Contemporary evaluation and treatment of tricuspid regurgitation.

Valvular heart disease is a global health burden with substantial mortality. The left-sided valvular diseases have been extensively described using the robust treatment strategies available. By contrast, the right-sided diseases, particularly the tricuspid valve (TV) and associated regurgitation, still have much to be delineated. Worsening tricuspid regurgitation (TR) is associated with increased mortality; the non-invasive management is suboptimal; and surgical approaches carry significant risk. With advances in multimodality imaging, 3D echocardiography, improved understanding of TV anatomy, and pathophysiological mechanisms of primary and secondary regurgitation, as well as favorable data with transcatheter therapies, the field of TV management is rapidly evolving. This review aims to highlight pathophysiological mechanisms of TR, describe echocardiographic approaches to diagnosis and TV interrogation, and outline the latest transcatheter developments.

Novel Initiative Increasing GDMT Use Among Patients With Heart Failure With Reduced Ejection Fraction.

Guideline-directed medical therapy utilization in patients with heart failure with reduced ejection fraction (HFrEF) remains low despite benefits in morbidity and mortality. The authors describe a unique quality improvement initiative designed to increase angiotensin receptor-neprilysin inhibitor (ARNI) and mineralocorticoid receptor antagonist (MRA) utilization in outpatients with HFrEF in a large cardiology practice, whereby eligible patients were identified in a standardized review process and medication utilization rates were linked to group quality metrics. Eligible HFrEF patients were defined as having a left ventricular ejection fraction (LVEF) ≤40% and NYHA functional class II to IV level of symptoms. Those with an LVEF >40%, no documented LVEF, or with NYHA functional class I symptoms were excluded. ARNI utilization was defined as any dose of sacubitril/valsartan prescribed, and MRA utilization was defined as any dose of either spironolactone or eplerenone prescribed. Group quality metric targets were set at >25% ARNI prescription and >60% MRA prescription in eligible patients. Following project implementation, ARNI utilization rose from 31% to 67% and MRA increased from 28% to 66%. Establishing clear quality metrics and formulating a proactive evaluation process was associated with a significant increase in prescription rates.

Cardiovascular Alterations and Structural Changes in the Setting of Chronic Kidney Disease: a Review of Cardiorenal Syndrome Type 4.

Cardiovascular and renal physiology are interrelated. More than a decade ago this was codified in guidelines defining the five subtypes of the cardiorenal syndrome. Morbidity and mortality for those with the cardiorenal syndrome is high compared to demographically matched individuals without cardiorenal disease, acute or chronic. The focus of this review will be the epidemiology, the impact of chronic kidney disease on cardiac structure and function, and associated clinical symptoms, outcomes, and potential treatments for patients with chronic reno-cardiac syndrome, or cardiorenal syndrome type 4. Cardiac structural changes can be profound and are described in detail both at a cellular and physiologic level. Integrating therapies for the treatment of causative or resulting comorbidities may ultimately slow progression of both cardiac and renal disease as well as minimize symptoms and death.

Intraparenchymal Brain Abscess in an Adult Male With Underlying Ebstein Anomaly and Cor Triatriatum Dexter.

A 21-year-old man presented with new-onset seizures and brain abscess. Echocardiography and cardiac magnetic resonance imaging revealed underlying Ebstein anomaly, secundum atrial septal defect, and cor triatriatum dexter. The elevated right heart pressures shunting through the septal defect and transient bacteremia were the likely mechanisms for his presentation. (Level of Difficulty: Intermediate.).

Aryl(trifluoroethyl)iodonium Triflimide and Nitrile Solvent Systems: A Combination for the Stereoselective Synthesis of Armed 1,2-trans-ß-Glycosides at Noncryogenic Temperatures.

Armed thioglycosides can be activated with aryl(trifluoroethyl)iodonium triflimide in 2:1 CH2Cl2/pivalonitrile or a solvent combination of CH2Cl2, acetonitrile, isobutyronitrile, and pivalonitrile (6:1:1:1) at 0 °C for glycosylation reactions that proceed in good yield and moderate to excellent selectivity (up to 25:1 ß/α). Comparison to other common glycosylation promoters reveals that both the mixed solvent and the iodonium salt promoter are required for stereoselectivity.

An air- and water-stable iodonium salt promoter for facile thioglycoside activation.

The air- and water-stable iodonium salt phenyl(trifluoroethyl)iodonium triflimide is shown to activate thioglycosides for glycosylation at room temperature. Both armed and disarmed thioglycosides rapidly undergo glycosylation in 68-97% yield. The reaction conditions are mild and do not require strict exclusion of air and moisture. The operational simplicity of the method should allow experimentalists with a limited synthetic background to construct glycosidic linkages.

Selective synthesis of 1,2-cis-α-glycosides without directing groups. Application to iterative oligosaccharide synthesis.

A method for the highly selective synthesis of 1,2-cis-α-linked glycosides that does not require the use of the specialized protecting group patterns normally employed to control diastereoselectivity is described. Thioglycoside acceptors can be used, permitting iterative oligosaccharide synthesis. The approach eliminates the need for lengthy syntheses of monosaccharides possessing highly specialized and unconventional protecting group patterns.