TAVR in a 65-Year-Old Man With a Bicuspid Aortic Valve With Extremely Large Annulus and Severe Left Ventricular Dysfunction.

This case illustrates that transfemoral transcatheter aortic valve replacement is safe and feasible in patients with bicuspid aortic stenosis with extremely large annulus and concomitant severe left ventricular dysfunction.

Cancer and Heart Failure: Understanding the Intersection.

Cancer and cardiovascular disease account for nearly half of all deaths in the US. The majority of cancer therapies are known to cause potential cardiac toxicity in some form. Patients with underlying cardiac disease are at a particularly increased risk for worse outcomes following cancer therapy. Most alarming is the potential for heart failure as a result of cancer treatment, which may lead to early disruption or withdrawal of life-saving cancer therapies and can potentially increase cardiovascular mortality. A multi-disciplinary cardio-oncology approach can improve outcomes through early surveillance, prevention and treatment strategies.

Heart failure with reduced ejection fraction.

Heart failure is a global public health problem that affects more than 26 million people worldwide. The global burden of heart failure is growing and is expected to increase substantially with the ageing of the population. Heart failure with reduced ejection fraction accounts for approximately 50% of all cases of heart failure in the United States and is associated with substantial morbidity and reduced quality of life. Several diseases, such as myocardial infarction, certain infectious diseases and endocrine disorders, can initiate a primary pathophysiological process that can lead to reduced ventricular function and to heart failure. Initially, ventricular impairment is compensated for by the activation of the sympathetic nervous system and the renin-angiotensin-aldosterone system, but chronic activation of these pathways leads to worsening cardiac function. The symptoms of heart failure can be associated with other conditions and include dyspnoea, fatigue, limitations in exercise tolerance and fluid accumulation, which can make diagnosis difficult. Management strategies include the use of pharmacological therapies and implantable devices to regulate cardiac function. Despite these available treatments, heart failure remains incurable, and patients have a poor prognosis and high mortality rate. Consequently, the development of new therapies is imperative and requires further research.

Serelaxin for the treatment of heart failure.

Outcomes for patients with acute heart failure remain suboptimal and treatments principally target improvement of symptoms. To date there has been no therapy approved for acute heart failure shown to improve mortality or readmission risk post-discharge. Serelaxin, a recombinant form of the naturally occurring polypeptide hormone relaxin, has demonstrated promise in preclinical and early clinical trials as a potentially novel therapy for acute heart failure. It is postulated through its anti-fibrotic and vasodilatory effects that this agent can improve outcomes in both the short and long term in these patients. Randomized clinical data has suggested that the medication is safe and well tolerated. However, definitive outcomes data is currently being assessed in a large multi-center trial.

Cancer Therapy-Related Cardiac Dysfunction and Heart Failure: Part 2: Prevention, Treatment, Guidelines, and Future Directions.

Success with oncologic treatment has allowed cancer patients to experience longer cancer-free survival gains. Unfortunately, this success has been tempered by unintended and often devastating cardiac complications affecting overall patient outcomes. Cardiac toxicity, specifically the association of several cancer therapy agents with the development of left ventricular dysfunction and cardiomyopathy, is an issue of growing concern. Although the pathophysiologic mechanisms behind cardiac toxicity have been characterized, there is currently no evidence-based approach for monitoring and management of these patients. In the first of a 2-part review, we discuss the epidemiologic, pathophysiologic, risk factors, and imaging aspects of cancer therapy-related cardiac dysfunction and heart failure. In this second part, we discuss the prevention and treatment aspects in these patients and conclude with highlighting the evidence gaps and future directions for research in this area.

Cancer Therapy-Related Cardiac Dysfunction and Heart Failure: Part 1: Definitions, Pathophysiology, Risk Factors, and Imaging.

Advances in cancer therapy have resulted in significant improvement in long-term survival for many types of cancer but have also resulted in untoward side effects associated with treatment. One such complication that has become increasingly recognized is the development of cardiomyopathy and heart failure. Whether a previously healthy person from a cardiovascular perspective develops cancer therapy-related cardiac dysfunction or a high-risk cardiovascular patient requires cancer therapy, the team of oncologists and cardiologists must be better equipped with an evidence-based approach to care for these patients across the spectrum. Although the toxicities associated with various cancer therapies are well recognized, limitations to our understanding of the appropriate course of action remain. In this first of a 2-part review, we discuss the epidemiologic, pathophysiologic, risk factors, and imaging aspects of cancer therapy-related cardiac dysfunction and heart failure. In a subsequent second part, we discuss the prevention and treatment aspects, concluding with a section on evidence gap and future directions. We focus on adult patients in all stages of cancer therapy from pretreatment surveillance, to ongoing therapy, and long-term follow-up.