When serving as the Attending Physician on the Cardiology Service it has been a common occurrence over the years to admit patients with the initial episode of acute heart failure. My standard teaching approach with the medical students and house staff was to ask for a differential diagnosis for the etiology. Most commonly the answer I received was a limited list of specific disorders. At that point I usually say that a better approach is to consider the etiologies of heart failure in terms of the anatomic structures that can be affected.
When asked to identify the cardiac structures that should be considered as the site of disease, the first response is usually the coronary arteries. In view of the prevalence of disease, this response probably should not be surprising. Some will point to the heart valves, or the pericardium, or the electrical system, or the aorta/pulmonary artery for hypertension. However, the myocardium itself is almost invariably the last structure mentioned, if mentioned at all. For some reason, when we think of cardiovascular disease structurally, we don’t include the myocardium as a cardiac structure.
Due to its predominant prevalence, atherosclerosis and coronary artery disease has usually received the bulk of the attention of the medical community. Moreover, the treatment of vascular disease involved medical, interventional, and surgical approaches, whereas disorders of non-vascular structures generally required surgical therapy, or were not amenable to therapy at all. Interventional cardiology meetings were almost entirely devoted to coronary artery disease and its complications. That all changed, of course, with the advent of Transcatheter Aortic Valve Replacement (TAVR) and the birth of the field of structural heart disease. However, just as primary myocardial disorders were not usually considered in the spectrum of vascular disease, they somehow have not been perceived as an integral part of structural heart disease either.
The lack of attention to primary myocardial disease is perhaps related to the focus on the percutaneous procedures which have created the field of structural heart disease and been responsible for most of its most exciting innovations. Thus, TAVR and transcatheter edge to edge mitral repair (TEER) have brought focus to valve disease, atrial septal defect and patent foramen ovale closure brought attention to congenital heart disease, and left atrial appendage occlusion devices have brought emphasis to electrical and thromboembolic disorders, among others. In fact, work and publication regarding the interventional aspects of structural disorders has been substantially greater than efforts regarding their pathophysiology, natural history, and non-interventional aspects. This has been reflected in Structural Heart Journal, in that the vast majority of submissions have dealt with interventions. The one primary myocardial disease that has generally be included in structural disorders is hypertrophic cardiomyopathy, perhaps due to the interventional aspects of septal myectomy.
The lack of attention to primary myocardial diseases by the structural heart community has had implications for Structural Heart Journal. As mentioned above, most of the submissions to the Journal have been devoted to percutaneous interventional procedures. This has raised a question as to whether we should even consider publishing manuscripts dealing with myocardial diseases. It is possible that our readership would not be interested in such topics. I cannot believe that this could be the case; the physicians working in structural heart disease that I know have an interest in the broad field of cardiology. Structuralists come from a wide variety of specialties including intervention, imaging, surgery, anesthesia, and general cardiology among others. The challenges presented by heart failure with preserved ejection fraction, which led to the conception of interatrial communication devices, exemplify the interdependence of all cardiovascular disciplines. In fact, the emerging percutaneous interventions in heart failure patients is an even better example. Moreover, including non-interventional content will help attract a wide variety of readers and provide even greater exposure to innovative percutaneous and surgical procedures.
I, for one, firmly believe that the myocardium is a cardiac structure, and should be an integral part of structural heart disease. We are open to and are soliciting manuscripts dealing with primary myocardial disorders. We believe that structuralists are interested in all aspects of cardiovascular disease, and that knowledge of non-interventional subject matter will provide the substrate for interventional procedures to address these pathologies. We recognize that the excitement and greatest innovation in structural heart disease is related to interventional, particularly transcatheter, procedures, and that manuscripts focused in this area will continue to predominate our table of contents. We are pleased to be the only journal that primarily emphasizes this material. However, in the process of focusing on traditional structural heart disease topics, we want to be sure to remember that the myocardium is the most important cardiac structure.
Disclosure statement
No potential conflict of interest was reported by the author(s).