Cardiology in Review

The Firehawk Stent: A Review of a Novel Abluminal Groove-Filled Biodegradable Polymer Sirolimus-Eluting Stent Despite recent advances in drug-eluting stent (DES) technology, late adverse events remain concerns after percutaneous coronary intervention. The persistence of polymer material on DES has been suggested as a trigger for chronic inflammation. The Firehawk, a novel DES, has a unique design with recessed abluminal grooves, to which sirolimus and biodegradable polymer are applied. The Firehawk stent is designed to minimize polymer volume and antiproliferative drug concentration to reduce inflammation and hypersensitivity reactions. Several recent trials have reported the clinical outcomes of this device. This article provides a review of the current clinical evidence concerning the Firehawk stent. Funding: None Disclosure: Alexandra Lansky has received a research grant and speaker fee from Microport. The other authors have reported no conflict of interests. Address for correspondence:Alexandra Lansky, MD, Division of Cardiovascular Medicine, Yale School of Medicine, 135 College Street, Suite 101, New Haven, Connecticut 06510, Phone: +1-203-737-2142, Fax: +1-203-737-7457, E-mail: alexandra.lansky@yale.edu Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Pulmonary Artery Denervation as an Innovative Treatment for Pulmonary Hypertension with and without Heart Failure Pulmonary hypertension (PH) is categorized into five groups based on etiology. The two most prevalent forms are pulmonary arterial hypertension (PAH) and PH due to left heart disease (PH-LHD). Therapeutic options do exist for PAH to decrease symptoms and improve functional capacity; however, the mortality rate remains high and clinical improvements are limited. PH-LHD is the most common cause of PH, however, no treatment exists and the use of PAH-therapies is discouraged. Pulmonary artery denervation (PADN) is an innovative catheter-based ablation technique targeting the afferent and efferent fibers of a baroreceptor reflex in the main pulmonary artery (PA) trunk and its bifurcation. This reflex is involved in the elevation of the PA pressure seen in PH. Since 2013, both animal trials and human trials have shown the efficacy of PADN in improving PAH, including improved hemodynamic parameters, increased functional capacity, decreased PA remodeling, and much more. PADN has been shown to decrease the rate of rehospitalization, PH-related complications, and death, and is an overall safe procedure. PADN has also been shown to be effective for PH-LHD. Additional therapeutic mechanisms and benefits of PADN are discussed along with new PADN techniques. PADN has shown efficacy and safety as a potential treatment option for PH. None of the authors have any conflicts of interest to disclose Address for correspondence: Wilbert S. Aronow, MD, FACC, FAHA, Professor of Medicine and Director of Cardiology Research, Cardiology Division, Westchester Medical Center,Macy Pavilion, Room 141, Valhalla, NY 10595, Telephone number: (941) 493-5311; fax number (914) 235-6274, E-mail: wsaronow@aol.com Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Myocardial Depression in Sepsis: Beneficial Adaptation or Sequelae that Requires Treatment? Myocardial depression is a common, yet reversible phenomenon that occurs in patients in septic shock. Initially, it was unclear whether this provided an adaptive survival benefit, as early studies showed decreased mortality in septic patients with myocardial depression. However, subsequent larger studies have debunked this myth. Given that no benefit exists, cardiac dysfunction in septic patients may be monitored via echocardiography and may be treated with inotropic agents. Beta-blockers provide a novel avenue of treatment as they aid in reducing adrenergic overstimulation and cytokine production, which may drive the pathogenesis of septic shock. This review chronicles how the understanding of myocardial depression in sepsis has evolved and how it should be clinically managed. The authors declare no conflict of interest in the preparation of this manuscript. Corresponding Author: William H. Frishman, MD, New York Medical College, 40 Sunshine Cottage Road, Valhalla, NY 10595, Phone: 914-594-2084 (Fax: 914-594-2081), Email: william_frishman@nymc.edu Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Stem Cell Therapy for Acute Myocardial Infarctions: A Systematic Review Each year 790,000 people in the United States suffer from a myocardial infarction. This results in the permanent loss of cardiomyocytes and an irreversible loss of cardiac function. Current therapies lower mortality rates, but do not address the core pathology, which opens a pathway to step-wise heart failure. Utilizing stem cells to regenerate the dead tissue is a potential method to reverse