Not just to survive but to thrive: delirium in the pediatric cardiac ICU Purpose of review Pediatric delirium has recently been recognized to occur frequently in the pediatric general and cardiac ICU. The purpose of this review is to highlight recent data on the prevalence, prevention, and management of this condition. Recent findings Pediatric delirium occurs in the pediatric cardiac ICU (PCICU) in as many as 67% of patients. Validated screening tools are now available to assist clinicians in the diagnosis of this condition. Research has shown a growing relationship between benzodiazepines, mainstays in the realm of sedation, and delirium. The full spectrum of risk factors has yet to be clearly elucidated. After normalization of the ICU environment, antipsychotics are infrequently required for treatment. While pediatric delirium has been associated with increased length of stay and cost, long-term morbidities are unknown at this time. Summary Application of bundles to normalize the PCICU environment may lead to decreased incidence of pediatric delirium. Multiinstitutional studies are indicated to further delineate optimal bundles, stratify treatment strategies, and investigate long-term morbidity in pediatric delirium. Correspondence to Kathleen M. Donnelly, MD, Pediatric Program Director, Pediatric Critical Care, Inova Children's Hospital, Falls Church, Virginia, 22042, USA. Tel: +1 703 776 6652; e-mail: Kathleen.donnelly@inova.org Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Biomarkers in the risk assessment for stroke and dementia in atrial fibrillation Purpose of review Atrial fibrillation is one of the most common clinically encountered arrhythmias exhibiting a strong association with a spectrum of cerebral injuries from the occurrence of clinical stroke, subclinical stroke, dementia, and cognitive decline. Dynamic noninvasive specific and sensitive diagnostic tests may allow a personalized approach to the atrial fibrillation patient's treatment based upon quantitative parameters, aiming to prevent or delay stroke, dementia, progressive cognitive decline, or to assess responses to these therapies. This review will explore molecular markers that have been shown to have an association with atrial fibrillation, and have a potential to be predictive for the risk for stroke, cognitive dysfunction, and dementia in these patients. Recent findings Circulating biomarkers of vascular disease, fibrosis, thrombosis, and inflammation are associated with risk of stroke in patients with atrial fibrillation. These biomarkers are additive to the predictive utility of the CHADS2 and CHA2DS2-VASc scores, and in some cases allow for additional risk prognostication of the broad categories allocated by CHADS2 and CHA2DS2-VASc scores of low, medium, and high. Summary Across the spectrum of cerebral injuries in patients with atrial fibrillation, biomarkers hold the promise of personalized risk stratification and management to minimize risks of disease. Correspondence to T. Jared Bunch, MD, Intermountain Heart Rhythm Specialists, Intermountain Medical Center, Eccles Outpatient Care Center, 5169 Cottonwood Street, Suite 510, Murray, UT 84107, USA. Tel: +1 801 507 3513; fax: +1 801 507 3584; e-mail: Thomas.bunch@imail.org Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Cardiac surgical missions: what works, what does not, where we need to go from here Purpose of review Although overall neonatal and infant mortality continues to decrease around the world, years of life lost to congenital heart disease (CHD) rank among the top 10 leading causes for that age group in Latin America, Central Asia, Africa and the Middle East. Short-term surgical missions (STSMs) continue to be the only resource available in some areas of the world. Recent findings There is a need for better communications between charity organizations and the supported institutions. We observe a raising concern with the limited published information on the results of the STSMs and a call for patient safety, the use of international databases and accountability. Funding and human resources in low-income and middle-income countries (LMIC) are a persistent problem and a shift toward long-term collaboration rather than short-term visits opens the path to sustainability. The cost-effectiveness of STSMs treating congenital heart disease in LMIC seems to be very high whereas the management of adults with CHD and rheumatic valvulopathies appear as a growing concern. Summary Pediatric cardiac surgery STSMs continue to deserve full support and funding, long-term commitments, accountability and coordinated international funding are needed to achieve global sustainable coverage. Correspondence to Marcelo Cardarelli, MD. MPH, Pediatric Cardiac Surgeon, Inova Children Hospital, Children Heart Program, 2921 Telestar Court, Falls Church, VA 22042-1205, USA. Tel: +1 703 280 5858 x1023; fax: +1 703 280 2654; e-mail: marcelo.cardarelli@inova.org Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Tetralogy of Fallot: risk stratification is straightforward. Or