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Background: Fontan surgery, a palliative procedure for single ventricle patients, often leads to the need for permanent pacing. Epicardial pacing has limitations, while transvenous pacing carries risks in the Fontan circulation. This case series introduces a novel approach of leadless pacemaker implantation in the extra‐cardiac Fontan (ECF) cohort to overcome these limitations. Methods: The study includes four cases of leadless pacemaker (Micra™) implantation in patients with ECF. Procedures were performed under general anesthesia with guidance from trans‐esophageal echocardiography. Various access routes were used, including trans‐carotid and trans‐fenestration approaches. Procedural details, parameters, and follow‐up data were collected. Results: All leadless pacemaker implantations were successful, with satisfactory electrical parameters and stable pacing postprocedural outcomes during short‐term follow‐up. One patient required closure of their fenestration for symptomatic desaturation post procedurally. Conclusions: Leadless pacemaker implantation via trans‐carotid and trans‐fenestration approaches appears to be a feasible back up option for pacing in Fontan patients where other options have been exhausted or there is a patient choice to avoid surgery. These techniques provide an option to avoid leaded systems or epicardial pacing, reducing the need for multiple thoracotomies and addressing challenges associated with surgical pacing leads. Further studies are needed to evaluate long‐term outcomes and assess the broader application of leadless pacemakers in the Fontan population. [ABSTRACT FROM AUTHOR]

Postoperative atrial fibrillation (POAF) is an ongoing complication following cardiac surgery, with an incidence of 15%–60%. It is associated with substantial mortality and morbidity, as well increased hospital stays and healthcare costs. The pathogenesis is not fully understood, but the literature suggests that POAF occurs when transient, postoperative triggers act on vulnerable atrial tissue produced by preoperative, procedure-induced and postoperative processes such as inflammation, oxidative stress, autonomic dysfunction and electrophysiological remodelling of the atrial tissues. This sets the stage for arrhythmogenic mechanisms, such as ectopic firing secondary to triggered activity and re-entry mechanisms generating POAF. Preoperative factors include advanced age, sex, ethnicity, cardiovascular risk factors, preoperative drugs, electrocardiogram and echocardiogram abnormalities. Procedural factors include: the use of cardiopulmonary bypass and aortic cross clamp, type of cardiac surgery, use of hypothermia, left ventricular venting, bicaval cannulation and exclusion of the left atrial appendage. Postoperative factors include postoperative drugs, electrolyte and fluid balance and infection. This review explores the pathogenesis of POAF and the contribution of these perioperative factors in the development of POAF. Patients can be risk stratified for targeted treatment and prophylaxis, and how these factors can be attenuated to improve POAF outcomes following cardiac surgery. [ABSTRACT FROM AUTHOR]

Coronary artery disease (CAD) remains one of the leading causes of death globally. In the United States of America, in 2016, 19% of all patients under the age of 65 died of cardiovascular disease despite improvements in primary prevention. The premature clinical onset of symptoms in the young population (<60 years) is much more aggressive than in the older population, and the overall long-term prognosis is poor. CAD appears to have a rapidly progressive form in those under the age of 60 due to genetic predisposition, smoking, and substance abuse, however, the ideal management strategy is still yet to be established. The two primary methods of establishing coronary revascularization are percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG). Despite the increasing prevalence of CAD in the young population, they are consistently underrepresented in major randomized clinical trials of each revascularization strategy. Both CABG and PCI are known to have similar survival rates, but PCI is associated with higher repeat revascularization rate. Many argue this may be due to the progressive nature of CAD combined with the vessel patency time required in a patient under 60 with potentially another 20-30 years of life. There is little in literature regarding the outcomes of these various revascularization strategies in populations under 60 years with CAD. This review summarises the current evidence for each revascularisation strategy in patients under the age of 60 and suggests future avenues of research for this unique age group. [ABSTRACT FROM AUTHOR]

Background: Mitral regurgitation (MR) is the most common valvular disease worldwide. MR has been managed surgically, with either a mitral valve replacement or repair. Percutaneous transcatheter mitral valve repair (TMVr) with MitraClip® insertion has gained wide popularity and success over medical and surgical therapy for MR. Some patients with acute MR or decompensated heart failure could benefit from urgent TMVr. This meta-analysis aims to compare clinical outcomes of urgent versus elective TMVr. Methods: We performed a study-level meta-analysis to compare the clinical outcomes of urgent versus elective TMVr using the MitraClip system. The primary endpoint outcome was all-cause mortality. Additional outcomes included procedural success, postoperative acute kidney injury (AKI), stroke, and length of in-hospital stay. Results: Overall, 30-day mortality was significantly higher in the urgent group (odds ratio [OR]: 2.74; 95% confidence interval [CI] [2.17, 3.48]; P < 0.00001; I2 =0%). However, subgroup analysis of matched cohorts showed no significant difference between both groups (OR: 1.80; 95% CI [0.94, 3.46]; P = 0.08; I2 =0%). One-year mortality was similar between both groups (and: 1.67; 95% CI [0.96, 2.90]; P = 0.07; I2 =0%). Procedural success was similar between both groups (89.4% vs. 89.8%; P = 0.43). Postoperative AKI was significantly higher in the urgent group (OR: 4.12; 95% CI [2.87, 5.91]; P < 0.00001; I2 =0%). Conclusion: Urgent TMVr should be indicated in select populations as it is considered therapeutic with acceptable outcomes therein. [ABSTRACT FROM AUTHOR]