Peggy M. Kostakou

Advanced heart failure (AHF) represents the terminal stage of heart failure (HF), characterized by persistent symptoms and functional limitations despite optimal guideline-directed medical therapy (GDMT). This review explores the clinical definition, pathophysiology, and therapeutic approaches for AHF. Characterized by severe symptoms, New York Heart Association (NYHA) class III-IV, significant cardiac dysfunction, and frequent hospitalizations, AHF presents substantial challenges in prognosis and management. Pathophysiological mechanisms include neurohormonal activation, ventricular remodeling, and systemic inflammation, leading to reduced cardiac output and organ dysfunction. Therapeutic strategies for AHF involve a multidisciplinary approach, including pharmacological treatments, device-based interventions like ventricular assisted devices, and advanced options such as heart transplantation. Despite progress, AHF management faces limitations, including disparities in access to care and the need for personalized approaches. Novel therapies, artificial intelligence, and remote monitoring technologies offer future opportunities to improve outcomes. Palliative care, which focuses on symptom relief and quality of life, remains crucial for patients ineligible for invasive interventions. Early identification and timely intervention are pivotal for enhancing survival and functional outcomes in this vulnerable population. This review underscores the necessity of integrating innovative technologies, personalized medicine, and robust palliative strategies into AHF management to address its high morbidity and mortality.

The therapeutical advances in recent years in the field of oncology treatment have increased survival rates and improved the quality of life of oncology patients, thus turning cancer into a chronic disease. However, most of the new cancer treatments come at the expense of serious cardiovascular adverse events threatening the success story of these patients. The establishment of multidisciplinary medical teams to prevent, monitor, and treat cardiovascular diseases in cancer-treated patients is needed now more than ever. The aim of this narrative review is to demonstrate the existing knowledge and practical approaches on how to establish and maintain a cardio-oncology program for the rising number of patients who need it.

Introduction: This study aims to investigate the correlation between severe aortic stenosis (sAS) and impairment of left ventricular global longitudinal strain (LVGLS) in particular segments, using two-dimensional speckle tracking echocardiography in patients with sAS and normal ejection fraction of left ventricle (LVEF). Methods: The study included 53 consecutive patients with asymptomatic sAS and preserved LVEF. The regional longitudinal systolic LV wall strain was evaluated at the area opposite of the aorta as the median strain value of the basal, middle, and apical segments of the lateral and posterior walls and was compared to the average strain value of the interventricular septum (IVS) at the same views. Results: LVGLS was decreased and was not statistically different between three- and four-chamber views (−12.5 ± 3.6 vs −11.4 ± 5.5%, p = 0.2). The average strain values of the lateral and posterior walls were statistically reduced compared to the average value of the IVS (lateral vs IVS: −7.8 ± 3.7 vs −10 ± 5.3%, p = 0.005, posterior vs IVS: −7.7 ± 4.2 vs −10.3 ± 3.8%, p < 0.0001). There was no significant difference between lateral and posterior walls (−7.8 ± 3.7 vs −7.7 ± 4.2%, p = 0.9). Conclusions: The strain of lateral and posterior walls of left ventricle, which lay just opposite to the aortic valve seem to be more reduced compared to other walls in patients with sAS and preserved LVEF possibly due to their anatomical position. This impairment seems to be the reason of the overall LVGLS reduction. Regional strain could be used as an extra tool for the estimation of the severity of AS as well as for prognostic information in asymptomatic patients.

Introduction: Although ejection fraction (EF) is the cornerstone of the assessment of left ventricular (LV) systolic function, its measurement faces a number of challenges related to image quality, assumptions of LV geometry, and expertise. The aim of this study was to test the inter‐observer variability of EF and GLS measurement in patients with a broad spectrum of LV function, between physicians and investigators (Inv) with different levels of expertise.Methods: In 122 patients, EF and GLS were measured by 4 Inv blinded to each other with different level of experience in echocardiography; EF was measured using 3 methods: visual assessment, biplane Simpson's method, and auto‐EF method. GLS was measured from the 3 apical views. A significant difference for LVEF and for LVGLS was considered to be >10 and >2 absolute values, respectively.Results: Intra‐observer agreement was excellent for visually assessed EF (ICC = 0.87, P < .001) and GLS (ICC = 0.82, P < .001) and good for EF measured by Simpson's method (ICC = 0.70, P < .001) and auto‐EF (ICC = 0.72, P < .001). Intra‐observer and inter‐observer agreements were excellent for GLS with ICCs above 0.8. GLS discordance between the 4 Inv was not significant. Discordance in EF and GLS measurements among the Inv was not related to image quality or wall motion abnormalities.Conclusion: Although EF has proved its prognostic value in various cardiovascular entities, GLS seems to be more reliable for serial assessment of LV function, demonstrating lower intra‐ and inter‐observer variability, even by different physicians with variant level of expertise.

Cardio-oncology is a new field of interest in cardiology that focuses on the detection, monitoring, and treatment of cardiovascular disease occurring as a side effect of chemotherapy and radiotherapy. Both cancer treatment modalities can cause cardiac dysfunction, a major cause of morbidity and mortality in the oncologic population. It is necessary to periodically monitor cancer patients under treatment, especially those receiving anthracyclines and trastuzumab (monoclonal antibody), using mainly 3D echocardiography to calculate left ventricular ejection fraction and to estimate myocardial deformation. Additionally, measuring various biomarkers, such as natriuretic peptides, could facilitate early identification and appropriate response to potential cardiotoxicity. In this regard, cardiological assessment before starting cancer treatment is essential and should be continued throughout, since cardiac dysfunction can occur at any time, even several years after therapy onset. High-risk individuals, in particular, should receive a detailed management plan designed in collaboration between an oncology and a cardiology specialist. If heart failure develops, even in the absence of overt clinical symptoms, standard heart treatment is to be followed and causal agent discontinued if possible. One important question is whether and when to stop cardiac medication in case of heart dysfunction reversal, after completion of cancer treatment. Further cardio-oncology evolution can lead to a deeper understanding of the adverse mechanisms and effects causing heart failure, as well as the development of personalized treatment regimens in order to limit cardiotoxicity.