Cardiology

Resurgence of the edge-to-edge repair of the mitral valve Purpose of review To provide a critical review of the application and outcomes of surgical edge-to-edge (E2E) or Alfieri repair for mitral valvulopathy. Recent findings The E2E repair is a surgical technique to address mitral regurgitation, particularly suited when the responsible mechanism is bileaflet prolapse combined with enlarged annular area. It can also be used for a range of mitral valve pathologies. Surgically, the technique has been employed as a bailout for unsuccessful repair including residual mitral regurgitation because of systolic anterior motion (SAM). E2E repair should be accompanied by a ring annuloplasty for long-term repair durability. The simplicity of this approach makes it an ideal strategy during minimally-invasive mitral valve repair. It may also be performed via a transaortic approach at the time of aortic valve surgery to address less-than-severe mitral regurgitation or to address residual SAM following myectomy for hypertrophic obstructive cardiomyopathy. We review the surgical indication, potential complications including risk of mitral stenosis and the long-term outcomes of E2E repair. Summary The E2E surgical repair is a simple and effective surgical strategy to address a wide range of mitral regurgitation. This is an important technique in the surgical armamentarium especially in cases of minimally-invasive mitral valve surgery. Correspondence to Bobby Yanagawa, MD, PhD, FRCSC, Assistant Professor, Department of Surgery, University of Toronto, Division of Cardiac Surgery, St. Michael's Hospital, 30 Bond Street, 8th Floor, Bond Wing, Toronto, ON M5B 1W8, Canada. Tel: +1 416 864 5706; fax: +1 416 864 5031; e-mail: yanagawab@smh.ca Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Ambulatory advanced heart failure patients: timing of mechanical circulatory support – delaying the inevitable? Purpose of review Current indications for continuous-flow left ventricular assist device (cfLVAD) implantation is for patients in cardiogenic shock or inotrope-dependent advanced heart failure. Risk stratification of noninotrope dependent ambulatory advanced heart failure patients is a subject of registries designed to help shared-decision making by clinicians and patients regarding the optimal timing of mechanical circulatory support (MCS). Recent findings The Registry Evaluation of Vital Information for VADs in Ambulatory Life enrolled ambulatory noninotrope dependent advanced systolic heart failure patients who had 25% annualized risk of death, MCS, or heart transplantation (HT). Freedom from composite clinical outcome at 1-year follow-up was 23.5% for the entire cohort. Seattle Heart Failure Model Score and Natriuretic pepides were predictors with modest discriminatory power. Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) profile 4 patients had the highest risk (3.7-fold) of death, MCS or HT compared to INTERMACS profile 7. Summary We propose individualized risk stratification for noninotrope dependent ambulatory advanced heart failure patients and include serial changes in end-organ function, nutritional parameters, frailty assessment, echocardiographic and hemodynamic data. The clinical journey of a patient with advanced heart failure should be tracked and discussed at each clinic visit for shared decision-making regarding timing of cfLVAD. Correspondence to Indranee Rajapreyar, MD, Section of Heart Failure and Transplantation Cardiology, Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham, 1900 University Blvd, THT 311, Birmingham, Alabama 35233, USA;. e-mail: irajapreyar@uabmc.edu Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Update of clinical echocardiographic assessment of heart failure with preserved ejection fraction Purpose of review Heart failure with preserved ejection fraction (HFpEF) has an increasing global prevalence. Diastolic dysfunction is the predominant cause of symptoms, most commonly, exertional dyspnea. Although prevalent, the syndrome is challenging to identify due to the comorbid conditions that can present similarly. This paper will review established, guideline recommended, echocardiographic variables, and pathophysiology. Recent findings Echocardiography is the primary diagnostic modality. The latest advances in strain analysis, algorithmic use of multiple parameters, and deeper understanding of exercise hemodynamics have improved our classification of those with HFpEF. Summary There remains a paucity of therapies with mortality benefit in this subgroup. Thus, improving diagnostic efficacy is important as it can clarify epidemiologic, phenotypic, and pathologic features of HFpEF. Correspondence to Mehnaz Rahman, MD, LSU Health Sciences Section of Cardiology, 533 Bolivar Street CSRB 3–42, New Orleans, Louisiana 70112, USA. Tel: +504 568 1276; fax: +504 568 2127; e-mail: mrahm3@lsuhsc.edu Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Cardiovascular implications and complications of the coronavirus disease-2019 pandemic: a world upside down Purpose of review The new pandemic of coronavirus disease-2019 (COVID-19) has produced a global tumult and has overburdened national health systems. We herein discuss the cardiovascular implications and complications of this pandemic analyzing the most recent data clustered over the last several months. Recent findings COVID-19 afflicts the cardiovascular system producing acute cardiac injury in 10–20% of cases with mild disease but in greater than 50–60% in severe cases, contributing to patients' demise. Other cardiovascular complications include arrhythmias, heart failure, pulmonary embolism and shock. Off-label therapies are being trialed with their own inherent cardiovascular risks, while supportive therapies currently dominate, until more specific and effective antiviral therapies