Current problems in cardiology
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Patent foramen ovale has become the subject of increasing interest in modern cardiovascular disease. This has been the result of several factors including, among others, description of paradoxical embolism, documentation of patent foramen ovale with right to left shunt, the rather ubiquitous use of echocardiography, the issue of stroke prevention, and more recently, the relationship between patent foramen ovale and migraine.
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Cardiogenic shock (CS) may result from ischemic heart disease, cardiomyopathy, valvular heart disease, inflammation, myocardial contusion, and cardiac surgery. CS is the leading cause of in-hospital death in patients with acute myocardial infarction. Although early revascularization strategies have resulted in a better prognosis, in-hospital mortality from CS remains exceptionally high. ⋯ This review evaluates the current treatment of CS. In addition, novel approaches to monitor and modulate peripheral circulation at the bedside are highlighted. It is expected that these techniques will improve our understanding of the pathogenesis of CS and will offer new opportunities to guide therapy in CS patients to improve long-term prognosis.
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Patients with scar-related ventricular tachycardia (VT) are subject to frequent arrhythmia recurrences; antiarrhythmic drug therapy has been disappointing due to poor efficacy and side effects. Patients receiving multiple implantable cardioverter-defibrillator shocks because of VT have impaired quality of life. The role of catheter ablation in the treatment of ventricular arrhythmias has been increasing in the last 2 decades. ⋯ Also, electroanatomic mapping systems have made substrate mapping feasible. The purpose of this article is to review the selection and preparation of patients who require catheter ablation for scar-related VT, the different mapping techniques, and the ablation strategies employed. An overview of the pathophysiology of scar-related VT and the variety of heart diseases that are related to scar-related VT is provided.
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The vast database of the Yale Center for Thoracic Aortic Disease--which includes information on 3000 patients with thoracic aortic aneurysm or dissection, with 9000 catalogued images and 9000 patient-years of follow-up--has, over the last decade, permitted multiple glimpses into the "playbook" of this virulent disease. Understanding the precise behavioral features of thoracic aortic aneurysm and dissection permits us more effectively to combat this disease. In this monograph, we will first review certain fundamentals--in terms of anatomy, nomenclature, imaging, diagnosis, medical, surgical, and stent treatment. ⋯ The specific genetics are being elucidated at the molecular level. 8 Matrix metalloproteinase overactivity participates in the destructive processes that degrade an aorta in individuals genetically preprogrammed to develop aneurysms. 9 Most dissections are brought on via presumed momentary hypertensive crises by severe exercise or emotion. We look forward to a future in which the aneurysm diathesis can be determined by a genetic test (RNA or DNA based), in which matrix metalloproteinases can be specifically antagonized by medications, in which exercise and emotion can be modulated in susceptible patients, and in which mechanical properties of the aorta (in addition to simple dimension) can be assessed serially to guide the timing of operation more precisely. Genetic-based therapies (eg, development of drugs on the basis of discovered molecular proteomics) will likely become possible to prevent susceptible patients from forming aneurysms over the long term.
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Patients with stenosis of the left main coronary artery present difficult challenges. The risks associated with this lesion have been known since the early days of angiography when patients were found to have increased mortality during follow-up. This information led to the general guidelines that surgical revascularization should be considered the treatment of choice in patients with significant left main coronary artery stenosis. ⋯ This trial is in the final stages of patient recruitment and will have important implications for the field. The other trial is the COMBAT trial, which is focused exclusively on left main coronary artery stenosis and randomizes patients with left main coronary artery disease either to a Sirolimus-eluting stent (Cypher, Johnson and Johnson Cordis, USA) or to coronary artery bypass graft surgery. The field of left main coronary artery disease continues to expand in terms of the evidence available for optimal patient evaluation and selection of treatment modalities.