is it? Purpose of review Tetralogy of Fallot (TOF) carries a long-term risk of arrhythmias and sudden death after surgical repair. Risk stratification is still less accurate than desired. Recent findings Several factors have been studied as risk predictors for ventricular arrhythmias and sudden death. Clinical parameters include age at surgery, time since repair, types of previous surgeries, and symptoms such as syncope and palpitations. Electrocardiographic parameters that have been studied include QRS interval, ventricular arrhythmias assessed with Holter monitors, signal averaged ECG, QRS fragmentation, QRS vector magnitude, and microvolt T-wave alternans. Exercising testing has been shown to have prognostic significance. Ventricular function assessment with imaging studies including echocardiography and magnetic resonance imaging (MRI) plays a significant role. Invasive hemodynamic and electrophysiologic studies, in addition to assessment for inducible tachycardia, can provide information regarding the electroanatomic substrate of VT. Summary Risk stratification for TOF has improved over the last years with several clinical, electrocardiographic, imaging, and invasive electrophysiologic findings showing promise, but there still a lack of uniformity in approach between various investigators and reproducibility of findings is difficult in larger populations. With use of a combination of factors, a more informed decision can be made. Correspondence to John Papagiannis, MD, Director of Electrophysiology, Ward Family Heart Center, Children's Mercy Hospital, 2401 Gillham Rd, Kansas City, MO 64108, USA. Tel: +1 816 2343255; e-mail: jpapagiannis@cmh.edu Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Dilated cardiomyopathy in children: moving beyond traditional pharmacologic therapy Purpose of review Dilated cardiomyopathy (DCM) is a rare myocardial disorder characterized by a dilated left ventricle and systolic dysfunction. Globally, it affects around 1 in every 100 000 children. The prognosis is generally poor, with 40% either failing traditional medical therapy within the first 2 years or requiring a heart transplant. This article will address the basic cause, epidemiology, pathobiology, and historical treatment approach of DCM and introduce novel contemporary medical and surgical strategies that may reduce the need for heart transplantation. Recent findings In the last 15 years, there has been a significant emphasis on identifying alternative treatment strategies in managing the child with a DCM and heart failure symptoms. New therapies have evolved to help bridge these critically ill children to transplant or have these therapeutic modalities serve as end-points in themselves. Thus subsequently, we will highlight contemporary as well as novel medical and procedural therapies that are being used for the treatment of pediatric DCM. Summary The child with a DCM and severe left ventricular dysfunction has a number of options available beyond simple diuretics and afterload reduction. Novel pacing strategies and mechanical assist device may provide not only a more stable clinical bridge environment but also may actually serve as an endpoint itself. Correspondence to Jordan A. Cohen, BS, University of Miami Miller School of Medicine, 1600 NW 10th Ave #1140, Miami, FL 33136, USA. E-mail: jac617@med.miami.edu Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Screening for prevention of sudden death in the young: what is new? Purpose of review The optimal approach to screening young people to decrease the risk of sudden death remains unknown. It deserves the passionate attention that researchers, clinicians and families have given it. The new data from January 2018 to July 2019 are reviewed here. Recent findings Cardiac findings associated with a risk of sudden death were reported in 0.4% of screened athletes. Well run programs continue report varying sensitivity for screening ECGs (between 86 and 100%). One major article reported a higher incidence of sudden death in young people than has been previously published (6.8/100 000 athletes). Summary The rate of important findings in sophisticated screening programs is approximately 0.4%, suggesting that this is near the population rate of detectable disease in most athletic groups. ECGs are unquestionably capable of detecting disease that can be missed by history and physical, but the performance characteristics of ECGs continue to vary from study to study. In addition, the underlying cost and infrastructure of ECG and echocardiographic screening remains unaddressed by the recent literature. A few small studies have started to look at alternative technology approaches to ECG screening. Video abstract http://links.lww.com/HCO/A58 Correspondence to Stuart Berger, MD, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 East Chicago Avenue, Box 21, Chicago, Illinois 60611, USA. Tel: +1 312 227 4100; fax: +1 312 227 9640; e-mail: stberger@luriechildrens.org Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (www.co-cardiology.com). Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Mechanical circulatory support in the context of coronary artery bypass grafting Purpose of review With the continuous innovation in mechanical circulatory support as an option for the management of patients in cardiogenic shock from myocardial infarction, it is important to understand the current evidence and recommendations for the use of these devices for patients who require or underwent coronary artery bypass surgery. Recent findings The use of mechanical circulatory support (MCS) in patients with cardiogenic shock who require or underwent coronary artery bypass surgery has not been well studied. Observational studies have shown that the use of intra-aortic balloon pump or percutaneous ventricular assist devices prior to revascularization lead to better survival. Extracorporeal membrane oxygenation (ECMO) still carries significant risk of mortality and complications; the use of additional MCS devices for left ventricular unloading during ECMO improves outcomes. Summary MCS will continue to play an important role in coronary artery surgery patients. Multidisciplinary Cardiac Shock Team can assist in proper patient selection and device choice, whereas prospective clinical trials are required to provide evidence-based guidance towards the management of these patients. Correspondence to Hadi Toeg, MD, MSc, MPH, FRCSC, Assistant Professor, University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, Ontario, Canada. Tel: +1 613 696 4091; e-mail: HToeg@OttawaHeart.ca Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Coronary artery surgery: a resurgence and new opportunity to serve our patients better No abstract available

Spontaneous coronary artery dissection: update 2019 Purpose of review Spontaneous coronary artery dissection (SCAD) is an important cause of myocardial infarction (MI) in women with few or no conventional cardiovascular risk factors. Lack of awareness about this condition among healthcare providers had led to significant underdiagnosis and misdiagnosis in this relatively young patient population. Recent findings The current review summarizes the contemporary data on cause, management strategies and outcomes of SCAD. Summary SCAD is not as rare as previously thought, accounting for up to 4% of all acute coronary syndromes. It is frequently linked with predisposing factors, such as fibromuscular dysplasia or other vasculopathies, and is often triggered by physical or emotional stress. Due to more fragile vessel architecture, coronary angiography as the first-line diagnostic tool should be performed meticulously to avoid iatrogenic dissection. Intravascular imaging may be required if angiographic findings are uncertain. Unless patients have high-risk features such as ongoing ischemia, recurrent chest pains, left main artery dissection, ventricular arrhythmias, or hemodynamic instability, a conservative treatment strategy is favored over revascularization. Close monitoring is essential after a SCAD-event as recurrent cardiovascular events post-SCAD are frequent. Correspondence to Jacqueline Saw, Interventional Cardiology, Vancouver General Hospital; Clinical Professor, University of British Columbia, 2775 Laurel Street, Level 9, Vancouver, BC, Canada V5Z1M9. Tel: +1 604 875 5547; fax: +1 604 875 5563; e-mail: jsaw@mail.ubc.ca Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Renal insufficiency and severe coronary artery disease: should coronary artery bypass grafting, off-pump coronary artery bypass grafting or percutaneous coronary intervention be performed? Purpose of review Chronic kidney disease (CKD) is an important determinant of long-term survival. However, the optimal revascularization strategy for patients with CKD is still controversial. Herein we review the impact of different treatment modalities on the outcomes of patients with CKD. Recent findings CABG could confer better long-term outcomes than PCI in patients with CKD, irrespective of CKD severity. CABG as compared with PCI may be associated with improved long-term survival albeit higher short-term risk. Off-pump as compared with on-pump CABG may be associated with better short-term outcomes but no demonstrable long-term benefit. In CKD patients who are treated with PCI, the use of drug-eluting stents may be associated with better intermediate-term outcomes than bare metal stents. Summary There is insufficient evidence to inform the optimal revascularization strategy for patients with CKD and severe coronary artery disease. CABG as compared with PCI confers greater long-term benefit but higher upfront risk. A multidisciplinary, team-based evaluation based on individual patient comorbidity, frailty and anatomical disease burden, is recommended when making treatment decisions. Correspondence to Louise Y. Sun, MD, SM, FRCPC, Division of Cardiac Anesthesiology, University of Ottawa Heart Institute, Rm H-2206, 40 Ruskin Street, Ottawa, ON, Canada K1Y 4W7. Tel: +1 613 696 7381; fax: +1 613 696 7099; e-mail: lsun@ottawaheart.ca Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.