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Welcome to this special supplement devoted to the proceedings of the 4th Annual Acute Cardiac Unloading and REcovery (A-CURE) Working Group meeting, which was held on 30 August 2019 in Paris, France. The A-CURE Working Group is comprised of leading academic experts in clinical and basic cardiac research who are dedicated to advancing the science and clinical application of acute cardiac unloading. This meeting brought together experts from multiple disciplines, including interventional cardiologists, heart failure specialists, cardiac surgeons, molecular biologists and biomedical engineers.

The 2019 symposium featured talks and posters that highlighted cutting-edge advances in the field of acute cardiac unloading that have taken place since the 2018 A-CURE symposium in Chicago, US.

Cardiac disease states, such as MI, myocarditis, cardiomyopathy and cardiogenic shock, impair the ability of the heart to pump blood, resulting in end-organ failure and, ultimately, death. Pharmacological therapies in these cases aim to maintain cardiac output, but in the process, impose further stress on the heart. Additional treatment strategies are needed. The A-CURE symposium focused on the basic science and clinical application of ventricular unloading using mechanical circulatory support technologies. Acute cardiac unloading decreases myocardial oxygen consumption and maximises the ability of the heart to rest and recover after damage. Mechanical unloading employs percutaneous ventricular assist devices, such as the Food and Drug Administration-approved Impella family of devices, to decrease the physical workload of the heart.

This supplement features a number of presentations covering a broad range of subjects related to cardiac unloading. The first session of the symposium was devoted to the advances in basic and pre-clinical science of acute unloading and myocardial salvage. Topics discussed ranged from the influence of acute unloading using Impella devices on the preservation of mitochondrial structure and function post-MI to improving intracoronary gene transduction efficiency. The impact of concomitant vasoactive treatment during active ventricular unloading in cardiogenic shock and a novel superior vena cava occlusion catheter system that reduces ventricular filling pressures while maintaining cardiac output in a model of congestive heart failure were also discussed.

In the keynote lecture, Douglas Mann shared insights on the cellular and molecular and mechanisms associated with left ventricular (LV) remodelling and reverse remodelling in a mouse model that combines clinically relevant comorbidities of moderate pressure overload and small ischaemic injury.

The second session focused on new frontiers and clinical translation of unloading. The wide spectrum of clinical studies presented included cardio-renal system interaction with the effect of haemodynamic support on acute kidney injury, the use of mechanical circulatory support for takotsubo syndrome with cardiogenic shock and clinical implications of prolonged use of Impella pumps for fulminant myocarditis with shock.

The afternoon’s presentations had a focus on the clinical translation of LV unloading. William O’Neill provided an update on the outcomes associated with the adoption of a standardised protocol for treatment in cardiogenic shock, the key features of which include the early initiation of mechanical support prior to reperfusion. Jason Williams discussed preoperative identification of high-risk cardiac surgery patients who may benefit from LV unloading with Impella. Jaime A Hernandez-Montfort presented a study of the global epidemiology and survival outcomes of patients receiving temporary circulatory support before durable ventricular assist device implantation. In the concluding talk, Navin K Kapur provided the rationale and discussed the design of the ST-elevation MI Door-To-Unload pivotal trial.

The presentations highlighted the exciting new developments and represented substantial advances in the field of acute myocardial unloading and recovery that have developed in the past year. The A-CURE Working Group meeting is unique in involving a diverse group of experts from multiple disciplines within an open, constructive and intimate public setting.

We hope that you find this supplement informative and interesting.