Current treatment options for the Failing Fontan Circulation

The Fontan operation was introduced in 1968. For congenital malformations where biventricular repair is not suitable, the Fontan procedure has provided a long-term palliation strategy with improved outcome compared to the initially developed procedures. Despite these improvements, several complications merely as a result of a failing Fontan circulation (including myocardial dysfunction, arrhythmias, increased pulmonary vascular resistance, protein losing enteropathy, hepatic dysfunction, plastic bronchitis and thrombo-embolism) will limit life-expectancy in this patient cohort. This review provides an overview of the most common complications of the Fontan circulation and the currently available treatment options.

Paradoxical Septal Motion after Uncomplicated Cardiac Surgery: A Consequence of Altered Regional Right Ventricular Contractile Patterns

Paroxysmal interventricular septal motion (PSM) is the movement of the septum toward the right ventricle (RV) during cardiac systole. It occurs frequently after uncomplicated cardiac surgery (CS), including coronary bypass (on-pump and off-pump), valve repair or replacement, and with all types of incisions (sternotomy or mini-thoracotomy). It sometimes resolves quickly but may persist for months or become permanent. Global RV systolic function, stroke volume and ejection fraction remain normal after uncomplicated CS, but regional contractile patterns are altered. There is a decrease in longitudinal shortening but an increase in transverse shortening in the endocardial and epicardial right ventricular muscle fibers, respectively. PSM is a secondary event as there is no loss of septal perfusion or thickening. The increased RV transverse shortening (free wall to septal fibers) may modify septal movement resulting in PSM that compensates for the reduced RV longitudinal shortening, thus preserving normal global right ventricular function.

Calcium Modifications Therapies in Contemporary Percutaneous Coronary Intervention

Coronary artery calcifications (CAC) has been known to be associated with worse Percutaneous Coronary Intervention (PCI) short- and long-term outcomes. Nowadays with the increased prevalence of the risk factors leading to CAC in the population and also more PCI procedures done in older patients and with the growing number of higher risk cases of chronic total occlusion (CTO) PCI and PCI after coronary artery bypass grafting(CABG), severe cases of CAC are now encountered on a daily basis in the catheterization lab and remain a big challenge to the interventional community, making it crucial to identify cases of severe CAC and plan a CAC PCI modification strategy upfront. Improved CAC detection with intravascular imaging helped identifying more of these severe CAC cases and predicting response to therapy and stent expansion based on CAC distribution in the vessel. Multiple available therapies for CAC modification has evolved over the years, familiarity with the specifics and special considerations and limitations of each of these tools is essential in the choice and application of these therapies when used in severe CAC treatment. In this review we discuss CAC pathophysiology, modes of detection, and different available therapies for CAC modification.

Fetal cardiac function: myocardial performance index

The Myocardial Performance Index (MPI) or Tei index, presented by Tei in 1995, is the ratio of the sum of the duration of the isovolumetric contraction time (ICT) and isovolumetric relaxation time (IRT) to the duration of the ejection time (ET). The Modified Myocardial Performance Index (Mod-MPI), proposed in 2005, is considered a reliable and useful tool in the study of fetal heart function in several conditions, such as growth restriction, twin-twin transfusion syndrome, maternal diabetes, preeclampsia, intrahepatic cholestasis of pregnancy, and adverse perinatal outcomes. Nevertheless, clinical translation is currently limited by poorly standardised methodology as variations in the technique, machine settings, calliper placement, and specific training required can result in significantly different MPI values. This review aims to provide a survey of the relevant literature on MPI, present a strict methodology and technical considerations, and propose future research.

Cryptogenic Stroke and Embolic Stroke of Undetermined Source: Risk Factors and Approaches for Detection of Atrial Fibrillation

