Abstract:It is not enough to treat cholesterol and blood pressure alone to prevent heart attacks; social causes must also be addressed: unequal educational opportunities, unemployment, and a lack of prevention. The extent of the impact of these factors can be seen in the federal state of Bremen. For this reason, targeted strategies were developed there ("Bremen model") to provide heart health from being a matter of income or background.

Die kardiovaskuläre Bildgebung liefert wichtige Informationen für die Diagnostik kardiovaskulärer Erkrankungen, für Therapieentscheidungen sowie zur individuellen Prognoseabschätzung. Die Magnetresonanztomographie (MRT) spielt dabei eine wachsende Rolle. Sie gibt Informationen zur kardialen Anatomie, zur kardialen Funktion, Perfusion, Vitalität und Inflammation sowie zum Blutfluss. Häufige Indikationen für eine kardiovaskuläre MRT sind die Beurteilung bei koronarer Herzkrankheit, Kardiomyopathien, entzündlichen Herzkrankheiten, Herzinsuffizienz, Herzklappenerkrankungen und angeborenen Herzfehlern. Dieser 2‑teilige Beitrag liefert einen praxisnahen Überblick.

Background Bleeding remains among the most common complications following catheter-based structural heart procedures. Its clinical implications following transcatheter tricuspid valve interventions have yet to be systematically evaluated. Objectives The aim of this study was to evaluate the incidence of bleeding and its predictors and prognostic implications following transcatheter tricuspid valve repair. Methods TriValve (International Multisite Transcatheter Tricuspid Valve Therapies Registry; NCT03416166) is an international multicenter registry capturing a range of transcatheter tricuspid valve interventions. Bleeding events were classified according to the Bleeding Academic Research Consortium (BARC). For this analysis, BARC bleeding events type 2, 3, and 5 occurring within 1 year of transcatheter tricuspid valve repair were retrospectively evaluated. Results A total of 440 patients (mean age 76.6 ± 8.9 years, 57.7% women) were included. The BARC major bleeding incidence was 11.4% (50 patients). Postprocedural tricuspid regurgitation severity (adjusted ORl]: 1.83; 95% CI: 1.12-3.01; P = 0.02), higher systolic pulmonary artery pressures (adjusted OR: 1.61; 95% CI: 1.16-2.24; P = 0.0048), and increasing procedure duration (adjusted OR: 1.49; 95% CI: 1.00-2.22; P = 0.049) were associated with bleeding, whereas concomitant oral anticoagulation was not (adjusted OR: 1.51; 95% CI: 0.74-3.10; P = 0.30). Major bleeding was associated with a markedly increased risk for in-hospital death (adjusted OR: 106; 95% CI: 1.31-8,553; P = 0.04). Likewise, bleeding was significantly associated with a 1-year composite of death or all-cause hospital readmission (adjusted HR: 2.41; 95% CI: 1.39-4.19; P = 0.002), all-cause death (adjusted HR: 3.55; 95% CI: 1.75-7.21; P = 0.0004), and cardiovascular death (adjusted HR: 3.72; 95% CI: 1.62-8.52; P = 0.002). Conclusions BARC major bleeding occurs in about 11% of patients following transcatheter tricuspid valve repair and is a major determinant of in-hospital and 1-year death. Enhanced patient selection and procedural optimization (with shorter procedural times) may help curb bleeding risk.

BACKGROUND:Despite device improvements for transcatheter aortic valve replacement (TAVR) and increased operator expertise, unfavorable aortic root anatomy might subtend worse procedural and clinical outcomes. The aim of the study is to assess procedural and clinical outcomes of transfemoral TAVR in patients with and without unfavorable aortic root anatomy and receiving Evolut PRO/PRO+ or SAPIEN 3 Ultra devices in contemporary clinical practice. METHODS:Patients enrolled in the multicenter OPERA-TAVI registry were considered. Patients were compared using propensity score matching according to the presence or absence of unfavorable anatomical characteristics of the aortic root [bicuspid aortic valve (BAV), moderate-to-severe left ventricular outflow tract calcifications, horizontal aorta]. Primary endpoints were Valve Academic Research Consortium (VARC)-3 device success and early safety. The secondary endpoint was a composite of 1-year all-cause death, disabling stroke and heart failure rehospitalization. RESULTS:Among a total of 1815 patients, 629 patients (34.7%) had at least one unfavorable characteristic. After adjustment, 624 matched pairs of patients were compared.VARC-3 device success (85.3% vs. 92.0%, P < 0.001) and early safety (72.9% vs. 79.6%, P = 0.006) were lower in patients with unfavorable characteristics. The secondary composite endpoint was higher in patients with unfavorable anatomical characteristics (Kaplan-Meier estimates 15.3 vs. 12.0%; Plogrank = 0.019). Among patients with unfavorable anatomical characteristics, BAV alone was associated with early safety [odds ratio 2.15, 95% confidence interval 1.04-4.70, P = 0.05]. CONCLUSIONS:Patients undergoing transfemoral TAVR had lower rates of device success and early safety in the presence of unfavorable anatomical characteristics, along with worse 1-year clinical outcomes. However, BAV was associated with higher early safety in this context.

