Left ventricular assist devices: A comprehensive review of major clinical trials, devices, and future directions.

Heart failure is an increasingly prevalent medical condition associated with significant morbidity and mortality. In spite of optimal medical therapy, a large number of patients continue to deteriorate clinically and could potentially benefit from advanced therapies. While cardiac transplantation is an established therapy for end-stage heart failure, there are a limited number of donor hearts, and many patients may not be candidates. Over the past two decades, mechanical circulatory support and left ventricular assist devices (LVAD) have altered the heart failure management landscape. Herein we review the indications for LVAD implantation and how they have changed over time. We will also outline major technological evolutions in LVADs and summarize the landmark clinical trials pertaining to them. We also highlight the adverse events associated with LVADs and assess the limitations of the existing literature. Finally, we look ahead to the future of LVAD therapy for patients with advanced heart failure.

Atrial fibrillation: Current and emerging surgical strategies.

OBJECTIVE: (a) To provide a comprehensive review of current literature on the surgical management of atrial fibrillation (AF), highlighting surgical approaches and outcomes. (b) To summarize the latest guidelines pertinent to the surgical management of AF. BACKGROUND: AF is associated with high rates of morbidity and mortality, primarily related to the associated risk of stroke. The mainstay of management is pharmacologic rate or rhythm control and catheter-based ablation. Surgical ablation (SA) is an alternative strategy that is effective in select patient populations. Recently, novel techniques and technologies have been introduced and this has expanded the surgical capacity to manage AF. METHODS: A comprehensive review of the literature was conducted. RESULTS: Surgery can be a highly effective alternative therapeutic option for the management of AF in the appropriate patient population. The need for permanent pacemaker implantation is controversial among patients undergoing surgical intervention for AF. Surgical outcomes are promising, with long-term control of AF and symptomatic relief achieved in select groups of patients. CONCLUSIONS: This article provides a comprehensive review of the surgical management of AF. We have summarized the latest surgical outcomes and contextualized the most recent guidelines.

Delayed dehiscence of modified mechanical Bentall 7 years postsurgery for Takayasu's arteritis.

Following aortic surgery for vasculitis, the incidence and duration of onset of anastomotic breakdown is unclear. A case is presented of a young female patient with Takayasu's arteritis (TA) who was found to have frank dehiscence of a modified Bentall repair 7 years after surgery. The case highlights (i) the lack of normal healing following aortic surgery in TA, and (ii) need to differentiate imaging protocols for patients with defined vasculitis as opposed to degenerative aortic conditions. A recommendation is made for appropriate surveillance imaging modality alternating between computed tomography and magnetic resonance imaging in the often young patient population affected by vasculitis.

Partial oral versus full intravenous antibiotic treatment of endocarditis in people who inject drugs: A systematic review.

Background: Prolonged intravenous (IV) antibiotic therapy may not be optimal for people who inject drugs (PWID) with infective endocarditis (IE) due to unique social and medical needs. The role of partial IV antibiotic therapy with continued oral (PO) antibiotic therapy is unclear. Methods: A systematic review was performed using EMBASE and MEDLINE databases. Included studies compared PO to IV antibiotic treatment for IE in PWID. Results: Four studies met eligibility. Observational studies included full IV treatment groups and partial IV, partial PO treatment groups for severe injection-related infections. PWID with IE comprised 41.0%-64.7% of the study populations but outcomes specific to IE were not separately reported. All-cause 90-day readmission rates were comparable between the IV treatment group (27.9%-31.5%) and partial IV, partial PO treatment group (24.8%-32.5%). Ninety-day mortality was non-significantly different between IV treatment (4.9%-10.7%) and partial IV, partial PO treatment groups (2.4%-13.0%). One small randomized clinical trial compared IV oxacillin or vancomycin with gentamicin to PO ciprofloxacin plus rifampin. The cure rates were 91% and 90%, respectively. Conclusion: There is limited evidence comparing IV treatment to partial IV, partial PO antibiotic treatment in PWID with IE. Observational studies suggest that PO antibiotic therapy after initial IV treatment may be equivalent to full IV treatment alone within specific parameters, but randomized trials are needed to inform recommendations. Substantial clinical and social benefits for PWID and advantages for the health care system will result if PO treatment strategies with equal efficacy can be implemented.

