Myocardial Injury After Noncardiac Surgery: A Systematic Review and Meta-Analysis Myocardial injury after noncardiac surgery (MINS) is a common postoperative complication associated with adverse cardiovascular outcomes. The purpose of this systematic review was to determine the incidence, clinical features, pathogenesis, management, and outcomes of MINS. We searched PubMed, Embase, Central and Web of Science databases for studies reporting the incidence, clinical features, and prognosis of MINS. Data analysis was performed with a mixed-methods approach, with quantitative analysis of meta-analytic methods for incidence, management, and outcomes, and a qualitative synthesis of the literature to determine associated preoperative factors and MINS pathogenesis. A total of 195 studies met study inclusion criteria. Among 169 studies reporting outcomes of 530,867 surgeries, the pooled incidence of MINS was 17.9% [95% confidence interval (CI), 16.2–19.6%]. Patients with MINS were older, more frequently men, and more likely to have cardiovascular risk factors and known coronary artery disease. Postoperative mortality was higher among patients with MINS than those without MINS, both in-hospital (8.1%, 95% CI, 4.4–12.7% vs 0.4%, 95% CI, 0.2–0.7%; relative risk 8.3, 95% CI, 4.2–16.6, P < 0.001) and at 1-year after surgery (20.6%, 95% CI, 15.9–25.7% vs 5.1%, 95% CI, 3.2–7.4%; relative risk 4.1, 95% CI, 3.0–5.6, P < 0.001). Few studies reported mechanisms of MINS or the medical treatment provided. In conclusion, MINS occurs frequently in clinical practice, is most common in patients with cardiovascular disease and its risk factors, and is associated with increased short- and long-term mortality. Additional investigation is needed to define strategies to prevent MINS and treat patients with this diagnosis.

The Incisura Analysis of the arterial pressure waveform remains useful in modern practice to assess alterations that may indicate significant abnormalities of cardiovascular parameters. The recognition of abnormalities of the incisura and dicrotic wave should alert the clinician to seek specific etiologic factors. Understanding the physiological origins of the incisura and dicrotic notch enhance its clinical utility in accurately diagnosing abnormal hemodynamic states. This review summarizes the hemodynamic events causing and affecting the inscription of the incisura in the arterial waveform.

Very Late Stent Thrombosis in Drug-Eluting Stents New Observations and Clinical Implications Despite the reduction in stent failure with newer-generation drug-eluting stents, very late stent thrombosis (VLST) remains an unpredictable and potentially catastrophic complication of coronary revascularization procedures and is associated with high morbidity and mortality. Here, we present an updated overview of the latest advances in understanding the causes of VLST. Clinical studies that revealed potential risk factors and pathophysiologic studies on the mechanisms of VLST are discussed. Importantly, novel insights from recent advances in intravascular imaging are included. To date, there is no clinical guideline for VLST treatment. We propose an evidence-based recommendation that an intravascular-imaging-informed percutaneous coronary intervention strategy combined with optimized antiplatelet therapy is the foundation for successful VLST clinical management. Moreover, the future of VLST prevention, such as improved patient risk stratification and advances in addressing late stent failure, are also discussed.

Cardiovascular Risk Assessment in Renal and Liver Transplant Candidates: A Multidisciplinary Institutional Standardized Approach In the modern era, renal and liver transplant candidates present with a greater medical complexity driven in part by a higher prevalence of cardiovascular conditions, including coronary artery disease, valvular heart disease, and cardiomyopathies. In fact, cardiovascular disease is the most common cause of death after kidney transplantation worldwide. Similarly, an increase in the number of patients being listed with end-stage liver disease from nonalcoholic steatohepatitis and a rising model for end-stage liver disease scores at the time of liver transplant in the United States parallel an increasing cardiovascular disease risk profile for liver transplant candidates. A large degree of variation exists among clinical practice guidelines and transplant center practice patterns regarding patient selection for routine cardiac testing and the choice of testing modalities. Here, we review the clinical practice guidelines established at our center by a multidisciplinary group, including transplant nephrology, hepatology, and surgery, as well as general and interventional cardiology, with the goal of improving patient selection and reducing adverse cardiac events posttransplant.

