Up to one third of patients with an implantable cardioverter defibrillator (ICD) experience shock discharges in the last 24 h before death, which no longer have any therapeutic benefit. Even in patients who have a living will (do not resuscitate, DNR, directive), the shock function of the ICD is activated in over 50% of those affected 24 h before death. A significant subgroup of ICD wearers must therefore experience painful, significantly stressful and unnecessary ICD shocks at the hour of their death. All available position papers on this topic call for patients to be informed about this issue in good time; however, in reality such a conversation almost never takes place. This paper outlines the legal basis that helps doctors to deactivate the ICD in the final stage of life and the specific conditions that must be met. This paper advocates repeatedly addressing the issue during the course of the illness and to involve relatives. The actual conversation about deactivation at the end of life should be proactively initiated by the responsible attending physician and should take the form of a structured, patient-centered dialogue in the spirit of good dialogue.

Previous leadless pacemaker systems were confined to the right ventricle, thus limiting the clinical applications. With the introduction of the first leadless atrial cardiac pacemaker, new perspectives in antibradycardia treatment were introduced. This device enables leadless atrial stimulation and electrical atrial sensing with the potential to reduce complications of cardiac pacemaker treatment. The atrial leadless atrial pacemaker is implanted transvenously with a delivery catheter via the femoral vein into the base of the right atrial appendage. In combination with a ventricular leadless pacemaker, a complete dual chamber pacemaker system can be created through galvanically coupled intracorporeal communication. This can be created as an upgrade from an already implanted ventricular or atrial leadless cardiac pacemaker or the system can be implanted directly (de novo). The possibility of an upgrade enables a flexible treatment adapted to the individual progression of the underlying disease. Current limitations for wider clinical use include economic considerations, limited battery capacity and insufficient data concerning retrievability after the battery is exhausted.

Defibrillator treatment should adhere to the guidelines to effectively prevent sudden cardiac death while minimizing all complications. As an entirely extrathoracic system, the subcutaneous implantable cardioverter defibrillator (S-ICD) eliminates the need for intracardiac leads, thus reducing procedural and lead-related complications as well as systemic infections. The evidence across > 5000 participants in randomized trials and registries demonstrates approximately 98% shock conversion with low complication rates. The PRAETORIAN study demonstrated that the S‑ICD is not inferior to the transvenous ICD (TV-ICD), long-term and secondary analyses indicate fewer severe, particularly lead-related, complications with S‑ICD treatment. Studies such as UNTOUCHED, EFFORTLESS, and PAS confirm its shock effectiveness and safety profile in routine clinical care, while the ATLAS study reports significantly fewer perioperative lead-related complications in younger patients. The procedure has been streamlined and standardized, incorporating best practices such as preoperative vector screening, a two-incision technique, intermuscular/submuscular pocket creation, and dual-zone programming with morphology/high-pass filtering. In the absence of indications for bradypacing, cardiac resynchronization therapy (CRT) or antitachycardia pacing (ATP), the S‑ICD should be considered a routine option in the clinical routine, especially for younger patients, those prone to infections, those with limited venous access and individuals with hereditary arrhythmia syndromes.

Patients with an implantable cardioverter defibrillator (ICD) who receive an appropriate ICD shock are known to subsequently have a worse prognosis. Despite the knowledge about the poorer prognosis, in the guidelines there are no clear instructions on how to proceed after the occurrence of an adequate ICD shock. The ToVAMI concept represents a treatment regimen for patients with first appropriate ICD shock after ventricular tachycardia (VT) or ventricular fibrillation (VF) and consists of three steps: 1) To = trigger optimization with the following triggers summarized under the acronym ICD-STEMi (ischemia, compliance, decompensation, stress, technical issue, electrolyte/endocrinological disorder and medication intoxication), 2) VA = ventricular arrhythmia treatment and 3) MI = medicinal and interventional prognostic heart failure treatment. The treatment after the first ICD shock consists not only of ablation or antiarrhythmic treatment but also encompasses a comprehensive suite of diagnostic and therapeutic measures, which require a systematic approach. The systematic application of this regimen can increase the detection rate of trigger factors for VT/VF and essentially contributes to an optimized medicinal and interventional prognostic heart failure treatment. Approximately 10% of patients have no clinical symptoms of worsening heart failure or ischemia during the first ICD shock, despite objective evidence of progressive heart failure or ischemia. In these patients, the first VT/VF shock is the sole warning signal for worsening of the cardiac status. This underscores the need for a systematic diagnostic work-up and treatment after the first ICD shock.

