in IHD patients, highlighting PCI's effectiveness in reducing stroke risk. These findings underscore the importance of personalized treatment strategies in IHD management and emphasize the need for ongoing research and evidence-based guidelines to aid in treatment selection for IHD patients.

Quercetin inhibits necroptosis in cardiomyocytes after ischemia-reperfusion via DNA-PKcs-SIRT5-orchestrated mitochondrial quality control

We investigated the mechanism by which quercetin preserves mitochondrial quality control (MQC) in cardiomyocytes subjected to ischemia-reperfusion stress. An enzyme-linked immunosorbent assay was employed in the in vivo experiments to assess myocardial injury markers, measure the transcript levels of SIRT5/DNAPK-cs/MLKL during various time intervals of ischemia-reperfusion, and observe structural changes in cardiomyocytes using transmission electron microscopy. In in vitro investigations, adenovirus transfection was employed to establish a gene-modified model of DNA-PKcs, and primary cardiomyocytes were obtained from a mouse model with modified SIRT5 gene. Reverse transcription polymerase chain reaction, laser confocal microscopy, immunofluorescence localization, JC-1 fluorescence assay, Seahorse energy analysis, and various other assays were applied to corroborate the regulatory influence of quercetin on the MQC network in cardiomyocytes after ischemia-reperfusion. In vitro experiments demonstrated that ischemia-reperfusion injury caused changes in the structure of the myocardium. It was seen that quercetin had a beneficial effect on the myocardial tissue, providing protection. As the ischemia-reperfusion process continued, the levels of DNA-PKcs/SIRT5/MLKL transcripts were also found to change. In vitro investigations revealed that quercetin mitigated cardiomyocyte injury caused by mitochondrial oxidative stress through DNA-PKcs, and regulated mitophagy and mitochondrial kinetics to sustain optimal mitochondrial energy metabolism levels. Quercetin, through SIRT5 desuccinylation, modulated the stability of DNA-PKcs, and together they regulated the "mitophagy-unfolded protein response." This preserved the integrity of mitochondrial membrane and genome, mitochondrial dynamics, and mitochondrial energy metabolism. Quercetin may operate synergistically to oversee the regulation of mitophagy and the unfolded protein response through DNA-PKcs-SIRT5 interaction.

Back to the basics: The need for an etiological classification of chronic heart failure

The left ventricular (LV) ejection fraction (LVEF), despite its severe limitations, has had an epicentral role in heart failure (HF) classification, management, and risk stratification for decades. The major argument favoring the LVEF based HF classification has been that it defines groups of patients in which treatment is effective. However, this reasoning has recently collapsed, since medical treatment with neurohormonal inhibitors, has proved beneficial in most HF patients regardless of the LVEF. In addition, there has been compelling evidence, that the LVEF provides poor guidance for device treatment of chronic HF (implantation of cardioverter defibrillator, cardiac resynchronization therapy) since sudden cardiac death may occur and cardiac dyssynchronization may be disastrous in all HF patients. The same holds true for LV assist device implantation, in which the LVEF has been used as a surrogate for LV size. In this review article we update the evidence questioning the use of LVEF-based HF classification and argue that guidance of chronic HF treatment should transition to more contemporary concepts. Specifically, we propose an etiologic chronic HF classification predominantly based on epidemiological data, which will be foundational for further higher resolution phenotyping in the emerging era of precision medicine.

Temporal Trend in Revascularization for Patients With Ischemic Cardiomyopathy and Multivessel Coronary Artery Disease

BACKGROUND

Current guidelines recommend revascularization in patients with ischemic cardiomyopathy (ICM). However, there is limited information about the trends and outcomes of coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) in ischemic cardiomyopathy patients with multivessel coronary artery disease.

METHODS AND RESULTS

Using New Jersey state mandatory registries, 8083 patients with ischemic cardiomyopathy with CABG or PCI revascularization for multivessel coronary artery disease from 2007 to 2018 were included in the analysis. Joinpoint regression and multivariable logistic regression analyses were performed to assess the annual percentage change in trends and predictors of the 30-day mortality rate, respectively. A decline in CABG procedures was observed from 2007 to 2011 (annual percentage change, -11.5%; P=0.003), followed by stabilization. The PCI trend remained unchanged from 2007 to 2010 and then increased significantly (annual percentage change, 3.2%; P=0.02). In the subsample of patients with proximal left anterior descending artery plus circumflex and right coronary artery, CABG was a predominant procedure until 2011, and the proportion of both procedures did not differ thereafter. In the subsample of patients with left anterior descending artery and any other artery stenosis, PCI remained dominant from 2007 to 2018, while in patients with left main and any other artery stenosis, CABG remained dominant from 2007 to 2018 (P<0.001). The 30-day risk-adjusted mortality rate was higher after PCI versus CABG for each year, but after adjustment for completeness of revascularization, there was no difference between groups.

