Radiofrequency versus cryoballoon ablation for atrial fibrillation: an argument for a ‘cryo-first’ approach Purpose of review: Radiofrequency and cryoballoon ablation are the two most common modalities for catheter ablation of atrial fibrillation. Radiofrequency, being more prevalent and having existed for a longer period, is often utilized for patients’ first ablations, despite the efficiency and efficacy of the cryoballoon tool. Here we examine the advantages of the cryoballoon for its use in first-time ablation of atrial fibrillation. Recent findings: The FIRE & ICE trial is established as conclusive evidence of the noninferiority of cryoballoon ablation to radiofrequency ablation in terms of efficacy. Since the study, cryoballoon has evolved in both form and technique, suggesting need for repeat consideration of the advantages of cryoablation over radiofrequency ablation. The second-generation cryoballoon has led to greater efficiency in achieving permanent pulmonary vein isolation, reducing complications, and reducing procedure times. Summary: There are advantages to the use of cryoballoon which could increase success of first-time ablations, delaying need for repeat procedure and lowering overall burden on patients and the healthcare system. Cryoballoon ablation should be considered for first-time ablation in patients with paroxysmal or persistent atrial fibrillation. Correspondence to Emrie Tomaiko, Banner Heart Institute, 755 E. McDowell Road Floor 4, Phoenix, AZ 85002, USA. E-mail: etomaiko@asu.edu Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Beyond atrial septal defect closure, it is time to start seriously considering closing ventricular septal defects with devices Purpose of the review The purpose of this review is to discuss the history and current state of transcutaneous device closure of ventricular septal defects. Recent findings Newer devices and techniques have expanded the role of transcutaneous device closure of ventricular septal defects. Device closure of ventricular septal defects is a mainstay of therapy in many parts of the world. Device closure in smaller infants has relatively higher risks than larger infants and older children. The potential for the development of complete heart block remains a concern with this procedure. Summary Transcutaneous device closure of ventricular septal defects is a safe alternative to surgical repair in many patients. Correspondence: Jim Thompson, MD, Inova Children's Hospital, 3300 Gallows Road; Fairfax, VA 22042, USA. Tel: +1 703 876 8410; e-mail: Jim_thompson@mednax.com Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Virtual reality in pediatric cardiology: hype or hope for the future? Purpose of review In the field of pediatric cardiology, a sub-specialty that relies on an understanding of complex three-dimensional structures, virtual reality technology may represent a new and exciting tool for both practitioners and patients. Here, the current medical and surgical applications of virtual reality are reviewed and the potential for future applications explored. Recent findings Multiple centers have begun to develop software designed to bring virtual reality technology to bear on congenital heart disease. These efforts have focused on surgical preparation, on education of medical providers, and on preparation of patients and their family members for cardiac interventions. Though relatively little statistical evidence for benefit has been generated to date, those studies currently available suggest that virtual reality may provide a significant benefit in all three of these aspects of medical care. Summary The immersive nature of virtual reality meshes well with the learning styles of adult practitioners and promises to be a powerful tool for both pediatric cardiologists and the patients with whose care they are entrusted. Though additional studies are clearly needed, this technology promises to improve the field's ability to prepare providers and patients alike for challenge of treating congenital heart disease. Correspondence to Loren D. Sacks, MD, Clinical Assistant Professor, Pediatric Cardiology, Stanford University School of Medicine, 750 Welch Road, Suite 321, Palo Alto, CA 94304, USA. Tel: +1 650 721 3290; fax: +1 650 723 5231; e-mail: lsacks@stanford.edu Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Partnering with robotic technology in electrophysiology: have we arrived at a tipping point? Purpose of review Bring readers up to date on the rationale for, current state of, and promising innovations in remote and robotic technology in electrophysiology. Recent findings There is a growing peer-reviewed literature regarding existing nontraditional technology for mapping and ablation. There also is accelerated innovation under early evaluation that promises significant impact. Summary The development and adoption of remote technologies in electrophysiology has faced considerable challenges yet holds tremendous promise for our patients. First principles must include benefit for patients in both safety and effectiveness, optimization of the process for providers, and sound economic and clinical justification for integration into healthcare systems. The limitations of traditional methods and tools that dominate current practice are discussed as a rationale for considering remote robotic systems. The growing library of published outcomes as well as the emergence of promising new technology merits fresh consideration. Correspondence to J. Peter Weiss, MD, MSc, Heart Institute, Banner University of Arizona Medical Center, 755 E McDowell Road, Floor 4, Phoenix, AZ 85006, USA. Phone: +1-801-599-9217;. fax: +1-602-521-3661. E-mail: peteweissmd@gmail.com Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Anomalous coronary arteries: what is known and what still remains to be learned? Purpose of review To report what is known and unknown regarding coronary anomalies in children, particularly anomalous aortic origin of a coronary artery, efforts undertaken to answer several questions regarding evaluation and management of this challenging young population, and where the future is heading. Recent findings Patients with anomalous aortic origin of a coronary artery (AAOCA) present as an incidental finding at least half of the time, advanced imaging is essential to define anatomic characteristics of this lesion, assessment of myocardial perfusion with stress cardiac magnetic resonance imaging is feasible and contributes to risk stratification, certain patient populations require invasive assessment of coronary flow with measurement of fractional flow reserve, and surgical intervention can be safely performed through long-term data on impact to prevent sudden events is lacking. Summary Optimal risk stratification in AAOCA is yet to be defined, though substantial strides are being made with a standardized approach to the evaluation and management of these patients. Continued collaboration among centers and the scientific community will positively impact patients and families living with AAOCA. Correspondence to Silvana Molossi, MD, PhD, Texas Children's Hospital, Baylor College of Medicine, 6651 Main Street, MC E1920, Houston, TX 77030, USA. Tel.: +1 832 826 5600;. fax: +1 832 826 4290; e-mail: smolossi@bcm.edu Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

A contemporary look at pediatric cardiology in 2020 No abstract available

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.