The use of ranolazine in non-anginal cardiovascular disorders: A review of current data and ongoing randomized clinical trials.

Ranolazine has characteristic properties of a selective inhibitor of the inward sodium current. It is primarily indicated as an anti-anginal agent in patients with coronary artery disease and chronic stable angina. Recently, ranolazine has been noted to possibly impart beneficial effects in various other cardiac conditions, including new-onset, paroxysmal, and chronic atrial fibrillation, post-operative atrial fibrillation, ventricular arrhythmias, post-revascularization coronary artery disease, chemotherapeutic cardiotoxicity, and diastolic and microvascular dysfunction. Herein, we present a review of the current clinical evidence describing the adjunctive or synergistic effects of ranolazine in non-angina related cardiovascular disorders, and include a discussion of the ongoing randomized trials investigating the therapeutic potential of ranolazine in a variety of cardiovascular diseases.

Late onset iatrogenic limb ischaemia after deployment of an Angio-Seal vascular closure device.

It is common practice to deploy a vascular closure device for access site closure after percutaneous angiography or cardiovascular interventions for immediate haemostasis and to facilitate early discharge. We encountered two octogenarian women who underwent and had subsequent vascular access site closure with Angio-Seal (St Jude) and who later presented with limb ischaemia needing surgical revascularisation. Our patients had undergone uneventful deployment of the Angio-Seal vascular closure device (VCD) at the right common femoral artery (CFA) access site with successful haemostasis. About 3 weeks later they presented with features of limb ischaemia needing further diagnostic work-up including repeat angiography, which revealed subtotal occlusion of right common femoral artery at the level of prior access and Angio-Seal deployment site. Both the patients underwent successful surgical repair with restoration of distal flow and resolution of symptoms. These cases illustrate the late presentation of VCD-related complications with limb ischaemia, needing surgical revascularisation.

Tricuspid Valve Repair with Pericardial Tube Placement via a Right Minithoracotomy.

The optimal surgical intervention for tricuspid valve endocarditis remains challenging in the setting of intravenous drug abuse. The situation is often complicated by aggressive bacterial pathogens, an increased risk of reinfection and reoperation, and poor long-term survival, despite a typically younger age at presentation. Herein, the case is presented of a 30-year-old female with infective endocarditis of the tricuspid valve secondary to intravenous drug abuse. The patient underwent minimally invasive tricuspid valve reconstruction utilizing a bovine pericardial tricuspid tube. This is a viable alternative to conventional techniques, and may reduce the risk of reinfection and reoperation, maintain ventriculo-tricuspid integrity, provide structural support, and also be performed via a minimally invasive approach.

Pleiotropic effects of the 3-hydroxy-3-methylglutaryl-CoA reductase inhibitors in pulmonary diseases: a comprehensive review.

The 3-hydroxy-3-methylglutaryl-CoA reductase inhibitors (statins) are used extensively in the treatment of hyperlipidemia. They have also demonstrated a secondary benefit in a variety of other disease processes, actions which are known as pleiotropic effects. Review of the current pulmonary literature suggests a potential advantage of statin usage in a variety of pulmonary conditions. Our paper serves as a focused discussion on the pleiotropic effects of statins in the most common pulmonary disorders.

Minimally invasive aortic valve replacement in octogenarians performed via a right anterior thoracotomy approach.

BACKGROUND AND AIM OF THE STUDY: A significant number of patients aged > or =80 years are denied aortic valve surgery due to the assumption of poor outcomes with surgery. The study aim was to evaluate the outcomes of minimally invasive aortic valve replacement (AVR), performed via a right anterior thoracotomy approach, in octogenarians. METHODS: A retrospective review was conducted of all minimally invasive isolated AVRs in patients aged > or =80 years performed at the authors' institution between February 2009 and April 2014. The operative times, postoperative complications, hospital length of stay and mortality were analyzed. RESULTS: A total of 255 consecutive patients (133 males, 122 females; mean age 83.5 +/- 3 years) was identified. The mean left ventricular ejection fraction was 57 +/- 10%, and 31 patients (12.2%) had prior cardiac surgery. The median predicted Society of Thoracic Surgeons mortality score was 3.2% (IQR 2.4-4.4%). Postoperatively, four patients (1.6%) had cerebrovascular accidents, 38 (14.9%) had prolonged ventilation, four (1.6%) required reoperation for bleeding, and eight (3.1%) had acute kidney injury. The median intensive care unit length of stay was 48.5 h (IQR 27-92 h) and the postoperative length of stay was 7 days (IQR 5-9 days). The 30-day mortality was 3.1% (n=8), and the combined end point of morbidity and mortality was 19.2% (n=49). The all-cause mortality at one and three years was 6.7%, and 10.2%, respectively. CONCLUSION: Minimally invasive AVR in octogenarians, performed via a right anterior thoracotomy approach, is associated with a low morbidity and mortality. This applies to both primary or reoperative surgery.

Wearable cardioverter defibrillator in stress cardiomyopathy and cardiac arrest.

A 57-year-old woman presented with nausea, vomiting and diarrhoea. She had severe hypokalaemia and hypomagnesemia with marked QTc (680 ms) prolongation after suspected viral diarrhoea. She then developed progressive dyspnoea with congestion. An echocardiogram was obtained and showed severe hypokinesis with apical ballooning and hyperdynamic cardiac base, suggestive of stress cardiomyopathy. A repeat ECG showed further prolongation of the QTc (883 ms) and she rapidly developed polymorphic ventricular tachycardia. She underwent cardiac arrest and was successfully resuscitated. A coronary angiogram confirmed the diagnosis of stress cardiomyopathy. We had therapeutic dilemma at discharge to implant a permanent automated implantable cardiac defibrillator in view of the high risk for recurrent ventricular tachycardia, or follow-up for resolution of both reversible causes of the prolonged QTc (stress cardiomyopathy and electrolytes abnormalities). We suggested an alternate treatment for sudden death prevention in high risk patients who have reversible cause for QT interval prolongation.

Type 2 diabetes does not attenuate racial differences in coronary calcification.

AIMS: Coronary artery calcification (CAC) is a strong predictor of atherosclerotic cardiovascular disease (CVD). Whites appear to have a higher prevalence of CAC than African-Americans (AAs), but it is unknown if type 2 diabetes, a major cardiovascular risk factor, attenuates this difference. We investigated the relationship of race and CAC in a sample of patients with type 2 diabetes without clinical CVD. METHODS: multivariable analyses of self-reported ethnicity and CAC scores, stratified by gender, in 861 subjects [32% AA, 66.9% male] with type 2 diabetes. RESULTS: AA race was associated with lower CAC scores in age-adjusted models in males [Tobit ratio for AAs vs. Whites 0.14 (95% CI 0.08-0.24, p<0.001)] and females [Tobit ratio 0.26 (95% CI 0.09-0.77, p=0.015)]. This persisted in men after adjustment for traditional, metabolic and inflammatory risk factors, but adjustment for plasma triglycerides [0.48 (95% CI 0.15-1.49, p=0.201)] and HOMA-IR [0.28 (95% CI 0.08-1.03, p=0.055)] partially attenuated the association in women. CONCLUSIONS: relative to African-Americans, White race is a strong predictor of CAC, even in the presence of type 2 diabetes. The relationship in women appears less robust possibly due to gender differences in metabolic risk factors.