CONCLUSIONS

The patterns of revascularization procedures for patients with ischemic cardiomyopathy with multivessel coronary artery disease have changed over the years, as evidenced by the changes in CABG and PCI trends. CABG and PCI had comparable 30-day risk-adjusted mortality risks.

Temporary mechanical circulatory support & enhancing recovery after cardiac surgery

PURPOSE OF REVIEW

This review highlights the integration of enhanced recovery principles with temporary mechanical circulatory support associated with adult cardiac surgery.

RECENT FINDINGS

Enhanced recovery elements and efforts have been associated with improvements in quality and value. Temporary mechanical circulatory support technologies have been successfully employed, improved, and the value of their proactive use to maintain hemodynamic goals and preserve long-term myocardial function is accruing.

SUMMARY

Temporary mechanical circulatory support devices promise to enhance recovery by mitigating the risk of complications, such as postcardiotomy cardiogenic shock, organ dysfunction, and death, associated with adult cardiac surgery.

Coronary Artery Bypass Surgery: Evidence-Based Practice

Coronary artery bypass graft (CABG) surgery remains a pivotal cornerstone, offering established symptomatic alleviation and prognostic advantages for patients grappling with complex multivessel and left main coronary artery diseases. Despite the lucid guidance laid out by contemporary guidelines regarding the choice between CABG and percutaneous coronary intervention (PCI), a notable hesitation persists among certain patients, characterized by psychological reservations, knowledge gaps, or individual beliefs that sway their inclination toward surgical intervention. This comprehensive review critically synthesizes the prevailing guidelines, modern practices, and outcomes pertaining to CABG surgery, delving into an array of techniques and advancements poised to enhance both short-term and enduring surgical outcomes. The exploration encompasses advances in on-pump and off-pump procedures, conduit selection strategies encompassing the bilateral utilization of internal mammary artery and radial artery conduits, meticulous graft evaluation methodologies, and the panorama of minimally invasive approaches, including those assisted by robotic technology. Furthermore, the review navigates the terrain of hybrid coronary revascularization, shedding light on the pivotal roles of shared decision-making and the heart team in shaping treatment pathways. As a comprehensive compendium, this review not only navigates the intricate landscape of CABG surgery but also aligns it with contemporary practices, envisioning its trajectory within the evolving currents of healthcare dynamics.

Treatment Strategies for Chronic Coronary Heart Disease with Left Ventricular Systolic Dysfunction or Preserved Ejection Fraction-A Systematic Review and Meta-Analysis

In this meta-analysis, we examine the advantages of invasive strategies for patients diagnosed with chronic coronary heart disease (CHD) and preserved left ventricular (LV) function, as well as those with significant LV systolic dysfunction (LV ejection fraction (EF) < 45%).

MATERIAL AND METHODS

We conducted a systematic search to identify all randomized trials directly comparing invasive strategies with optimal medical therapy (OMT) in patients diagnosed with chronic CHD. Data from these trials were pooled using a random-effects meta-analysis. The primary outcome assessed was the all-cause mortality, while secondary endpoints included cardiovascular (CV) death, stroke, myocardial infarction (MI), and unplanned revascularization. This study was designed to assess the benefits of both invasive strategies and OMT in patients with preserved LV function and in those with LV systolic dysfunction. The statistical analysis of the data was conducted using the Review Manager (RevMan) software, version 5.4.1 (The Cochrane Collaboration, 2020).

RESULTS

Twelve randomized studies enrolling 13,912 patients were included in the final analysis. Among the patients with chronic CHD and preserved LV systolic function, revascularization did not demonstrate a reduction in all-cause mortality (8.52% vs. 8.45%, p = 0.45), CV death (3.41% vs. 3.62%, p = 0.08), or the incidence of MI (9.88% vs. 10.49%, p = 0.47). However, the need for unplanned myocardial revascularization was significantly lower in the group following the initial invasive approach compared to patients undergoing OMT (14.75% vs. 25.72%, p < 0.001). In contrast, the invasive strategy emerged as the preferred treatment modality for patients with ischemic LV systolic dysfunction. This approach demonstrated lower rates of all-cause mortality (40.61% vs. 46.52%, p = 0.004), CV death (28.75% vs. 35.82%, p = 0.0004), and MI (8.19% vs. 10.8%, p = 0.03).

