Closing the gap between type A and type B aortic dissections Purpose of review Given its rarity little is known about natural history, surgical indications, and results of acute non-A non-B dissections. With this review, we aim to review the current knowledge of this subject. Recent findings non-A non-B aortic dissections should be differentiated from type B aortic dissections. A strikingly high proportion of these patients have a complicate course requiring treatment and the mortality of patients treated with medical therapy is substantially higher compared to type B dissections. Surgical and endovascular treatment can be accomplished safety, with very good results in terms of mortality and morbidity also in the acute setting. Several treatments options are available including endovascular repair with thoracic endovascular aortic repair (TEVAR) associated with Chimney grafts or carotid to subclavian by pass, open arch replacement mainly by means of the frozen elephant trunk technique and hybrid arch repair with debranching of the supra-aortic vessel and zone 0 TEVAR. Summary considering the high rate of complication, the high mortality of patients managed medically and the safety of surgical and endovascular repair, early invasive treatment of non-A non-B dissections may be further considered. The treatment should be tailored to the morphology of the dissected aorta with TEVAR reserved to more distal lesions and open arch replacement with the FET technique for more proximal lesions. Correspondence to Davide Carino, MD, Department of Cardiovascular Surgery, Institut Clínic Cardiovascular, Hospital Clínic de Barcelona, Villarroel 170, 08036 Barcelona, Spain. Tel: +39 349 7207720; e-mail: davidecarino88@gmail.com Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Multiarterial coronary artery bypass grafting: is the radial artery fulfilling the unkept promise of the right internal thoracic artery? Purpose of review The debate on the second best conduit for CABG is still intense. In this review, we discuss the role of the radial artery and the right internal thoracic artery (RITA) compared with saphenous vein grafts (SVG). Recent findings The recent RADIAL STUDY has been the first evidence based on randomized trials of a clinical benefit using a second arterial graft in CABG. On the other hand, the definitive 10-year results of the ART trial failed to show a clinical advantage associated with the use of bilateral internal thoracic artery (BITA). A thorough and contextualized analysis of this and other studies, however, may offer a different perspective. Summary Arterial conduits in CABG have shown better patency rates than SVG. Whether this leads to better clinical outcomes is still debated. In this setting, the radial artery and the RITA seem to offer a similar advantage, although with different indications and contraindications. Correspondence to Alessandro Affronti, MD, PhD, Division of Cardiac Surgery, University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, ON, Canada K1Y 4W7. Tel: +1 613 761 4893; fax: +1 613 761 5367; e-mail: alessandroaffronti@yahoo.it Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Thrombophilia evaluation in pulmonary embolism Purpose of review Patients with pulmonary embolism commonly undergo thrombophilia evaluation for a variety of reasons including risk stratification for recurrent venous thromboembolism (VTE) and treatment planning. However, the utility of thrombophilia testing in many clinical scenarios remains unclear. This review evaluates current recommendations for thrombophilia testing described in consensus VTE guidelines, recent literature on the clinical application of these recommendations, novel genetic assessments for hereditary thrombophilias, and studies evaluating use of direct oral anticoagulants (DOACs) in VTE patients with thrombophilias. Recent findings Current VTE guidelines advise limited use of thrombophilia testing, recognizing that testing may be misinterpreted and frequently does not lead to a change in management. Testing and test results are not necessarily benign, are frequently misinterpreted, and can lead to increased anxiety in both patients and clinicians. Recent studies have offered innovative techniques to better align clinical practice with these recommendations as well as expanded genomic assessments to improve the scope and predictive value of thrombophilia testing. There is also emerging literature on the appropriateness of direct oral anticoagulant therapy for VTE patients with hereditary thrombophilias or antiphospholipid syndrome. Summary Thrombophilia testing in its current form does not significantly impact clinical management or improve outcomes for most VTE patients. Therefore, it should be employed judiciously and only in patients for whom it is likely to alter clinical management. Novel expanded genomic thrombophilia testing approaches and additional studies evaluating optimal anticoagulant treatment in various thrombophilia subpopulations will make thrombophilia testing more useful for patients moving forward. Correspondence to Jean M. Connors, MD, Hematology Division, Brigham and Women's Hospital, 75 Francis Street, SR322, Boston, MA 02115, USA. Tel: +1 617 732 5190; fax: +1 617 264 6388; e-mail: jconnors@partners.org Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Anomalous origins of the coronary arteries: current knowledge and future perspectives Purpose of review The purpose of this review is to survey the contemporary literature surrounding congenital anomalies of origin of the coronary arteries and to identify remaining gaps in knowledge. Recent findings In recent years, lineage tracing analyses and mechanistic studies in model organisms have enhanced our understanding of the normal embryologic development of the coronary arteries, and how disruption of this intricate process can lead to congenital coronary anomalies. The true incidence of these anomalies