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Oxidative Stress in Heart Failure

Oxidative stress is increased in heart failure (HF), and experimental studies suggest that this contributes to structural and functional changes in the heart that are central to both cardiac dysfunction and disease progression. Reactive Oxygen Species and Antioxidant Systems ( Fig. 8.1 ) Reactive Oxygen Species Reactive oxygen species (ROS) are a by-product of aerobic metabolism, and so the highly metabolically active myocardium is rich in…

Role of Innate Immunity in Heart Failure

Although clinicians recognized the pathophysiological importance of inflammation in the heart as far back as 1669, the formal recognition that inflammatory mediators were activated in the setting of heart failure did not occur for another three centuries. Since the initial description of inflammatory cytokines in patients with heart failure in 1990, there has been a growing interest in the role that these molecules play in regulating…

Adrenergic Receptor Signaling in Heart Failure

Normal and pathophysiological stresses result in increased myocardial demand that is met by a commensurate increase in cardiac adrenergic drive. To facilitate this increase, the neurotransmitter norepinephrine (NE) is released from adrenergic (sympathetic) nerve endings within the heart. Upon binding to β-adrenergic receptors (β-ARs), multiple signaling pathways are activated, resulting in increases in heart rate, force of contraction, and rate of relaxation. Increased adrenergic drive also…

Molecular Signaling Mechanisms of the Renin-Angiotensin System in Heart Failure

A Perspective on the Renin Angiotensin Aldosterone System Although Bright (1827) first associated kidney hardness with a strong arterial pulse, current knowledge regarding the role of the renin angiotensin aldosterone system to homeostasis has been gained over the last 50 years. It is not to be denied that the discoveries associated with characterization of this critically important circulating and tissue-borne hormonal system transcended the field of…

Myocardial Basis for Heart Failure: Role of Cardiac Interstitium

Acknowledgments Dr. Francis Spinale is supported by the Research Service of the Department of Veterans Affairs. The author wishes to recognize the significant contributions of past MUSC and USC medical and graduate students that participated in our cardiovascular research program over the past two decades. Extracellular matrix (ECM) remodeling in the context of heart failure (HF) is not readily described by a specific pathological stimulus, but…

Cellular Basis for Myocardial Regeneration and Repair

Cardiac regeneration refers to the process of heart repair after an injury through repopulation of specific cell types to replace the damaged tissue, to regain functional capacity. Although credible evidence existed for this phenomenon in lower vertebrates, the belief in the potential for cardiac regeneration in mammals is a recent development. It was previously believed that the heart is a “postmitotic” organ whose workhorse cell, the…

Cellular Basis for Heart Failure

Acknowledgments The authors’ work is supported by the British Heart Foundation; a Fondation Leducq Transatlantic Network of Excellence award; and the Department of Health via a National Institute for Health Research (NIHR) Biomedical Research Centre award to Guy’s & St Thomas’ NHS Foundation Trust in partnership with King’s College London and King’s College Hospital NHS Foundation Trust. The development of heart failure in the context of…

Molecular Basis of Heart Failure

Types of Heart Failure Heart failure (HF) is a multisystemic disorder characterized by profound disturbances in circulatory physiology and a plethora of myocardial structural and functional changes that adversely affect the systolic pumping capacity and diastolic filling of the heart. A discrete inciting event, such as myocardial infarction (MI) or administration of a chemotherapeutic agent, may be identifiable as a proximate trigger in some cases. However,…

Transcatheter biopsy for intracardiac masses

Introduction Intracardiac masses (ICMs) are rare entities in clinical practice. The differential diagnosis is wide, including pathologies such as infective, thrombotic, neoplastic, autoimmune, iatrogenic, or hamartomatous lesions. Unless clearly associated with a specific clinical scenario, such as valvar vegetations in infective endocarditis or appendage thrombus in atrial fibrillation, they can present a significant diagnostic challenge. Although imaging modalities like transthoracic echocardiography (TTE), transesophageal echocardiography (TEE), computed…

Pulmonary balloon angioplasty for chronic thromboembolic pulmonary hypertension

Chronic thromboembolic pulmonary hypertension (CTEPH) is a pulmonary vascular disease that results from fibrotic transformation of thromboemboli causing obstruction in the pulmonary vasculature. If left untreated, pulmonary artery pressure worsens, affecting right ventricular function and causing significant morbidity and mortality, with up to 68% 5-year survival. European registry data suggest that the annual incidence of CTEPH is about 5 per million adults per year, which is…