Third-Generation LVADs: Has Anything Changed? The field of durable left ventricular assist devices has advanced dramatically since its introduction into the clinical realm. From the first-generation pulsatile HeartMate XVE device to the second-generation continuous axial flow HeartMate-2 to the current third-generation centrifugal flow devices, the left ventricular assist device has undergone significant evolution. This review describes the technology and its changes over the course of time, with a focus on the fundamental question: Has anything changed?

Insights From Atrial Fibrillation Genomics: From Bedside to Bench and Back Again From the bedside of patients contributing samples to large genome-wide association studies for atrial fibrillation (AF), over 100 AF risk loci have been identified. The top locus is near a gene implicated in pulmonary vein formation; the ostia of the pulmonary veins harbor initiating triggers of AF, and isolation of these areas is the cornerstone of ablation therapies for AF. Transcriptomic studies suggest that AF is associated with impaired or overwhelmed responses to cell stress. A dual risk model proposes that in genetically-susceptible individuals, inadequate transcriptional responses to stress predispose to AF in later life. Drugs targeting metabolic, oxidative, or protein handling stress may be novel upstream agents to bring back to the bedside for study in the prevention of AF.

Role of Imaging in the Management of Ventricular Arrhythmias The management of ventricular arrhythmias (VA) has evolved over time to an advanced discipline, incorporating many technologies in the diagnosis and treatment of the myriad types of VA. The first application of imaging is in the assessment for structural heart disease, as this has the greatest impact on prognosis. Advanced imaging has its greatest utility in the planning and execution of ablation for VA. The following review outlines the application of different imaging modalities, such as ultrasonography, magnetic resonance imaging, computed tomography, and positron emission tomography, for the treatment of VA.

Using High Sensitivity Troponins to Rule Out Acute Coronary Syndrome and Lower Admission Rates Chest pain is a common complaint encountered by Emergency Medicine physicians in the emergency department (ED). History taking, electrocardiograms, and cardiac biomarkers are the mainstays of the evaluation process of patients who present to the ED with symptoms of an acute coronary syndrome. Cardiac troponin is the primary biomarker used for the diagnosis of acute myocardial infarction. In January 2017, high sensitivity cardiac troponins (hs-cTns) were approved for use in the United States. These markers have increased sensitivity and can more rapidly detect myocardial injury, making them very useful in the ED. However, despite improved sensitivity, elevations in hs-cTn can occur in a large number of patients who are not currently experiencing an acute myocardial infarction. As a result, it is important that clinicians understand the value of serial cardiac biomarker measurements and how to incorporate hs-cTn levels below the limit of detection into clinical decision-making. A large percentage of these low-risk patients end up having negative cardiac work-ups. This article will include a discussion on how to utilize common risk stratification tools in the ED to identify cohorts of patients suitable for discharge without additional testing. ED physicians must understand the limitations and benefits of hs-cTn levels and how to incorporate the information obtained from these biomarkers into risk scores in order to strengthen disposition decisions and safely discharge patients from the ED.

Premature Ventricular Contractions and Cardiomyopathy Premature ventricular contractions (PVCs) are a common arrhythmia that may cause symptoms of variable severity. PVCs have recently garnered interest in their ability to induce adverse structural heart remodeling in an entity known as PVC-induced cardiomyopathy. This entity is a retrospective diagnosis that likely remains under-recognized and may occur concurrently with other forms of cardiomyopathy. The appropriate identification and management of PVCs in the setting of associated cardiomyopathy may have a significant impact on cardiac function and the clinical course, including recovery of left ventricular ejection fraction and improvement in patient functional status. Treatment consists of catheter ablation and/or antiarrhythmic drug therapy, but continued monitoring and follow-up are required, as the recurrence of high PVC burden may lead to redevelopment of cardiomyopathy.

Functional Mitral Regurgitation in Heart Failure Functional mitral regurgitation (FMR) in the setting of left ventricular (LV) dysfunction and heart failure portends a poor prognosis. Guideline-directed medical therapy remains the cornerstone of initial treatment, with emphasis placed on treatment of the underlying LV dysfunction, as FMR is a secondary phenomenon and a disease due to LV remodeling. Surgical correction of FMR is controversial because it typically does not address the underlying mechanism and etiology of the condition. However, new, minimally invasive transcatheter therapies, in particular the MitraClip system, have shown promise in the treatment of FMR in selected patients. This review will summarize the pathophysiology underlying FMR, the prognosis of patients with heart failure and FMR, and the various medical and procedural treatment options currently available and under investigation.