Background: Stroke is a problem worldwide because of its high mortality and disability rates. Almost 90% of strokes are ischemic, and more than half of the deaths are caused by an ischemic stroke. Most risk factors for stroke are manageable so that it can be avoided with proper prevention. Despite the success in determining the causes of stroke in recent years, selectively, the "culprit" causing stroke remains unsolved. In such cases, a diagnosis of undetermined etiology (cryptogenic stroke) or embolic stroke of undetermined source (ESUS) is generated, resulting the prevention of a recurrent cerebrovascular occurrence impossible. Atrial fibrillation (AF) can be a cause of stroke by causing blood clots in the chambers of the heart. Purpose: The aim was to determine the optimal method of heart rate monitoring in patients with ischemic stroke, as methods and approaches for detecting AF are very diverse, but there is still no single opinion, which would be universal. Procedures: In our review, we consider epidemiology, risk factors for the stroke of undetermined etiology, as well as analytical methods for detecting heart rhythm disturbances in this category of patients. Findings: Atrial fibrillation (AF) is detected by thorough monitoring of heart rate of patients with cryptogenic stroke and ESUS can be diagnosed in up to 46% of patients. Conclusion. After AF detection, consideration should be given to prescribing anticoagulants, instead of antiplatelet agents, for the secondary prevention of stroke.

An Update on New Cholesterol Inhibitor: Bempedoic Acid

: An increase in the level of cholesterol day by day is easily seen in most people just because of poor life style, food with high cholesterol, lack of physical work, etc. There are lots of molecules available, which lower down the cholesterol level. In this field a new molecule has been introduced that is bimpedoic acid. Researches indicate that bempedoic acid has the same mechanism of action as statins, which means that it also inhibits the HMG-CoA reductase enzyme. This letter to the editor is my best collection of published scientific data on bempedoic acid till now. It also includes the chemistry, pharmacodynamic and pharmacokinetic parameters of the mentioned new molecule.

Impact of racial differences on the epidemiology and clinical outcomes of atrial fibrillation

: Atrial fibrillation (AF) is the most common cardiac arrhythmia and is associated with increased morbidity and mortality. The overall AF burden is expected to rise over the next decade, and this will have significant implications on the healthcare cost. Current literature on the pathophysiology, epidemiology and management of patients with AF have focused mainly on predominantly Caucasian/white population while published studies in non-white populations have been mainly observational or retrospective in nature. Hence, the implications of AF in terms of management and complications in the non-white population have not been fully appreciated. In this review, we summarized based on the available literature, the racial differences in the prevalence, management and outcomes of patients with AF comparing the white vs non-white population.

Efficacy and Complications of Subcutaneous versus Conventional Cardioverter Defibrillators: A Systematic Review and Meta-Analysis

Background/Objectives: Implantable cardioverter defibrillators are used to prevent sudden cardiac death. The subcutaneous implantable cardioverter defibrillator was newly developed to overcome the limitations of the conventional implantable cardioverter defibrillator-transvenous device. The subcutaneous implantable cardioverter defibrillator is indicated for young patients with heart disease, congenital heart defects, and poor venous access, who have an indication for implantable cardioverter defibrillator without the need for anti-bradycardic stimulation. We aimed to compare the efficacy and complications of subcutaneous with transvenous implantable cardioverter defibrillator devices. Methodology: A systematic review was conducted using different databases. The inclusion criteria were observational and clinical randomized trials with no language limits and no publication date limit that compared subcutaneous with transvenous implantable cardioverter defibrillators. The selected patients were aged > 18 years with complex ventricular arrhythmia. Results : Five studies involving 2111 patients who underwent implantable cardioverter defibrillator implantation were included. The most frequent complication in the subcutaneous device group was infection, followed by hematoma formation and electrode migration. For the transvenous device, the most frequent complications were electrode migration and infection. Regarding efficacy, the total rates of appropriate shocks were 9.04% and 20.47% in the subcutaneous and transvenous device groups, respectively, whereas inappropriate shocks to the subcutaneous and transvenous device groups were 11,3% and 10,7%, respectively. Conclusion: When compared to the transvenous device, the subcutaneous device had lower complication rates owing to lead migration and less inappropriate shocks due to supraventricular tachycardia; nevertheless, infection rates and improper shocks due to T wave oversensing were comparable for both devices

Concise Review of the Rationale for Pulmonary Embolism Treatment and Endovascular Device Therapies

: In the ever-changing landscape of device therapy for pulmonary embolism, it is important to understand the rationale behind the ongoing explosion in the development of new device therapies. There needs to be an in-depth understanding of risk stratification in pulmonary embolism and indications for therapy. Selecting the ideal device for a particular pulmonary embolism subset remains elusive and poorly defined. Knowledge of the risks, bene-fits, capabilities, and potential limitations of each device is crucial.