Current cardiology reports
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Clear guidelines on when to select a subcutaneous ICD (S-ICD) over a transvenous ICD (TV-ICD) are lacking. This review will provide an overview of the most recent clinical data on S-ICD and TV-ICD therapy by pooling comparison studies in order to aid clinical decision making. ⋯ Pooling of observational-matched studies demonstrated an incidence rate ratio (IRR) for device-related complication of 0.90 (95% CI 0.58-1.42) and IRR for lead-related complications of 0.15 (95% CI 0.06-0.39) in favor of S-ICD. The IRR for device infections was 2.00 (95% CI 0.95-4.22) in favor of TV-ICD. Both appropriate shocks (IRR 0.67 (95% CI 0.42-1.06)) and inappropriate shocks (IRR 1.17 (95% CI 0.77-1.79)) did not differ significantly between both groups. With randomized data underway, the observational data demonstrate that the S-ICD is associated with reduced lead complications, but this has not yet resulted in a significant reduction in total number of complications compared to TV-ICDs. New technologies are expected to make the S-ICD a more attractive alternative.
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Modern cancer therapy comes at a cost of increased risk of cardiotoxicity. The purpose of our paper is to provide an updated review highlighting research incorporating biomarkers and imaging findings for the detection of subclinical cardiac dysfunction and management of cancer treatment-related cardiotoxicity. ⋯ Biomarkers, particularly troponin, NTproBNP, and myeloperoxidase, have been shown to have a predictive role in the development of cancer treatment-related cardiotoxicity. Early reductions in global longitudinal strain and the more recently reported, circumferential strain, have been shown to be predictive of subsequent cardiotoxicity. Integrating troponin levels with longitudinal strain may have incremental value in predicting future cardiotoxicity. Initiating troponin-guided heart failure therapy following cancer treatment may impact the development of cardiotoxicity. Strain-guided heart failure therapy is currently under investigation. Early detection of subclinical cardiac dysfunction in high-risk cancer patients and subsequent medical intervention using biomarkers and imaging may help to alter the course of cancer treatment-induced cardiotoxicity. Current guidelines and expert consensus offer a general framework for monitoring high risk patients for cardiotoxicity. However, additional research is needed to provide a more sophisticated and structured approach in detecting and managing subclinical cardiac dysfunction with hopes of minimizing subsequent cardiotoxicity.
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Coronary artery event includes acute coronary syndrome (ACS), percutaneous coronary intervention (PCI), and coronary artery bypass graft (CABG) surgery. Following such an event, risk of noncardiac surgery is increased. Of major concern is what can make this surgery safer? ⋯ High functional capacity improves cardiovascular (CV) risk; at least 4.0 metabolic equivalents (METs) on stress test are favorable. Risk scores can suggest need for further evaluation. Coronary angiography prior to surgery usually is not indicated since revascularization shows disappointing CV risk reduction results. Due to high association of peripheral arterial disease (PAD) with coronary artery disease (CAD), low ankle-brachial index (ABI) indicates increased CV risk. New perioperative beta blockade has shown disappointing benefit, but if ongoing should be continued. De novo perioperative beta blockade is for the highest CV risk patient undergoing noncardiac vascular surgery. Good evidence supports CV risk reduction from new or existing statin in the perioperative period, especially for the diabetic. Diabetics should also be on an angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) secondarily, during the perioperative period to decrease 30-day perioperative mortality. Optimal timing of elective noncardiac surgery following a coronary artery event appears to be 180 days with CV risk decreased by a statin and an ACEI or an ARB.
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Percutaneous mechanical circulatory support devices (PMCSD) consist of the intra-aortic balloon pump (IABP), Impella (Abiomed Inc., Danvers, Massachusetts), Tandem Heart (Cardiac Assist, Inc., Pittsburgh, Pennsylvania), or extracorporeal membranous oxygenation (ECMO). They augment cardiac output, cardiac index, and cardiac power which allow the operator to mitigate hemodynamic perturbations during high-risk percutaneous coronary intervention (HR-PCI). This review discusses PMCSD and their contemporary literature. ⋯ Recent literature has substantiated the hemodynamic benefits of PMCSD in HR-PCI and cardiogenic shock, but no mortality benefit was found. As stent technology improves, PCI is expanding into high-risk cases in which PMCSD provide hemodynamic support allowing safe and complete revascularization.
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Tricuspid regurgitation is common; however, recognition and diagnosis, clinical outcomes, and management strategies are poorly defined. Here, we will describe the etiology and natural history of tricuspid regurgitation (TR), evaluate existing surgical outcomes data, and review the evolving field of percutaneous interventions to treat TR. ⋯ Previously, the only definitive corrective therapy for TR was surgical valve repair or replacement which is associated with significant operative mortality. Advances in percutaneous valve repair techniques are now being translated to the tricuspid valve. These novel interventions may offer a lower-risk alternative treatment in patients at increased surgical risk. Significant TR adversely impacts survival. Surgery remains the only proven therapy for treatment of TR and may be underutilized due to mixed outcomes data. Early experience with percutaneous interventions is promising, but large clinical experience is lacking. Further study will be required before these therapies are introduced into broader clinical practice.