remains unknown. Although a majority of cases are believed to be clinically silent, clinical presentation varies widely, from asymptomatic to sudden cardiac death. Cardiac computed tomography angiography and/or magnetic resonance angiography are the mainstay diagnostic modalities. Management of anomalous coronary arteries depends on the morphology and clinical presentation. Surgery is the gold-standard treatment for anomalous left coronary artery arising from the pulmonary artery and anomalous aortic origin of a coronary artery with intramural or interarterial course. Summary Several large multicenter initiatives are currently underway and should help address some of the numerous knowledge gaps surrounding the evaluation and management of anomalous coronary arteries. Correspondence to Edward J. Hickey, MD, The Hospital for Sick Children, 555 University Ave., Toronto, ON, Canada M5G 1X8. E-mail: edward.hickey@sickkids.ca Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Assessment of myocardial viability by myocardial contrast echocardiography: current perspectives Purpose of review The current guidelines recommend the use of myocardial contrast echocardiography (MCE) to assess myocardial viability. There are two clinical scenarios where detection of myocardial viability has clinical significance: in ischemic cardiomyopathy and following acute myocardial infarction with significant left ventricular dysfunction. Myocardial contrast echocardiography (MCE), which utilizes microbubbles can assess the integrity of the microvasculature, which sustains myocardial viability in real time and can hence rapidly provide information on myocardial viability at the bedside without ionizing radiation. Recent findings We discuss the value of MCE to predict myocardial viability through the detection of the integrity of myocardial microvasculature, the newer evidences behind the MCE-derived coronary flow reserve and use of MCE postmyocardial infarction to detect no-reflow. Newer studies have also demonstrated the comparable sensitivities and specificities of MCE to single photon-emission computed tomography (SPECT), cardiac myocardial resonance imaging and PET for the detection of myocardial viability. Summary Ample evidence now exist that supports the routine use of MCE for the detection of viability as laid down in recent guidelines. Correspondence to Professor Roxy Senior, MD, DM, FRCP, FESC, FACC, Royal Brompton Hospital & National Heart and Lung Institute, Imperial College, London, UK. E-mail: roxysenior@cardiac-research.org Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Revascularization in left ventricular dysfunction: an update Purpose of review The purpose of this article is to provide an overview of revascularization in patients with coronary artery disease (CAD) and left ventricular dysfunction (LVD). Recent findings Patients with significant CAD and LVD are a high-risk patient population. They make up a minority of the cases from the largest, prospective coronary revascularization trials. The Surgical Treatment for Ischemic Heart Failure (STICH) Trial and its substudies are the most important and well cited in this field. The 10-year data from STICH showed that surgical revascularization was associated with lower all-cause mortality compared with medical therapy. Several smaller studies have confirmed that surgical revascularization carries a significant risk of short-term mortality but overall improved long-term outcomes in patients with LVD. Data from multiple observational studies further confirm that coronary artery bypass graft (CABG) is superior to percutaneous coronary revascularization for long-term survival and freedom from repeat revascularization in patients with LVD. We suggest that patients with LVD undergoing CABG should be considered for multiarterial grafting and that some patients may benefit from an off-pump procedure. Summary Surgical revascularization confers a long-term survival benefit in patients with significant CAD and LVD. Further studies will be needed to precisely determine the ideal candidate for surgical versus percutaneous revascularization. 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, Canada M5B 1W8. Tel: +1 416 864 5706; fax: +1 416 864 5031; e-mail: yanagawab@smh.ca Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Assessment of myocardial viability by cardiac MRI Purpose of review Left ventricular systolic dysfunction because of coronary artery disease is common, and ascertaining which patients will benefit from revascularization can be challenging. Viability testing is an accepted means by which to base this decision, with multiple noninvasive imaging modalities available for this purpose. This review aims to highlight the key role of cardiac magnetic resonance in myocardial viability assessment, with a focus on its unique strengths over other imaging modalities. Recent findings Transmural extent of hyperenhancement with late gadolinium imaging has been shown to be greater acutely in ST elevation myocardial infarction patients undergoing primary percutaneous coronary intervention and regress at follow-up studies. An explanation for this reported phenomenon and an argument against redefining CMR viability criteria in the acute setting will be offered. Summary Although not universally available, cardiac magnetic resonance is an exceptionally powerful and well tolerated imaging modality that should be considered when viability testing will influence patient management. Although observational outcomes data suggest a promising prognostic role for viability, randomized studies in this area are needed. Correspondence to Dipan J. Shah, MD, Division of Cardiovascular Imaging, Department of Cardiology, Houston Methodist DeBakey Heart and Vascular Center, 6550 Fannin Street, Smith Tower, Suite #1801, Houston, TX 77030, USA. Tel: +1 713 441 3625; e-mail: djshah@houstonmethodist.org Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

