Abstract Cardiovascular disease remains the leading global cause of morbidity and mortality. Although advances in prevention, diagnostics, and disease-modifying therapies have prolonged survival, many individuals now live longer with high symptom burden, functional decline, and complex decisional needs. Palliative care (PC) for adults with advanced cardiovascular disease can improve quality of life, support caregivers, and align treatments with patient values and goals. Core elements include symptom management, effective communication, shared decision-making, advance care planning, and integration of psychosocial and spiritual support across the disease trajectory and different care settings. Current evidence demonstrates that early PC intervention can improve symptom control, enhance quality of life, reduce psychological distress, and decrease high-intensity yet low-value care near the end of life. Nevertheless, outside of heart failure populations, gaps in widespread PC implementation across populations supported with cardiac devices as well as across diverse cultural and health systems remain. This state-of-the-art review (i) synthesizes conceptual foundations, referral triggers, and delivery models for PC in cardiovascular medicine; (ii) reviews disease-specific considerations across heart failure, valvular disease, pulmonary hypertension, arrhythmias, and congenital heart disease; (iii) outlines ethical and legal issues including advance directives and device deactivation; (iv) provides practical guidance for symptom management and communication frameworks; and (v) proposes a pragmatic algorithm to support clinical integration of PC into cardiovascular medicine.
Abstract Atherosclerotic plaque healing is a dynamic biological mechanism that occurrs after plaque disruption and represents an endogenous reparative response within the atherosclerotic lesion. This process unfolds through three partially overlapping phases: endogenous thrombus lysis, granulation tissue formation, and re-endothelialization. Through the coordinated interaction of circulating cells, vascular wall components, and soluble mediators, plaque healing promotes fibrous repair and structural stabilization of the disrupted plaque. For many years, plaque healing remained primarily a histopathological observation described in post-mortem studies. The advent of high-resolution intracoronary imaging, particularly optical coherence tomography, has enabled in vivo visualization of the characteristic layered morphology of healed plaques, providing direct clinical confirmation of these early pathological findings. These observations have significantly improved our understanding of the clinical significance of plaque healing. Healed plaques are more frequently observed in patients with chronic coronary syndromes, supporting the concept that healing contributes to plaque stabilization. At the same time, recurrent cycles of plaque disruption followed by repair may lead to progressive luminal narrowing, thereby contributing to the long-term progression of coronary atherosclerosis. This review provided an updated overview of the clinical significance and implications of healed plaques in coronary artery disease, the mechanisms underlying plaque healing, and examines emerging intracoronary and non-invasive imaging modalities that allow their in vivo identification.
Abstract Left ventricular outflow tract obstruction (LVOTO) remains one of the most catastrophic complications of transcatheter mitral valve replacement (TMVR) interventions, including TMVR in native valve, valve-in-valve, valve-in-ring, and valve-in-mitral annular calcification procedures. Its incidence varies widely across procedural types (0%–40%), with mortality rates approaching 36%, and represents a leading cause of patient ineligibility, excluding 4%–50% of candidates from TMVR. Accurate pre-procedural risk stratification relies on cardiac computed tomography, which enables annular sizing, virtual valve implantation, neo- and skirt neo-left ventricular outflow tract area quantification, and fluoroscopic projection planning. Key anatomic determinants of LVOTO include anterior mitral leaflet length, aortomitral angle, septal hypertrophy, left ventricular cavity size, and device-related factors. To mitigate LVOTO risk and expand treatment eligibility, in addition to septal modification, anterior mitral leaflet modification techniques have emerged, broadly categorized into electrosurgical laceration approaches—LAMPOON and ELASTA—and balloon-assisted translocation techniques for balloon-expandable valves—BATMAN, CLEVE, DETROIT, and ROBIN. Each strategy addresses distinct anatomic substrates and procedural scenarios, and their complementary profiles support individualized technique selection. This review aims to present an in-depth discussion of LVOTO in TMVR and anterior leaflet modification strategies.