Pseudoaneurysm diagnosis and management

Introduction Cardiac pseudoaneurysms are an uncommon occurrence; however, they are associated with significant risk of complications. , A pseudoaneurysm is a contained rupture of the arterial vessel or myocardial wall. A single layer of pericardium or adhesions lines the sac, increasing the risk of rupture and cardiac mortality approaching 30% to 50%. This is in comparison to a true aneurysm, which is thinning of the wall…

Pulmonary valve interventions: Valvuloplasty and transcatheter pulmonary valve replacement

Pulmonary valvuloplasty Background Pulmonary valve stenosis (PS) is a common form of congenital heart disease that may present at any age, but often in infancy or early childhood in its more severe forms. The adult patient with PS tends to have more clinical symptoms than a child with a similar degree of PS; gradients can be progressive, often due to acquired right ventricular outflow tract (RVOT)…

Closure of abnormal coronary communications: Coronary, fistulae, congenital, and iatrogenic

Introduction Congenital fistulae cover a wide spectrum of vascular disorders including a variety of arteriovenous (AV) malformations, but also can include venovenous communications. Structural and congenital cardiology interventionalists most often may be asked to evaluated those fistulae involving the heart, great vessels, and pulmonary circulation. Because of the widespread nature of such vascular malformations, it is difficult to determine an exact epidemiologic incidence of such disorders,…

Coarctation and PDA closure

Coarctation of the aorta can most simply be characterized as a discrete stenosis of the upper descending thoracic aorta. Since in many cases coarctation occurs at or near the origin of the ductus arteriosus, these can be described as juxtaductal coarctation. However, longer segment stenosis and aortic arch hypoplasia may also be recognized in some patients. Clinical presentation The clinical presentation may vary from severe congestive…

Novel percutaneous tricuspid repair techniques

Introduction The tricuspid valve apparatus is a complex and dynamic structure that interacts intricately with surrounding anatomy. The vast majority of patients with tricuspid valve disease have tricuspid valve regurgitation (TR), whereas a minority present with tricuspid stenosis (TS). TR represents a significant epidemiologic burden, with an estimated 1.6 million Americans affected by this condition and only 8000 tricuspid valve surgeries performed nationwide on a yearly…

Tricuspid valve-in-valve/valve-in-ring therapy

Background Transcatheter valve replacement is becoming an increasingly favored option to treat a failing tricuspid bioprosthetic valve (BPV). As clinical experience grows and valve technology expands, the option of implanting a new tricuspid valve in the cardiac catheterization laboratory is a viable alternative to a conventional surgical valve replacement therapy, which remains relatively high risk. Patients may have undergone tricuspid valve replacement for underlying congenital heart…

Pulmonary vein stenosis: Management and outcomes

Introduction Pulmonary vein stenosis (PVS) is a relatively infrequent yet detrimental complication of atrial fibrillation (AF) ablation thought to be related to intimal thermal or barotrauma of the pulmonary veins (PV). Early AF ablative techniques focusing specifically on the PV ostia resulted in PVS rates of over 40%. , However, with improved ablation techniques, the incidence of severe PVS has decreased and is now reported between…

Left atrial appendage occlusion

Atrial fibrillation (AF) accounts for the majority of cardioembolic strokes, especially in elderly individuals. Although anticoagulation reduces the risk of embolic stroke, a significant proportion of AF patients have relative or absolute contraindications to anticoagulation. Patients with high bleeding risk are also the patients at highest risk of stroke with AF. Imaging studies have previously documented that >90% of embolic strokes in nonvalvular AF originate from…

Alcohol septal ablation for obstructive hypertrophic cardiomyopathy

Background Hypertrophic cardiomyopathy (HCM) is characterized by left ventricular hypertrophy not explained by secondary causes, with a predisposition for outflow tract obstruction in some patients. As the most commonly encountered genetic cardiac condition, HCM affects 1 out of 500 individuals in the general population with a myriad of morphologic variants and clinical presentations. HCM can manifest with symptoms of dyspnea, chest pain, and syncope from a…