these devastating effects. Several clinical trials have already demonstrated the safety of stem cell therapy. In this review we will highlight clinical trials which have utilized various stem cell lineages, and discuss areas for future research. No conflicts to report with the preparation of this manuscript. Correspondence to: William H. Frishman MD, Dept. of Medicine, New York Medical College, 40 Sunshine Cottage Road, Valhalla, New York 10595, William_Frishman@nymc.edu Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Arrhythmogenic Right Ventricular Cardiomyopathy Diagnosis Arrhythmogenic right ventricular cardiomyopathy (ARVC), formerly called "arrhythmogenic right ventricular dysplasia", is an under-recognized clinical entity characterized by ventricular arrhythmias and a characteristic ventricular pathology. Diagnosis is often difficult due to the nonspecific nature of the disease and the broad spectrum of phenotypic variations. Therefore, consensus diagnostic criteria have been developed which combine electrocardiographic, echocardiographic, cardiac magnetic resonance imaging and histologic criteria. In 1994, an international task force first proposed the major and minor diagnostic criteria of ARVC based on family history, arrhythmias, electrocardiographic abnormalities, tissue characterization, and structural and functional right ventricular abnormalities. In 2010, the task force criteria were revised to include quantitative abnormalities. These diagnostic modalities and the most recent task force criteria will be discussed in this review. None of the authors have any conflicts of interest to disclose Address for correspondence: Wilbert S. Aronow, MD, FACC, FAHA, Westchester Medical Center and New York Medical College, Division of Cardiology, Macy Pavilion, Room 141, 100 Woods Road, Valhalla, NY 10595, Valhalla, NY 10595, E-mail: wsaronow@aol.com Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Peripartum Cardiomyopathy Incidence, Risk Factors, Diagnostic Criteria, Pathophysiology and Treatment Options Peripartum cardiomyopathy (PPCM) is a rare and a severe form of heart failure that affects women during pregnancy or shortly after delivery. Risk factors include advanced age, race, multi-parity, multifetal pregnancy, socioeconomic disparity, and medical comorbidities including systemic hypertension, diabetes, asthma, and anemia. PPCM is associated with increased morbidity and mortality, as well as a detrimental long-term impact on quality of life. Its etiology is not clear, although it is thought to be a combined effect of a hyperdynamic fluid state associated with pregnancy, hormonal changes unique to gestation, and a genetic predisposition. There is no current expert consensus on an optimal treatment regimen. This article will provide a comprehensive review and update on this important disease state. None of the authors have any conflicts of interest to disclose Correspondence to: Wilbert S. Aronow MD, FACC, FAHA, Westchester Medical Center Macy Pavilion, Room 141, Valhalla, NY 10595, USA. E-mail: wsaronow@aol.com Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Towards a Saphenous Vein Graft Moratorium Atherosclerosis develops and rapidly progresses in saphenous veins grafts after coronary bypass surgery. In contrast to native coronary artery, percutaneous revascularization does not impede the progression of saphenous vein atherosclerosis and saphenous vein graft failure commonly ensues. The protracted patency of arterial grafts is likely to account for most of the long-term superiority of coronary artery bypass surgery over percutaneous revascularization in patients with complex coronary artery disease. Long-lasting, complete coronary revascularization may be best achieved by combining surgical arterial grafting of diseased coronary arteries to percutaneous revascularization with drug-eluting stents than by the continued use of saphenous vein grafts. Acknowledgements: We are grateful to Dr. Achal Sahai for his insightful feedback. Funding sources: We have no funding sources to declare Disclosures: None of the authors have any conflict of interest to declare. Corresponding Author: Thierry H. Le Jemtel, Tulane University Heart and Vascular Institute 1430 Tulane Avenue, SL-48, New Orleans, LA 70112, USA Email: lejemtel@tulane.edu, Fax number: 504-988-4237, Phone number: (917) 804-2212 Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Mineralocorticoid Receptor Antagonist Use in Heart Failure with Reduced Ejection Fraction and End Stage Renal Disease Patients on Dialysis: A Literature Review Mineralocorticoid receptor antagonists (MRAs) are known to have a proven mortality benefit in heart failure with reduced ejection fraction (HFrEF) without kidney disease. As patients with end stage renal disease (ESRD) requiring either peritoneal dialysis