CONCLUSIONS

In individuals diagnosed with chronic CHD and preserved LV EF, the initial invasive approach did not demonstrate a clinical advantage over OMT. Conversely, in patients with ischemic LV systolic dysfunction, myocardial revascularization was found to reduce the risks of CV events and enhance the overall outcomes. These findings hold significant clinical relevance for optimizing treatment strategies in patients with chronic CHD, contingent upon myocardial contractility status.

Understanding the role of coronary artery revascularization in patients with left ventricular dysfunction and multivessel disease

Coronary artery disease (CAD) is the most common cause of heart failure with reduced ejection fraction (HFrEF). Advances and innovations in medical therapy have been shown to play a crucial role in improving the prognosis of patients with CAD and HFrEF; however, mortality rate in these patients remains high, and the role of surgical and/or percutaneous revascularization strategy is still debated. The Surgical Treatment for Ischemic Heart Failure (STICH) trial and the Revascularization for Ischemic Ventricular Dysfunction (REVIVED) trial have attempted to provide an answer to this issue. Nevertheless, the results of these two trials have generated further uncertainties. Their findings do not provide a definitive answer about the ideal clinical phenotype for surgical or percutaneous coronary revascularization and dispute the historical dogma on myocardial viability and the theory of myocardial hibernation, raising new questions about the proper selection of patients who are candidates for coronary revascularization. The aim of this review is to provide an overview on the actual available evidence of coronary artery revascularization in patients with CAD and left ventricular dysfunction and to suggest new insights on the proper selection and management strategies in this high-risk clinical setting.

Phenotyping heart failure by nuclear imaging of myocardial perfusion, metabolism, and molecular targets

Nuclear imaging techniques can detect and quantify pathophysiological processes underlying heart failure, complementing evaluation of cardiac structure and function with other imaging modalities. Combined imaging of myocardial perfusion and metabolism can identify left ventricle dysfunction caused by myocardial ischaemia that may be reversible after revascularization in the presence of viable myocardium. High sensitivity of nuclear imaging to detect targeted tracers has enabled assessment of various cellular and subcellular mechanisms of heart failure. Nuclear imaging of active inflammation and amyloid deposition is incorporated into clinical management algorithms of cardiac sarcoidosis and amyloidosis. Innervation imaging has well-documented prognostic value with respect to heart failure progression and arrhythmias. Emerging tracers specific for inflammation and myocardial fibrotic activity are in earlier stages of development but have demonstrated potential value in early characterization of the response to myocardial injury and prediction of adverse left ventricular remodelling. Early detection of disease activity is a key for transition from broad medical treatment of clinically overt heart failure towards a personalized approach aimed at supporting repair and preventing progressive failure. This review outlines the current status of nuclear imaging in phenotyping heart failure and combines it with discussion on novel developments.

Prognostic impact of cardiac resynchronization therapy guided by phase analysis: a CZT study

Aims

To evaluate whether phase analysis imaging may predict treatment response and long-term prognosis after cardiac resynchronization therapy (CRT).

Methods and results

Sixty-nine patients underwent myocardial perfusion imaging followed by CRT. Patients with ischaemic heart disease and non-ischaemic cardiomyopathy (NICM) were identified. Left ventricular (LV) mechanical dyssynchrony (LVMD) was assessed at phase analysis and the region of the latest mechanical activation was identified. LV pacing lead position was considered 'concordant' when located in the region of the latest mechanical activation, and 'discordant' otherwise. The '6 months post-CRT'/'baseline' ratio of LV ejection fraction was computed as a measure of CRT response. LVMD was revealed in 47/69 patients, 27 of whom (57%) had a concordant LV lead implantation. Only concordant pacing was associated with LV functional improvement (ejection fraction ratio: 1.28 ± 0.25 vs. 1.11 ± 0.32 in discordant stimulation, P = 0.028). However, this relationship persisted only in patients with NICM (P < 0.001), while it disappeared in those with ischaemic heart disease (P = NS). Twenty-eight events occurred during 30 ± 21 months follow-up. While discordant LV lead location was the major predictor of unfavourable prognosis (hazard ratio 3.29, 95% confidence interval 1.25-8.72; P = 0.016), this relationship was confirmed only in patients with NICM.

Conclusions

Phase analysis of myocardial perfusion imaging may guide CRT implantation, identifying patients who would most likely benefit from this procedure.