Direct stimulation of the conduction system (conduction system pacing, CSP) can be performed at multiple levels and for different indications. The most physiological option is direct stimulation of the bundle of His, which is technically simpler and possible at the level of the left bundle branch and with more stable electrical parameters. This stimulation results not only in "nice" ECG leads but, above all, in a homogeneous, synchronous, physiological contraction pattern, especially of the left ventricle. In many situations there is a direct competition with the established stimulation modalities of the right ventricle in isolated bradycardia and cardiac resynchronization therapy (CRT) in heart failure. A clear distinction and recommendation in the guidelines are not yet definitive, also due to pending and constantly accumulating data and an evolving portfolio of sheaths and leads from all manufacturers; however, overall there is a clear preference for CSP over right ventricular apical pacing, if possible but this still needs to be confirmed in comparison to CRT.

The extravascular implantable cardioverter-defibrillator (EV-ICD) offers a fully extravascular alternative to transvenous ICDs, combining substernal lead placement with defibrillation and limited pacing capabilities. Designed to mitigate intravascular complications while maintaining generator size and longevity comparable to conventional ICDs, the EV-ICD supports antitachycardia pacing, post-shock pacing, and temporary bradycardia management. Procedural experience demonstrates high implantation success, low rates of major complications, and effective arrhythmia termination. Early real-world data indicate that lead dislodgement, pneumothorax, and pocket infection are uncommon, and lead explantation is feasible when required. Antitachycardia pacing effectively terminates a substantial proportion of ventricular tachycardias, while inappropriate therapies have been reduced through optimized lead positioning and advanced detection algorithms. Patient selection should exclude, among others, those with permanent pacing needs, anatomical constraints, and prior radiotherapy or sternotomy. Future directions include optimization of lead design and exploration of alternative implantation sites, with ongoing evaluation of long-term device performance and safety. Current evidence supports the EV-ICD as a safe and effective option in selected patients, including younger populations or those with limited vascular access, although its definitive role in sudden cardiac death prevention requires further long-term study.

Noninvasive cardiac imaging using cardiac computed tomography (CCT) and cardiac magnetic resonance imaging (CMRI) has become established as an indispensable diagnostic instrument in modern cardiology for the assessment of cardiovascular diseases. Both techniques are complementary in their diagnostic potential and enable an individualized clinical care, including diagnostic confirmation, prognosis estimation and treatment planning. The use of CCT enables a precise visualization of the coronary vessels, including the detection and quantification of luminal stenosis and additional plaque characterization. It is particularly suitable for the noninvasive clarification of coronary artery disease (CAD) in patients with a low to moderate pretest probability and for procedural planning in cardiology. The high negative predictive value of CCT enables its use as a gatekeeper for unnecessary invasive diagnostics of CAD. The use of CMRI provides a combination of functional morphological diagnostics with a precise myocardial tissue characterization, which are helpful for the assessment of CAD, inflammatory heart diseases and cardiomyopathies. Due to the possibility to quantify myocardial damage, CMRI has a high prognostic value. The combination of both non-invasive techniques in the present-day modern cardiac diagnostics is essential for guideline-compliant and patient-centered care by the coverage of the broad spectrum of cardiac diseases and the supplementary methods.

Infective endocarditis is a rare disease with increasing incidence and high mortality. Due to its nonspecific symptoms, complex diagnostics, the prolonged treatment and poor prognosis, it represents a major clinical challenge. This review article outlines the contemporary management of infective endocarditis, including prevention, the role of the endocarditis team, diagnostic criteria, outpatient oral antibiotic treatment, the timing and indications of surgical treatment as well as the significance of infections of cardiovascular implantable electronic devices.

Studies assessing transcatheter edge-to-edge mitral valve repair (M-TEER) suggest lower rates of in-hospital mortality (IHM) at high-volume hospitals, and guidelines recommend minimum caseloads to assure quality standards.

The treatment of valvular heart disease plays an important role in cardiovascular medicine. The 2025 European Society of Cardiology (ESC)/European Association for Cardio-Thoracic Surgery (EACTS) guidelines for the management of valvular heart disease set new standards for diagnostics and treatment based on scientific evidence with the aim to avoid both undertreatment and overtreatment. Recommendations for interventional treatment of valvular diseases are given greater importance compared to the 2021 guidelines. At the same time, surgical expertise remains indispensable, especially in younger patients and those with complex anatomy. Particular emphasis is placed on precise diagnostics using multimodal imaging, the recommendation for treatment of patients in high-volume centers (Heart Valve Centers) and an optimal patient selection by the multidisciplinary heart team. The ESC/EACTS guidelines advocate individualized, multidisciplinary treatment decisions based on the best available evidence. In practice, this can only be achieved by more intensive cooperation between the individual institutions of outpatient and inpatient care as well as specialized centers.