INTRODUCTION:The impact of coexisting left-sided valvular heart disease (VHD) on clinical outcomes following tricuspid valve edge-to-edge repair (T-TEER) for tricuspid regurgitation (TR) remains unclear, particularly under real-world conditions. To evaluate the prevalence and prognostic impact of concomitant left-sided VHD in patients undergoing T-TEER. METHODS:This study included all patients undergoing T-TEER from the European Registry of Transcatheter Repair for Tricuspid Regurgitation (EuroTR; NCT06307262) with complete echocardiographic data on left-sided valve disease. Study endpoints included survival and heart failure hospitalizations (HFH) at 2 years, NYHA functional class, and TR reduction. RESULTS:Among a total of 1647 eligible patients, 95.8%, 35.6%, and 3.8% had ≥mild, moderate, and severe concomitant VHD, respectively. Moderate or higher VHD was associated with a significantly reduced 2-year survival (P < .001) and reduced 2-year HFH-free survival (P = .005). Multivariate regression analysis confirmed ≥ moderate VHD to be an independent predictor of mortality (hazard ratio 1.54, 95% CI 1.21-1.96, P < .001). Despite worse TR and NYHA functional class at baseline in patients with ≥moderate VHD, T-TEER was associated with a significant TR reduction (P < .001) and symptomatic improvement (P < .001). CONCLUSION:Concomitant left-sided VHD is common among patients undergoing T-TEER and is independently associated with worse survival and higher rates of HFH. Nevertheless, T-TEER provides meaningful symptomatic benefit and durable TR reduction in patients with and without VHD burden.

Infantile nystagmus (IN) is a common neuro-ophthalmological disorder that presents as early-onset involuntary oscillations of the eyes. Here, we report a novel genotype-phenotype correlation that associates sequence alterations in the calcium voltage-gated channel auxiliary subunit beta 3 (CACNB3) gene, encoding the CaVβ3 protein, with idiopathic infantile nystagmus (IIN). Linkage analysis, whole exome and Sanger sequencing identified a homozygous missense mutation (c.316G>C) in CACNB3 co-segregating with IIN. Our calcium imaging experiments suggest that the p.Gly106Arg mutation in the Src homology 3 domain of CaVβ3 may impair voltage-gated calcium channel function at the plasma membrane and may increase ligand-triggered inositol trisphosphate receptor mediated calcium release at the endoplasmic reticulum. Co-localization studies indicate reduced plasma membrane localization of the calcium channel. We propose CACNB3 to be a novel gene associated with IIN. Our findings point towards an important role of calcium-signalling in IIN and may contribute to deciphering its aetiology.

Importance:Proprotein convertase subtilisin-kexin type 9 (PCSK9) inhibition is recommended as second- or third-line lipid-lowering therapy after myocardial infarction (MI), resulting in prolonged periods of inadequate low-density lipoprotein cholesterol (LDL-C) control. Whether in-catheterization laboratory decision of PCSK9 inhibition, started before mechanical reperfusion, could improve LDL-C control and clinical outcomes at 1 year is unknown. Objective:To evaluate evolocumab as first-line therapy vs standard care in patients with high-risk acute MI undergoing percutaneous coronary intervention (PCI). Design, Setting, and Participants:This international, phase 4, prospective randomized, open, blinded end-point adjudication study was conducted at 48 sites in 6 countries. Adults with high-risk ST-elevation MI (STEMI; aged >55 years) or non-ST-elevation MI (NSTEMI) with 1 or more additional high-risk characteristics were enrolled beginning September 29, 2021, through May 22, 2025, with final follow-up on May 22, 2026. Interventions:Patients were randomized 1:1 to receive evolocumab 140 mg subcutaneously every 2 weeks for 1 year (first injection before PCI) in addition to standard care (n = 1087) or standard care alone (n = 1074). Standard care included high-intensity oral lipid-lowering therapy with the optional PCSK9 inhibitor use per guideline indication in the control group. Main Outcomes and Measures:The primary outcome was LDL-C less than 55 mg/dL and at least 50% reduction in LDL-C from baseline at 12 months. The main clinical end point was all-cause death or unplanned cardiovascular hospitalization at 12 months. Results:Among 2161 randomized patients (mean age, 67 years; 1703 males [79%]; 1261 [58%] with STEMI; 900 [42%] with NSTEMI), the primary outcome was achieved in 792 of 970 patients (82%) with evolocumab vs 370 of 934 (40%) with standard care (adjusted odds ratio, 5.54 [95% CI, 4.50-6.82]; P < .001). At 6 weeks, median LDL-C was 16 mg/dL with evolocumab vs 56 mg/dL with standard care. The main clinical end point occurred in 159 of 1087 patients (14.6%) with evolocumab vs 165 of 1074 (15.4%) with standard care (adjusted odds ratio, 0.94 [95% CI, 0.73-1.19]; P = .59). Conclusions and Relevance:In patients with acute MI undergoing PCI, first-line evolocumab combined with high-intensity lipid-lowering therapy produced rapid and sustained LDL-C reduction, with more than 80% of patients reaching the guideline-recommended target at 1 year. However, no clinical benefit was detected during the first year of follow-up, arguing against clinically meaningful acute pleiotropic effects of PCSK9 inhibitors in addition to standard care. Trial Registration:ClinicalTrials.gov Identifier: NCT04951856.

