Radiation-associated Cardiac Injury.

Chest radiotherapy continues to play an important role in the treatment of breast cancer, Hodgkin's lymphoma, and other malignancies. Subsequent cardiac injury has been described involving essentially all structures of the heart, with most radiation-induced injury being progressive in nature. Our understanding over the multifactorial etiology and development of radiation-associated cardiac injury has advanced, leading to improved techniques aimed at decreasing cardiac radiation exposure and associated risks. Monitoring after radiotherapy clearly appears to be indicated; however, optimal recommendations regarding cardiac screening remain difficult to establish.

Cardiotoxicity of molecular-targeted drug therapy.

Cardiotoxicity is a well-known side-effect described in patients receiving various antineoplastic agents. With the abundance of clinical research and a heavy focus on drug development over the past decade, there has been a major shift in the use of non-specific cytotoxic drugs to molecular-targeted drug therapy. However, as a result, it has become clear that these drugs have numerous adverse effects, both on-target and off-target. Small-molecule tyrosine kinase inhibitors and other molecular-targeted agents, including monoclonal antibodies, have been the primary agents associated with cardiotoxicity. As more molecular-targeted therapies are developed, early recognition and management of drug-related cardiotoxicity will be extremely important in order to reduce morbidity and mortality. Pre-treatment evaluation with a surface electrocardiogram, echocardiography, cardiac history, and comprehensive review of concomitant medications are the current mainstay of treatment. However, much is still unknown about the potential cardiotoxic side-effects of these drug and optimal management. In the present article, we aim to review the cardiovascular implications and related cardiotoxicities associated with molecular target-based chemotherapeutic agents, with special emphasis on hypertension, cardiac dysfunction, and QT prolongation. Their implication, mechanism, and management are discussed where possible.

Percutaneous methods of left atrial appendage exclusion: an alternative to the internist.

Thromboembolic stroke from the left atrial appendage (LAA) is the most feared complication in patients with atrial fibrillation (AF). The cornerstone for the management of chronic non-valvular AF is stroke reduction with oral anticoagulation (OAC). However, poor compliance, maintaining a narrow therapeutic window, and major side effects such as bleeding have severely limited their use, which creates a therapeutic dilemma. As much as 20% of AF patients are not receiving OAC due to contraindications and less than half of AF patients are not on OAC due to reluctance of the prescribing physician and/or patient non-compliance. Fortunately, over the past decade, there have been great interests in providing an alternative strategy unbeknownst to the practicing internist. The introduction of percutaneous approaches for LAA occlusion has added a different dimension to the management of chronic AF in patients with OAC intolerance. Occlusion devices such as the Amplatzer Cardiac Plug and WATCHMAN device are currently being investigated for stroke prophylaxis. More recently, the LARIAT device may provide an alternative means for potential stroke prophylaxis without the need for short-term post-procedural OAC. We aim to review the current literature and bring attention to an alternative strategy for high-risk AF patients intolerant to OAC.

Hepatic hydrothorax.

Hepatic hydrothorax is defined as a pleural effusion in patients with liver cirrhosis in the absence of cardiopulmonary disease. The estimated prevalence among patients with liver cirrhosis is approximately 5-6%. The pathophysiology involves the passage of ascitic fluid from the peritoneal cavity to the pleural space through diaphragmatic defects. The diagnosis is made from clinical presentation and confirmed by diagnostic thoracentesis with pleural fluid analysis. The initial medical management is sodium restriction and diuretics, but liver transplantation provides the only definitive therapy. For patients who are not transplant candidates and those who await organ availability, other therapeutic modalities that are to be considered include transjugular intrahepatic portosystemic shunt placement, videoassisted thoracoscopic surgery repair, pleurodesis, and vasoconstrictors (eg, octreotide and terlipressin). The primary therapeutic goals are to reduce ascitic fluid production and improve symptoms to bridge the time for liver transplantation.

The role of endoscopy in bariatrics: past, present, and future.

The exponential increase in the rate of obesity and its associated co-morbidities has increased the demand for bariatric surgery. Over the past few decades, surgical weight reduction by gastric restriction, malabsorption, or a combination of both has been the preferred approach to achieve sustained weight loss in the morbidly obese. Although extremely effective, surgical procedures carry significant complications and risk with mortality rates of 1%. Because of the cost, surgical risk, and complications, there is a demand for less invasive procedures. Endoscopic approaches include placement of endoluminal space-occupying devices, stapling devices to reduce gastric volume, barrier devices to reduce small bowel absorptive area, and methods to regulate gastric emptying. Current and ongoing studies have delivered promising results across many aspects of endoscopic approaches. However, many technical obstacles still exist that have to be resolved with further research before endoscopic bariatrics can be widely deployed. At present the role of endoscopy is well established in preoperative evaluation as well as in recognition and management of many postoperative complications in bariatrics. In this article, we review the current and future endoscopic methods for weight reduction that are either in practice or in testing.