The heart team is an important component for guideline-conform treatment of patients with complex coronary artery disease (CAD). Nevertheless, this integrative, multiprofessional approach is not always consistently implemented in clinical practice. This article highlights the role of the heart team, with a particular focus on cardiovascular centers with cardiac surgery on site, presents evidence-based benefits and draws attention to existing structural gaps in daily care, such as the probably widespread use of ad hoc percutaneous coronary intervention (PCI) in multivessel CAD or the lack of interdisciplinary coordination. Numerous studies have shown that consistently implemented heart team decisions and a culture of professional and evidence-based interaction improve patient outcomes. This article appeals to cardiological and cardiac surgery departments to actively shape the heart team process. The presence of both the heart team and cardiac surgery on site paired with modern possibilities of digital communication tools and the wish for individual treatment recommendations should enable faster heart team decisions (practically ad hoc) to improve patient care.

In recent years the treatment for heart failure (HF) has become much more complex. This development has highlighted the importance of a multidisciplinary HF team to ensure the best possible individually adapted treatment decisions, taking the patient's personal wishes into account and to achieve optimal results. In Germany, specialized HF practices, clinics and tertiary bespoke HF unit centers were established to ensure qualified care for HF patients. These institutions fulfil defined standards and quality features for outpatient and inpatient treatment and cooperate closely in the framework of HF networks. The interdisciplinary HF team should be involved in the treatment from the initial step of correct diagnosis through availability for changes of the clinical status up to HF-related hospitalization due to acute or advanced HF. The core team encompasses cardiologists, skilled HF nursing personnel, cardiac surgeons and coordinators for heart transplantation and ventricular assist devices and is complimented by other specialists depending on the patient's specific etiology and severity of HF as well as relevant comorbidities. The quality of treatment is also enhanced by personal HF additional qualifications. One of the most essential goals of this multidisciplinary collaboration is patient-centered team-based recommendations and decision making, which aim to improve the prognosis of patients, reduce hospitalization rates and improve the quality of life.

This study focused on exploring the correlation between the electrical and mechanical dyssynchrony of the right ventricle (RV) in patients with pre-capillary pulmonary hypertension (PcPH). It also aimed to compare the predictive capabilities of these dyssynchronies for risk stratification.

Since the earliest studies on transcatheter aortic valve implantation (TAVI), the heart team concept has been an integral component of treatment planning for patients with aortic valve stenosis (AS). The primary objective is to ensure patient-specific, guideline-based treatment through the structured involvement of all relevant medical disciplines. The TAVI heart team is strongly recommended with a class I indication in both European and US clinical guidelines. A TAVI heart team typically consists of interventional cardiologists, cardiac surgeons, anesthesiologists and cardiac imaging specialists and can be supplemented by additional experts depending on the clinical scenario. The team's responsibilities span the entire continuum of care, from diagnostic assessment and procedural planning to complication management and structured follow-up. The concept of lifetime management is gaining importance, aiming for a long-term strategic approach to valve care throughout the patient's lifespan. Given the evolving age boundaries for intervention, an extension of the heart team approach to all patients with AS is warranted. Clearly defined roles, standardized protocols and defined decision-making processes, supported by a dedicated TAVI coordinator, can substantially enhance both efficiency and quality of care. Looking ahead, digital technologies, artificial intelligence and structured upstream screening strategies for asymptomatic AS patients are expected to play an expanding role.

Acute chest pain is a common emergency department (ED) presentation requiring rapid risk stratification for major adverse cardiovascular events (MACE; including death, myocardial infarction, and urgent revascularization). While the HEART (History, ECG, Age, Risk factors, Troponin) and GRACE scores are widely used, their comparative predictive accuracy for short-term MACE remains unclear. This study aimed to directly compare the diagnostic performance of HEART and GRACE (Global Registry of Acute Coronary Events) in predicting 30-day MACE among ED patients with acute chest pain.

The protective function of the tetrandrine (TET)-mediated transient receptor potential vanilloid 2 (TRPV2) channel in myocardial ischemia/reperfusion injury (MI/RI) has been established in numerous investigations. The objective of the current study was to explain how TRPV2 further modulates downstream factors to influence the progression of MI/RI.

The coronary sinus (CS) can reflect the pressure and volume load of the right heart chambers. Idiopathic pulmonary arterial hypertension (IPAH) is a progressive, life-threatening disease in which risk assessment plays a critical role. We aimed to evaluate (a) the correlation between CS diameter and risk assessment parameters in IPAH patients and (b) the utility of CS diameter in predicting mortality and hospitalization.