The selection of the optimal antithrombotic regimen in patients with atrial fibrillation and acute coronary syndrome remains challenging. Previous trials have demonstrated that dual antithrombotic therapy (DAT), consisting of direct oral anticoagulants (DOACs) plus a P2Y12 inhibitor, reduces bleeding compared to a triple-therapy regimen using vitamin K antagonists. However, subsequent meta-analyses have suggested an increased risk of ischemic events with DAT, particularly within the first month of treatment. Clopidogrel has been the predominant P2Y12 inhibitor used across these studies, despite the risk of high on-treatment platelet reactivity when using this drug. In this study, we conducted an open-label, randomized controlled trial (EPIDAURUS) in patients with atrial fibrillation and acute coronary syndrome, designed to assess the efficacy and safety of a 1-month regimen of DOAC plus potent P2Y12 inhibitor (prasugrel or ticagrelor) compared to DOAC plus clopidogrel and in-hospital aspirin. The primary outcomes of the trial were an efficacy endpoint, recurrent ischemic events and safety endpoints, including death and major bleeding, which were evaluated 6 weeks after randomization using separate win-loss ratio analyses. The study was prematurely terminated after enrollment of 602 patients (154 female) of an expected 1,474 patients, owing to safety concerns raised by the Data and Safety Monitoring Board. Exploratory analyses of secondary safety endpoints, including bleeding type ≥2 and ≥3 according to the Bleeding Academic Research Consortium scale, revealed that, compared to clopidogrel and in-hospital aspirin, treatment with a potent P2Y12 inhibitor was associated with higher bleeding rates without a clear reduction in the risk of ischemic complications. These findings do not support the routine use of potent P2Y12 inhibitors in combination with DOACs in this patient population. ClinicalTrials.gov identifier: NCT04981041 .

AIMS:Cardiogenic shock (CS) is often treated with catecholamines titrated to an adequate target mean arterial pressure (MAP) while minimizing adverse effects. We aim to assess the optimal catecholamine dose/MAP balance in heart failure-associated CS (HF-CS). METHODS:Patients with HF-CS were retrospectively enrolled from 16 tertiary centres in 5 European countries (2016-2021; NCT03313687). Dosage was quantified by inotropic scores (epinephrine, norepinephrine, and dobutamine). Associations of baseline and seven-day summarized dosage with intensive care unit (ICU) discharge (mixed-effects logistic regression) and 30-day mortality (Cox regression) were analysed. Potential catecholamine/MAP target ratios for optimized outcomes were assessed in models adjusted for age, sex, pH, lactate and prior resuscitation, stratified by centre. RESULTS:N = 704 patients: median age 63 years, 74% male, 34% post-resuscitation, median lactate 5.2 mmol/l. Of these, 53% were discharged from ICU, 48% died within 30 days. Higher inotropic scores independently predicted a lower probability of ICU discharge (baseline score: OR 0.78 [95%-CI 0.69-0.88]; summarized score: OR 0.46 [0.38-0.56]; both P < .001) and higher risk of 30-day mortality (baseline score: HR 1.27 [1.15-1.40], summarized score HR 1.83 [1.60-2.09]; both P < .001). A score/MAP ratio <0.403 µg/kg/min/mmHg was associated with higher ICU discharge odds (ceiling effect); a < 0.426 µg/kg/min/mmHg with lower 30-day mortality hazards (no ceiling effect). Lowering catecholamine doses by accepting reduced MAP targets was linked to better outcomes. CONCLUSION:In HF-CS, higher catecholamine support independently associates with worse outcomes. Accepting lower blood pressure targets to reduce catecholamine dosage may improve outcomes. Validation in randomized controlled trials is urgently needed.