and vaccinations become available. A controversial issue relates to the safety of drugs blocking the renin--angiotensin system as an angiotensin-converting enzyme (ACE) homologue, ACE2, serves as the receptor for viral entry into host cells. However, to-date, no harm has been proven for these drugs. Summary In the cardiovascular system, COVID-19 can induce acute cardiac injury, arrhythmias, heart failure, pulmonary embolism, shock and death, whereas anti-COVID therapies also confer serious cardiovascular side-effects. Ongoing extensive efforts focus on specific vaccines and antivirals. Meanwhile, cardiovascular risk factors and diseases should be jointly controlled according to current evidence-based guidelines. Correspondence to Antonis S. Manolis, MD, First Department of Cardiology, Ippokrateio Hospital, Vas. Sofias 114, Athens 11527, Greece. Tel: +30 213 2088470; e-mail: asm@otenet.gr Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Novel technologies in the management of heart failure with preserved ejection fraction: a promise during the time of disappointment from pharmacological approaches? Purpose of review Despite numerous attempts, none of a wide variety of tested drugs achieved meaningful improvement in the outcomes of heart failure with preserved ejection fraction (HFpEF), making new therapeutic strategies a major unmet medical need. The medical device industry embraced the challenge, developing novel technologies directed to face specific aspects of the pathophysiology of HFpEF. This review focuses on some of the most promising technologies attaining meaningful clinical progress recently in the field of HFpEF therapy. Recent findings Implantable pulmonary artery pressure, monitoring for optimization of medical therapy, proved to be beneficial in heart failure admissions in a large postmarketing clinical study. Investigational devices, such as inter-atrial shunts and transvenous phrenic nerve stimulators for the treatment of central sleep apnea with Cheyne–Stokes breathing, are currently being evaluated in HFpEF cohorts in recent trials. Summary Device-based therapies for HFpEF demonstrated encouraging safety and efficacy results in various stages of the disease. Further efforts are needed to ensure that these devices will reach clinical use and contribute to the management of HFpEF patients. Correspondence to Dr Dean Nachman, MD, Heart Institute, Hadassah Medical Center, POB 12272, Jerusalem, 91120, Israel. Tel: +972-50-2217665, +972-2-6757657; fax: +972-2-6757660; e-mail: Dean@hadassah.org.il Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Skeletal muscle (dys)function in heart failure with preserved ejection fraction Purpose of review Skeletal muscle dysfunction contributes to exercise intolerance, which manifests as dyspnea and fatiguability in patients with heart failure with preserved ejection fraction (HFpEF). This review aims to summarize the current understanding of skeletal muscle dysfunction in HFpEF. Recent findings Animal and human studies in HFpEF provide insights into the pathophysiological alterations in skeletal muscle structure and function with the identification of several molecular mechanisms. Exercise training and novel pharmacological therapies that target skeletal muscle are proposed as therapeutic interventions to treat HFpEF. Summary There is evidence that skeletal muscle dysfunction plays a pathophysiological role in HFpEF. However, precise mechanistic insights are needed to understand the contribution of skeletal muscle dysfunction in HFpEF. Correspondence to Flora Sam, MD, Whitaker Cardiovascular Institute, Boston University School of Medicine, 700 Albany Street, W507, Boston, MA 02118, USA. Tel: +1 617 358 8208; e-mail: florasam@bu.edu Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Review of transapical off-pump mitral valve intervention with NeoChord implantation Purpose of review Mitral valve repair surgery has recently shifted from resection-based techniques to leaflet sparing approaches using synthetic neochordae. This has facilitated the growth of a new strategy of transapical off-pump mitral valve intervention with neochord implantation. Recent findings Minimally invasive approaches for mitral valve repair with robotic or video-assisted mini-right anterolateral thoracotomy have been developed to mitigate the morbidity associated with conventional median sternotomy. Recently, an alternative, less invasive surgical strategy has emerged. This transapical off-pump technique employs the NeoChord DS1000 (NeoChord, Inc., Minneapolis, MN, USA) system to achieve repair with neochordae via a left minithoracotomy incision. With appropriate patient selection, advanced cardiac imaging, and training in device deployment are important for procedural success. Summary Early results suggest that transapical off-pump mitral valve intervention with NeoChord implantation is a safe procedure with favorable outcomes for select patients with degenerative mitral regurgitation. Continued experience and clinical trials will assess the potential of this minimally invasive strategy, but this technique is likely to become part of the surgical repertoire for managing chronic degenerative mitral valve disease. Correspondence to Corey Adams, MD, MSc, FRCSC, Department of Cardiac Sciences, Section of Cardiac Surgery, Libin Cardiovascular Institute of Alberta, Foothills Medical Centre, 1403 29th Street, NW, Office 880C, Calgary, AB, Canada T2N 2T9. Tel: +1 403 944 1090; fax: +1 403 944 4895; e-mail: corey.adams@albertahealthservice.ca Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

