Current cardiology reviews
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Endothelium plays a crucial role in the maintenance of vascular tone and structure. Endothelial dysfunction is known to precede overt coronary artery disease. A number of cardiovascular risk factors, as well as metabolic diseases and systemic or local inflammation cause endothelial dysfunction. ⋯ Increased levels of ADMA have been shown to be the strongest risk predictor, beyond traditional risk factors, of cardiovascular events and all-cause and cardiovascular mortality in people with coronary artery disease. Interventions such as treatment with L-arginine have been shown to improve endothelium-mediated vasodilatation in people with high ADMA levels. However the clinical utility of modifying circulating ADMA levels remains uncertain.
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The majority of children awaiting heart transplantation require inotropic support, mechanical ventilation, and/or extracorporeal membrane oxygenation (ECMO) support. Unfortunately, due to the limited pool of organs, many of these children do not survive to transplant. Mechanical circulatory support of the failing heart in pediatrics is a new and rapidly developing field world-wide. ⋯ In the spring of 2004, five contracts were awarded by the National Heart, Lung and Blood Institute to support preclinical development for a range of pediatric ventricular assist devices and similar circulatory support systems. The support of early development efforts provided by this program is expected to yield several devices that will be ready for clinical trials within the next few years. Our work reviews the current international experience with mechanical circulatory support in children and summarizes our own experience since 2005 with the Berlin Heart, comparing the indications for use, length of support, and outcome between these modalities.
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The right ventricle (RV) is integral to normal cardiac function, but receives little attention in the medical literature. The etiologic causes of acute RV failure often differ from those encountered in left ventricular dysfunction. Thus, RV failure frequently requires diagnostic procedures and management strategies that differ from those routinely used in the management of intrinsic left ventricular dysfunction. ⋯ We will then focus on two distinct populations of patients who are at risk for acute RV failure: those with chronic pulmonary arterial hypertension (PAH) and those with acute pulmonary embolism. In chronic PAH, we will examine clinical circumstances common to hospitalized patients that may provoke acute RV decompensation, as well as pharmacologic therapies that are unique to RV failure management in PAH. Individuals with acute RV failure in the setting of pulmonary embolism represent a group with particularly high mortality, and the specific diagnostic and management strategies that are important for improved survival will be discussed.