See one, simulate many, do one, teach one: cardiac surgical simulation Purpose of review To review the cardiac surgical simulation experience with a focus on data supporting its use. Recent findings Simulators have been used to improve trainee performance across multiple surgical domains. Few cardiac surgery residency programs have incorporated the use of simulation individually and Boot Camp programs in the United States and Canada have also introduced surgical simulation early in cardiac surgical training. Simulation curricula have some common elements: component tasks, deliberate practice, progressive operative responsibility, and coaching by an experienced surgeon. Cardiac surgical simulators can range from inexpensive, low-fidelity models for the practice of isolated skills to high-fidelity, operating room-scenarios. Multiple small studies have consistently demonstrated that the use of simulation improves qualitative and quantitative performance measures as well as overall resident confidence in clinical settings. To our knowledge, no study has demonstrated that use of simulation has led to improved quantitative performance measures in the operating room or patient outcomes. The barriers to wider use of surgical simulators include perceived lack of time and resources, the need for sustained practice and the lack of high-quality data to demonstrate clinical benefit. Summary Incorporation of cardiac surgery simulation has been slow in most residency programs. There is consistent data demonstrating that simulation improves resident performance measures of simulation-based tasks but whether this will lead to improved patient outcomes remains an open question. Correspondence to Bobby Yanagawa, MD, PhD, FRCSC, Program Director, Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada; Assistant Professor, Division of Cardiac Surgery, St. Michael's Hospital, 30 Bond Street, 8th Floor, Bond Wing, Toronto, ON, Canada M5B 1W8. Tel: +1 416 864 5706; fax: +1 416 864 5031; e-mail: yanagawab@smh.ca Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Dobutamine echocardiography for assessment of viability in the current era Purpose of review Studies from the 1990s and early 2000s documented the utility of dobutamine echocardiography for the prediction of functional recovery and prognosis with revascularization. The results of The Surgical Treatment of Ischemic Heart Failure (STICH) trial called into question the value of viability assessment using dobutamine echocardiography. The purpose of this review is to re-examine the literature on dobutamine echocardiography, put into context the STICH results, and provide insight into the current role of dobutamine echocardiography viability testing. Recent findings In contrast to the results of previous nonrandomized trials, the STICH trial showed that patients with viability defined by nuclear perfusion imaging or dobutamine echocardiography did not have improved survival with CABG compared with optimal medical therapy. Viability by dobutamine echocardiography was defined as the presence of contractile reserve in at least five segments with baseline dysfunction. The results of dobutamine echocardiography studies published before and after initiation of the STICH trial suggest that the definition of viability utilized in that trial may be suboptimal for assessment of improvement in global function and prognosis in patients undergoing revascularization. Assessment of global contractile reserve using wall motion score (WMS) or ejection fraction may be superior to utilization of a binary definition of viability confined to assessment of contractile reserve in a fixed number of segments because these indices provide information on both the magnitude and extent of contractile reserve of the entire left ventricle (LV). Summary Assessment of WMS or ejection fraction with dobutamine echocardiography may be the optimal means of evaluating the impact of viability on prognosis. Video abstract http://links.lww.com/HCO/A56 Correspondence to Abhishek Khemka, MD, MBA, 1800 N Capitol Avenue, Noyes Building, Suite E371, Indianapolis, IN 46202, USA. Tel: +1 317 274 0992; fax: +1 317 963 3340; e-mail: akhemka@iu.edu 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.

Current and future role of lipoprotein(a) in preventive cardiology Purpose of review The purpose of this review is to highlight our emerging understanding of lipoprotein(a) [Lp(a)]'s role in atherosclerotic cardiovascular disease (ASCVD), its structure–function relationship, and promising developments within the therapeutic pipeline. Recent findings Elevated levels of Lp(a) are strongly associated with an increased risk of coronary heart disease, calcific aortic valve stenosis, and ischemic stroke. With circulating levels almost exclusively genetically mediated, increased levels of Lp(a) contribute significantly to the residual cardiovascular disease risk in individuals with otherwise well controlled risk factors. The unique structure of Lp(a) – comprised of a genetically heterogeneous apolipoprotein(a) molecule bound to an LDL-like moiety – provides insight into its pathogenic role in cardiovascular disease and also complicates its accurate measurement. Emerging therapies targeting the apolipoprotein(a) component of Lp(a) have the potential to revolutionize the management of individuals with elevated Lp(a). Summary With promising therapies on the horizon, there has been a renewed focus on the role of Lp(a) in ASCVD. Given Lp(a)'s strong and independent association with key cardiovascular outcomes, it is hopeful that these promising targeted therapies will add another therapeutic option for the prevention of cardiovascular disease. Correspondence to Ron Blankstein, MD, FACC, Cardiovascular Division, Department of Medicine; Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA. E-mail: rblankstein@bwh.harvard.edu Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.