COVID-19 myocarditis and long-term heart failure sequelae Purpose of review The clinical syndrome of coronavirus disease 2019 (COVID-19) has become a global pandemic leading to significant morbidity and mortality. Cardiac dysfunction is commonly seen in these patients, often presenting as clinical heart failure. Accordingly, we aim to provide a comprehensive review on COVID-19 myocarditis and its long-term heart failure sequelae. Recent findings Several suspected cases of COVID-19 myocarditis have been reported. It is often not clear if the acute myocardial dysfunction is caused by myocarditis or secondary to generalized inflammatory state of cytokine release or microvascular thrombotic angiopathy. Ischemia may also need to be ruled out. Regardless, myocardial dysfunction in these patients is associated with poor overall prognosis. Laboratory testing, echocardiography, cardiac magnetic resonance imaging, and even endomyocardial biopsy may be needed for timely diagnosis. Several treatment strategies have been described, including both supportive and targeted therapies. Summary COVID-19 can cause a spectrum of ventricular dysfunction ranging from mild disease to fulminant myocarditis with hemodynamic instability. Future research is needed to understand the true prevalence of COVID-19 myocarditis, as well as to better define various diagnostic protocols and treatment strategies. Correspondence to Umair Khalid, MD, FACC, Section of Cardiology, Department of Medicine Michael E. DeBakey VA Medical Center & Baylor College of Medicine, Houston, TX;. e-mail: mukhalid@bcm.edu Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Mitral valve surgery for rheumatic heart disease: replace, repair, retrain? Purpose of review Rheumatic heart disease (RHD) affects over 30 million people worldwide. Substantial variation exists in the surgical treatment of patients with RHD. Here, we aim to review the surgical techniques to treat RHD with a focus on rheumatic mitral valve (MV) repair. We introduce novel educational paradigms to embrace repair-oriented techniques in cardiac centers. Recent findings Due to the low prevalence of RHD in high-income countries, limited expertise in MV surgery for RHD, technical complexity of MV repair for RHD and concerns about durability, most surgeons elect for MV replacement. However, in some series, MV repair is associated with improved outcomes, fewer reinterventions, and avoidance of anticoagulation-related complications. In low- and middle-income countries, the RHD burden is large and MV repair is more commonly performed due to high rates of loss-to-follow-up and barriers associated with anticoagulation, international normalized ratio monitoring, and risk of reintervention. Summary Increased consideration for MV repair in the setting of RHD may be warranted, particularly in low- and middle-income countries. We suggest some avenues for increased exposure and training in rheumatic valve surgery through international bilateral partnership models in endemic regions, visiting surgeons from endemic regions, simulation training, and courses by professional societies. Correspondence to Bobby Yanagawa, MD, PhD, FRCSC, Program Director, Division of Cardiac Surgery, University of Toronto Assistant Professor, Division of Cardiac Surgery, St. Michael's Hospital 30 Bond Street, 8th Floor, Bond Wing Toronto, ON M5B 1W8, Canada. Tel: +416 864 5706; fax: +416 864 5031; e-mail: yanagawab@smh.ca Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Antithrombotic therapy after transcatheter aortic valve replacement: current perspective Purpose of review Transcatheter aortic valve replacement (TAVR) has expanded as a treatment option for severe aortic stenosis throughout the surgical risk spectrum. Decreasing procedural risk and inclusion of lower risk population has shifted the focus to optimization of postprocedural management and balancing the thrombotic and bleeding complications. In this review, we outline various patient and procedure related factors affecting choice of antithrombotic therapy post TAVR and provide an update of recent development in this area. Recent findings Multiple studies have confirmed the high incidence of both ischemic and bleeding complications in the early to midterm post-TAVR. In addition, new data has emerged for the role of high resolution computed tomography to detect decreased leaflet mobility and leaflet micro thrombi associated with implications for bioprosthetic valve dysfunction and cerebrovascular events post TAVR. Randomized clinical trials have reported increased bleeding with dual antiplatelet therapy (DAPT) and oral anticoagulation (OAC) plus antiplatelet therapy. These findings suggest that aspirin monotherapy or OAC monotherapy likely provides the appropriate balance for antithrombotic protection and risk of bleeding. Summary Majority of patients undergoing TAVR have multiple comorbidities and are at increased risk of ischemic and bleeding complications. In the absence of robust clinical evidence, there is significant variability among guideline recommendations and antithrombotic therapy post TAVR across institutions. The available evidence confirms a high rate of bleeding with more potent and prolonged antithrombotic regimens without a documented benefit for clinical endpoints. The authors favor a conservative anti thrombotic approach and suggest monotherapy with aspirin or systemic anticoagulation based upon an individual's risk of thromboembolic complications. DAPT is reserved for patients with recent stenting and OAC plus aspirin is prescribed for patients with established CAD in the post TAVR setting. Correspondence to Dr Asim N. Cheema, Southlake Regional Health Centre, 596 Davis Drive, Newmarket, Ontario, Canada L3Y 2P9. E-mail: acheema@southlakeregional.org Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

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Medicine by Alexandros G. Sfakianakis,Anapafseos 5 Agios Nikolaos 72100 Crete Greece,00302841026182,00306932607174,alsfakia@gmail.com,

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