Lifetime management for aortic stenosis: Planning for future therapies.

A shift to lifetime management has gained more focus with the approval of low-risk transcatheter aortic valve replacement (TAVR). This paper is therefore focused on the different approaches for lifetime management. Herein we discuss the procedural safety, durability, performance, and future options for each lifetime management strategy. In younger patients that elect to undergo surgical aortic valve replacement (SAVR), options for bioprosthetic failure are TAV-in-SAV or redo SAVR. Among patients that undergo TAVR, options for valve failure include TAVR explant with SAVR or TAV-in-TAV. Additionally, there are patients who may require a third valvular intervention. The initial therapy may limit re-intervention options down the road. This review discusses how options for future therapies affect the decision of SAVR vs TAVR in younger patients.

Antiplatelet and anticoagulation therapy during percutaneous coronary interventions: A review for the interventionalist.

Pharmacotherapy for percutaneous coronary interventions is essential to optimize the balance between thrombosis and bleeding. Currently, choices abound for the selection of antiplatelet and anticoagulation therapies during percutaneous intervention (PCI). This review article discusses the mechanisms, pharmacokinetics/dynamics, and clinical data behind the various pharmacotherapies including; aspirin, thienopyridines, glycoprotein IIb/IIIa inhibitors, vorapaxar, heparin, direct thrombin inhibitors, and factor Xa inhibitors.

Recurrent isolated oculomotor nerve palsy after radiation of a mesencephalic metastasis. Case report and mini review.

INTRODUCTION: Recurrent oculomotor nerve palsies are extremely rare clinical conditions. CASE REPORT: Here, we report on a unique case of a short-lasting recurrent unilateral incomplete external and complete internal oculomotor nerve palsy. The episodic palsies were probably caused by an ipsilateral mesencephalic metastasis of a breast carcinoma and occurred after successful brain radiation therapy. DISCUSSION: While the pathogenic mechanism remains unclear, the recurrent sudden onset and disappearance of the palsies and their decreasing frequency after antiepileptic treatment suggest the occurrence of epilepsy-like brainstem seizures. A review of case reports of spontaneous reversible oculomotor nerve palsies is presented.

Exercise as stroke prophylaxis.

BACKGROUND: Stroke is the third most common cause of death in industrialized countries, accounting for more than 10% of deaths over age 65. Most strokes are due to arteriosclerosis. Regular physical activity lowers arterial blood pressure and body weight and improves glucose and lipid metabolism, thereby slowing the development of arteriosclerosis and its cardiovascular complications, particularly myocardial infarction. This review focuses on the question whether physical activity might also have a preventive effect on cerebral infarction and hemorrhage. METHODS: This analysis is based on 33 prospective cohort studies and 10 case-control studies that addressed the potential effect of physical activity on stroke-related morbidity and mortality. RESULTS: Our meta-analysis shows that physical activity reduces the risk of all types of stroke (infarction, hemorrhage, and stroke of unspecified type). The relative risk (RR) of fatal or non-fatal cerebral infarction is 0.75, while the corresponding figures for cerebral hemorrhage and stroke of unspecified type are 0.67 and 0.71, respectively. The reduction of risk is only statistically significant for men. The case-control studies show an RR of 0.32 for men and women combined. CONCLUSIONS: When a multivariate analysis is performed that takes other vascular risk factors into account, physical activity is found to have an independent protective effect against cerebrovascular events. The effect is statistically significant only for men, not for women.

Volume flow rate evaluation in patients with obstructive arteriosclerotic disease.

This study was performed to quantify the volumetric impact of extracranial arteriosclerotic lesions. We investigated patients with different degrees of carotid stenosis as defined by conventional velocity-based duplex criteria and different patterns of collateralization. We studied the volume flow rate (color duplex M-mode device) in 37 patients with symmetrical internal carotid artery (ICA) plaques (<50% stenosis) and compared these data to 43 patients with a unilateral 50-74% stenosis, 75-99% stenosis (n = 73) and occlusion of the ICA (n = 37). A 75-99% stenosis caused an ipsilateral flow reduction of 36% with a wide interindividual variability, and an occlusion of 51%. Collateralization via the ophthalmic artery only caused a nonsignificant ipsilateral volume flow increase, whereas the contralateral volume flow was significantly higher in patients with a patent anterior communicating artery. The increase was more pronounced in patients with an occluded vessel. Our data demonstrate a wide diversity of the hemodynamic impact of carotid stenosis as defined by 'classical' Doppler criteria. Collateral flow reflects a dynamic quantitative process.

Peripartum acute myocardial infarction: management perspective.

Acute myocardial infarction in pregnancy and puerperium is an uncommon event with substantial morbidity and mortality rates. Atherosclerosis may be the cause, but often the coronary arteries are healthy at angiography. In such cases, the suggested mechanism is a decreased coronary perfusion related to coronary spasm or in situ thrombosis. Most pregnant women who died after myocardial infarction did so at the time of initial infarction, and maternal mortality was greatest if the infarction was late in pregnancy. Increasing cardiovascular stresses of late pregnancy, especially when intensified by parturition, seriously compromise women with ischemic heart disease. Therefore, there should be efforts to limit myocardial oxygen demand throughout pregnancy, and particularly during parturition. It is important for diagnosis to have increased awareness of its possible occurrence. Although principles of management can be generalized, it is necessary to provide individualized care for these high-risk patients by a multidisciplinary team of cardiologists, anesthesiologists, and obstetricians.