Do the Few Dictate Care for the Many? Revascularisation Considerations That Go Beyond the Guidelines.

The burden of coronary artery disease (CAD) is large and growing, commonly presenting with comorbidities and older age. Patients may benefit from coronary revascularisation with percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG), yet half of patients with CAD who would benefit from revascularisation fall outside the eligibility criteria of trials to date. As such, the choice of revascularisation procedures varies depending on the CAD anatomy and complexity, surgical risk and comorbidities, the patient's preferences and values, and the treating team's expertise. The recent American guidelines on coronary revascularisation are comprehensive in describing recommendations for PCI, CABG, or conservative management in patients with CAD. However, individual challenging patient presentations cannot be fully captured in guidelines. The aim of this narrative review is to summarise common clinical scenarios that are not sufficiently described by contemporary clinical guidelines and trials in order to inform heart team members and trainees about the nuanced considerations and available evidence to manage such cases. We discuss clinical cases that fall beyond the current guidelines and summarise the relevant evidence evaluating coronary revascularisation for these patients. In addition, we highlight gaps in knowledge based on a lack of research (eg, ineligibility of certain patient populations), underrepresentation in research (eg, underenrollment of female and non-White patients), and the surge in newer minimally invasive and hybrid techniques. We argue that ultimately, evidence-based medicine, patient preference, shared decision making, and effective heart team communications are necessary to best manage complex CAD presentations potentially benefitting from revascularisation with CABG or PCI.

Multimodality Imaging Approach Evaluation of the Congenital Pericardial Defect: a Contemporary Review.

PURPOSE OF REVIEW: This review presents the etiology, clinical manifestations, diagnostic approach, and treatment of congenital pericardial defects. It also highlights the critical role of echocardiography, cardiac computed tomography (CCT), and cardiac magnetic resonance (CMR) in the diagnosis and management approach. RECENT FINDINGS: Congenital pericardial defects are rare. Although most cases are found incidentally, some cases could potentially be associated with serious outcomes including sudden cardiac death. The diagnosis is often challenging due to non-specific clinical manifestations and electrocardiogram findings. Echocardiography is the first-line imaging investigation for the evaluation of this condition. Advanced cardiac imaging modalities, including CCT and CMR, play important adjuvant roles in establishing the diagnosis and assists with prognostication.

Hands-on defibrillation with a safety barrier: An analysis of potential risk to rescuers.

BACKGROUND: Interruptions in compressions reducethe efficacy of cardiopulmonary resuscitation (CPR) and are inevitable during hands-off periods for shocks. Clinical exam gloves were found to facilitate safe contact with patients during shock delivery but the safety of this practice has been questioned. Polyethylene is of interest because of its safety record in the medical arena and its electrical insulation properties. METHODS: This study measured the current leak through 2 mil (0.002 inch) polyethylene drapes during shock delivery. The current leak was assessed by measurement of voltage changes in a circuit recommended by the International Electrotechnical Commission (IEC) for current leak safety testing. Current flowed off the drape, through the circuit and to electric ground in a manner consistent with standardized testing. Perceptibility was assessed in a subset with the investigator's bare hands pressed into the drape during shock delivery. RESULTS: Thirty-three patients undergoing elective cardioversion at Emory University Hospital underwent analysis (age 23-90, 36% female). Biphasic energies were 200-360 J. The root mean square (RMS) current leak averaged 0.072 ± 0.022 mA and peak current leak averaged 0.67 ± 0.21 which is well below IEC recommendations of 3.5 mA RMS and 5.0 mA peak. Finally, no instances of dielectric breakdown occurred and no shocks were perceptible. CONCLUSIONS: Polyethylene is a common medical material which may facilitate safe hands-on defibrillation. Our data illustrates that a thin, semitransparent layer of polyethylene is a safe and feasible adjunct to cardiac arrest kits to allow continued compressions and simplification of the CPR process.