or hemodialysis were excluded in clinical trials of HFrEF, the data are scant on the appropriate use of MRAs in this population. The unknown efficacy, along with concerns of adverse effects such as hyperkalemia, have limited the willingness of clinicians to consider using MRAs in these patients. However, it is unclear whether the risk of hyperkalemia is present if a patient is oliguric or anuric. Current guidelines recommend against the use of MRAs in patients with chronic kidney disease, but do not address the use of MRAs in patients requiring dialysis. This paper will review the epidemiology of HF in ESRD, the pathophysiological derangements of the renin-angiotensin aldosterone system in patients with kidney disease, and the results from case series and trials of the use of MRAs in ESRD with HFrEF. Although limited to several small trials using MRAs in peritoneal and hemodialysis patients with or without HFrEF, the current literature appears to show the potential for clinical benefits with little risk. Corresponding author: Gregg M. Lanier, MD, Westchester Medical Center, Macy Pavilion, Rm 110, 100 Woods Rd., Valhalla, NY 10595, (914) 493-8804 Gregg.Lanier@wmchealth.org Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Restarting Oral Anticoagulation in Patients with Atrial Fibrillation After an Intracranial Hemorrhage Atrial fibrillation is the most common sustained cardiac arrhythmia in the general population. In western countries with aging populations, atrial fibrillation poses a significant health concern, as it is associated with a high risk of thromboembolism, stroke, congestive heart failure, and myocardial infarction. Thrombi are generated in the left atrial appendage, and subsequent embolism into the cerebral circulation is a major cause of ischemic stroke. Therefore, patients have a lifetime risk of stroke, and those at high risk, defined as a CHA2DS2-VASc2 (congestive heart failure, hypertension, age >75 years, diabetes mellitus, stroke, vascular disease, sex category) ≥2, are usually placed on oral anticoagulants. Unfortunately, long-term anticoagulation poses bleeding risks, of which intracranial hemorrhage is the most feared and deadly complication. In patients who survive an intracranial hemorrhage, the question of oral anticoagulation resumption arises. It is a therapeutic dilemma in which clinicians must decide how to manage the risk of thromboembolism versus recurrent hemorrhage. Although there is a substantial amount of retrospective data on the topic of resumption of anticoagulation, there are, at this time, no randomized controlled trials addressing the issue. We therefore sought to address intracranial hemorrhage risk and management, summarize high quality existing evidence on restarting oral anticoagulation, and suggest an approach to clinical decision making. No conflict of interest in the preparation of this manuscript Address for Correspondence: William H. Frishman MD, Department of Medicine, New York Medical College, 40 Sunshine Cottage Road, Valhalla, NY 10595, William_Frishman@nymc.edu Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

A Practical Approach to Hybrid Coronary Revascularization Combined surgical and percutaneous coronary revascularization i.e. hybrid coronary revascularization (HCR) consists of surgical left internal mammary artery (LIMA) bypass to the left anterior descending artery (LAD) and percutaneous revascularization of other diseased coronary arteries. Developed as 1-stage procedure, HCR has not been widely adopted by the cardiovascular community. The recommended minimally invasive approach through a small left thoracotomy incision is technically demanding and same day percutaneous revascularization requires a hybrid operating room that is not available in most hospitals. In this review, we consider present HCR protocols, barriers to widespread adoption of HCR, and we give special attention to the surgical approach for the LIMA graft to the LAD and the timing of percutaneous revascularization. We conclude that grafting the LIMA to the LAD through a median sternotomy approach and delaying the percutaneous revascularization may facilitate the widespread use of HCR in patients with multivessel coronary artery disease and a low to intermediate Synergy between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery (SYNTAX) score. Disclosures: The authors report no financial relationships or conflicts of interest regarding the content herein. Acknowledgements: The authors have no conflicts of interest to report. No funding sources to declare. Corresponding Author: Thierry H Le Jemtel, MD, Tulane University Heart and Vascular Institute, 1415 Tulane Avenue, ew Orleans, LA 70112. USA. Phone: (917) 804-2212 , Fax: (504)-988-4237, Email: lejemtel@tulane.edu Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.