Cardiogenic shock complicates takotsubo syndrome (TTS) in approximately 10

Heart failure with preserved ejection fraction (HFpEF) is a heterogeneous syndrome defined by diastolic dysfunction and limited therapeutic options, with increasing recognition of right ventricular (RV) involvement. Using invasive pressure-volume loop analysis, we assessed biventricular hemodynamics in lean and obese ZSF1 rats, a well-established rodent model of HFpEF. Obese rats exhibited significantly increased RV and left ventricular (LV) chamber stiffness, with a positive correlation between RV and LV stiffness constants, indicating biventricular diastolic dysfunction. RV end-systolic elastance was preserved, whereas LV contractility was increased. Despite elevated RV stiffness, myocardial fibrosis was unchanged, while RV and septal cardiomyocyte hypertrophy was significantly increased. These findings demonstrate that RV diastolic dysfunction in this HFpEF model is driven primarily by myocytic stiffening rather than fibrotic remodeling. Our data provide invasive haemodynamic evidence of RV involvement in HFpEF and further support the translational relevance of the ZSF1 rat model for studying biventricular HFpEF pathophysiology.

Background An enhanced understanding is needed of the clinical trajectories seen in contemporary practice among patients with cardiogenic shock (CS) due to different acute myocardial infarction (AMI) types. Objectives The objective of the study was to compare clinical characteristics, management strategies, and outcomes among patients with CS due to AMI with and without ST-segment elevation. Methods All adults treated for CS due to STEMI or NSTEMI within a multilevel of care health system spanning 11 hospitals from 2016 to 2022 were included. The primary and secondary outcomes were 6-month and in-hospital all-cause mortality. Results We identified 1,375 patients: 57% ST-segment elevation myocardial infarction with CS (STEMI-CS) and 43% non-STEMI-CS (NSTEMI-CS). STEMI-CS patients had more severe shock with more cardiac arrest and higher initial lactate whereas NSTEMI-CS patients were older with more comorbidities and more severe coronary disease. NSTEMI-CS patients received more coronary artery bypass grafting (33% vs 8%) and lower rates of percutaneous coronary intervention (35% vs 73%) in those undergoing left heart catheterization. Management patterns were consistent across hospital levels. Rates of in-hospital and 6-month mortality (STEMI-CS 37.1% vs NSTEMI-CS 34.0%; P = 0.53) were similar in both groups. On multivariable analysis, revascularization was associated with lower 6-month mortality in both groups, whereas intra-aortic balloon pump or percutaneous ventricular assist device use was associated with lower mortality only in STEMI-CS. Venoarterial extracorporeal membrane oxygenation was associated with increased mortality in both AMI types. Conclusions STEMI and NSTEMI patients with CS have distinct clinical profiles and management strategies across all hospital levels. Although they experience similar rates of short and long-term mortality, associations between mechanical circulatory support use and outcomes differ by phenotype. These findings suggest that AMI type should inform management strategies and research design in CS.

Delirium is a common yet underrecognized neuropsychiatric syndrome in cardiovascular medicine associated with prolonged hospitalization, increased mortality, and long-term cognitive decline. Patients undergoing interventional or surgical cardiovascular procedures-such as transcatheter aortic valve replacement, surgical aortic valve replacement, coronary artery bypass grafting, or percutaneous coronary interventions-may be particularly vulnerable to its development. Delirium incidence varies widely across cardiovascular procedures, influenced by patient characteristics, procedural invasiveness, and diagnostic methodology. Risk factors include advanced age, baseline cognitive impairment, cerebrovascular disease, extended operative times, perioperative complications, and systemic inflammation. Diagnostic tools such as the Confusion Assessment Method (CAM) and the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) score are established but underutilized in the diagnosis of delirium. While preventive strategies emphasizing non-pharmacological, multicomponent approaches-such as early mobilization, cognitive stimulation, and sleep hygiene-are supported by strong evidence, preventive use of pharmacologic agents remains controversial. Pharmacologic treatment is reserved for select cases; dexmedetomidine shows benefits in intensive care unit settings, while antipsychotics like quetiapine and risperidone may be used cautiously. Overall, delirium poses a significant clinical challenge in cardiovascular medicine and requires a proactive, interdisciplinary approach. Systematic risk assessment and multimodal preventive strategies should be the standard of care, while pharmacologic treatment should be symptom- and context-specific. Further high-quality studies are needed to inform evidence-based guidelines tailored to cardiovascular populations. The present state-of-the-art review summarizes the current literature on the epidemiology, mechanisms, clinical manifestations, diagnosis, prevention, and treatment of delirium in cardiovascular medicine. By integrating findings and interdisciplinary expert discussions from interventional cardiology, cardiac surgery, and psychiatry, it aims to define the unique vulnerability of this patient population, highlight critical knowledge gaps, and lay the foundation for developing targeted, evidence-based management strategies.