Historique: L'antibiothérapie intraveineuse (IV) prolongée n'est peut-être pas optimale chez les utilisateurs de drogues par injection (UDI) atteints d'une endocardite infectieuse (EI) découlant de besoins médicaux et sociaux particuliers. On ne connaît pas clairement le rôle de l'antibiothérapie IV partielle conjuguée à l'antibiothérapie par voie orale (PO). Méthodologie: Les chercheurs ont procédé à une analyse systématique au moyen des bases de données EMBASE et MEDLINE. Les études incluses comparaient l'antibiothérapie PO à l'antibiothérapie IV en cas d'EI chez les UDI. Résultats: Quatre études respectaient les critères d'admissibilité. Les études observationnelles incluaient des groupes de traitement IV complets et des groupes de traitements IV et PO partiels en raison de de graves infections liées aux injections. Les UDI atteints d'une IE formaient de 41,0 % à 64,7 % de la population à l'étude, mais les résultats cliniques propres à l'IE n'étaient pas déclarés séparément. Les taux de réadmission toutes causes confondues au bout de 90 jours étaient comparables entre le groupe de traitement IV (27,9 % à 31,5 %) et le groupe de traitement IV et PO partiel (24,8 % à 32,5 %). La mortalité au bout de 90 jours n'était pas sensiblement différente entre le groupe de traitement IV (4,9 % à 10,7 %) et le groupe de traitement IV et PO partiel (2,4 % à 13,0 %). Une petite étude clinique randomisée a comparé l'oxacilline ou la gentamicine IV à la ciprofloxacine conjuguée à la rifampine PO. Les taux de guérison actuels s'élevaient à 91 % et à 90 %, respectivement. Conclusion: Les données probantes sur la comparaison entre l'antibiothérapie IV et l'antibiothérapie IV et PO partielle sont limitées chez les UDI ayant une IE. Selon les études observationnelles, l'antibiothérapie PO après un traitement IV initial pourrait équivaloir à un traitement IV complet unique selon des paramètres précis, mais des études randomisées s'imposent pour étayer les recommandations. Les UDI tireront des avantages cliniques et sociaux importants s'il est possible d'adopter des stratégies de traitement PO de même efficacité, et le système de santé en profitera également. Summary: Injection drug use significantly increases the risk of infective endocarditis, a bacterial infection of one or more heart valves. When diagnosed, infective endocarditis typically requires weeks of antibiotic therapy, often intravenous. This can amount to long hospital stays, particularly for people who inject drugs, as outpatient antibiotic therapies are often not feasible. As a result, there can be significant consequences in this population such as loss of housing, childcare, and employment, which may have already been unstable at the time of their hospital admission. As such, some people who inject drugs leave the hospital before their antibiotic course is completed. This can predispose them to redeveloping the infection and can lead to other complications including death. In the general population with infective endocarditis, the outcomes with oral antibiotics after a short course of intravenous antibiotics has been shown to be similar to a full course of intravenous treatment in some patients or in patients with specific clinical characteristics. Most of the current studies, however, do not include, or include very few people who inject drugs, so limited conclusions can be made for this population. This systematic review examines the current literature for oral compared to intravenous antibiotic treatment of infective endocarditis in people who inject drugs, in order to provide a baseline of our current understanding and advocate for more research.

Echocardiographic and clinical outcomes following beating heart NeoChord DS1000 mitral valve repair: a single centre case series.

Background: The NeoChord DS1000 system implants artificial neochords transapically, through a left mini-thoracotomy to treat degenerative mitral valve regurgitation (MR). Performed without cardiopulmonary bypass, neochord implantation and length adjustment is guided by transesophageal echocardiography. We describe imaging and clinical outcomes for a single center case series using this innovative device platform. Methods: In this prospective series, all study patients had degenerative MR and were considered for conventional mitral valve surgery. Moderate to high-risk candidates were screened for NeoChord DS1000 eligibility based on echocardiographic criteria. Study criteria included isolated posterior leaflet prolapse, leaflet-to-annulus index greater than 1.2, and coaptation length index greater than 5 mm. Patients with bileaflet prolapse, mitral annular calcification, and ischemic MR were excluded from our early experience. Results: Ten patients underwent the procedure, including 6 males and 4 females, with a mean age of 76 ± 9.5 years. All patients had severe chronic MR and normal left ventricular function. One patient required conversion to an open procedure for failure to deploy neochords with the device transapically. The median number of NeoChord sets was 3 (IQR 2.3-3.8). Immediate post-procedure (POD#0) degree of MR on echocardiography ranged from mild or less, and on postoperative day 1 (POD#1) from moderate or less. Average length of coaptation was 0.85 ± 0.21 cm and average depth of coaptation was 0.72 ± 0.15 cm. At 1-month follow-up echocardiography, MR was graded from trivial to moderate and left ventricular inner diameter dimensions decreased from an average of 5.4 ± 0.4 cm to 4.6 ± 0.3 cm. None of the patients who had successful NeoChord implantation required blood products. There was 1 perioperative stroke with no residual deficits. There were no device-related complications or serious adverse events. The median length of hospital stay was 3 (IQR 2.3-10) days. 30-day and 6-weeks postoperative mortality and readmission rates were 0%. Conclusion: We report the first Canadian case series using the NeoChord DS1000 system for off-pump, transapical, beating heart mitral valve repair, through a left mini-thoracotomy. The early surgical outcomes suggest this approach is feasible, safe, and effective in reducing MR. This novel procedure has the advantage of offering a minimally invasive, off-pump option for select patients with high surgical risk.