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Introduction: Complementary, alternative and integrative medicine includes a myriad of therapies including herbal medicines, vitamins, dietary interventions and more, that are taken alone or in adjunct to standard conventional treatment. Often the main goals are to slow progression of disease, increase effectiveness of a drug, reduce side effects and improve quality of life. The study of these therapies and their influence in heart failure is not new. However, even for an experienced clinician, a gap exists between the literature and the application of knowledge to make a confident recommendation., Areas Covered: This review has a focus on specific supplements that are commonly used for individuals with HF. It discusses the mechanism of action, expected benefits, potential adverse effects, suggested doses, forms and drug interactions of these therapies. The literature search methodology included using medical subject headings terms to search in PubMed. Articles used were screened and critically appraised by the authors of this review., Expert Opinion: There are promising outcomes pertaining to the use of CAM in patients with HF. Advances in large scale, randomized, placebo-controlled trials are necessary to support evidence-based decision making regarding the use of supplements in conjunction, and in comparison, to conventional therapies for heart failure.

In this update, we focus on selected topics of high clinical relevance for health care providers who treat patients with heart failure (HF), on the basis of clinical trials published after 2017. Our objective was to review the evidence, and provide recommendations and practical tips regarding the management of candidates for the following HF therapies: (1) transcatheter mitral valve repair in HF with reduced ejection fraction; (2) a novel treatment for transthyretin amyloidosis or transthyretin cardiac amyloidosis; (3) angiotensin receptor-neprilysin inhibition in patients with HF and preserved ejection fraction (HFpEF); and (4) sodium glucose cotransport inhibitors for the prevention and treatment of HF in patients with and without type 2 diabetes. We emphasize the roles of optimal guideline-directed medical therapy and of multidisciplinary teams when considering transcatheter mitral valve repair, to ensure excellent evaluation and care of those patients. In the presence of suggestive clinical indices, health care providers should consider the possibility of cardiac amyloidosis and proceed with proper investigation. Tafamidis is the first agent shown in a prospective study to alter outcomes in patients with transthyretin cardiac amyloidosis. Patient subgroups with HFpEF might benefit from use of sacubitril/valsartan, however, further data are needed to clarify the effect of this therapy in patients with HFpEF. Sodium glucose cotransport inhibitors reduce the risk of incident HF, HF-related hospitalizations, and cardiovascular death in patients with type 2 diabetes and cardiovascular disease. A large clinical trial recently showed that dapagliflozin provides significant outcome benefits in well treated patients with HF with reduced ejection fraction (left ventricular ejection fraction ≤ 40%), with or without type 2 diabetes., (Copyright © 2020 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Introduction: Both types of sleep-disordered breathing (SDB), obstructive and central sleep apnoea (OSA and CSA, respectively), are common in patients with heart failure and reduced ejection fraction (HFrEF). In such patients, SDB is associated with increased cardiovascular morbidity and mortality but it remains uncertain whether treating SDB by adaptive servo-ventilation (ASV) in such patients reduces morbidity and mortality., Aim: ADVENT-HF is designed to assess the effects of treating SDB with ASV on morbidity and mortality in patients with HFrEF., Methods: ADVENT-HF is a multicentre, multinational, randomized, parallel-group, open-label trial with blinded assessment of endpoints of standard medical therapy for HFrEF alone vs. with the addition of ASV in patients with HFrEF and SDB. Patients with a history of HFrEF undergo echocardiography and polysomnography. Those with a left ventricular ejection fraction ≤45% and SDB (apnoea-hypopnoea index ≥15) are eligible. SDB is stratified into OSA with ≥50% of events obstructive or CSA with >50% of events central. Those with OSA must not have excessive daytime sleepiness (Epworth score of ≤10). Patients are then randomized to receive or not receive ASV. The primary outcome is the composite of all-cause mortality, cardiovascular hospital admissions, new-onset atrial fibrillation requiring anti-coagulation but not hospitalization, and delivery of an appropriate discharge from an implantable cardioverter-defibrillator not resulting in hospitalization during a maximum follow-up time of 5 years., Conclusion: The ADVENT-HF trial will help to determine whether treating SDB by ASV in patients with HFrEF improves morbidity and mortality., (© 2017 The Authors. European Journal of Heart Failure © 2017 European Society of Cardiology.)

Anthracycline-induced cardiomyopathy (AIC) may progress to end-stage heart failure requiring mechanical circulatory support or orthotopic heart transplantation (OHT). Previous studies have described important clinical differences between AIC and nonischemic cardiomyopathy (NIC) cohorts requiring these advanced interventions. Therefore, we sought to extend this literature by comparing echocardiographic parameters, treatment strategies, and the prognosis between matched patients from these cohorts. This is a retrospective matched cohort study. All patients who received a ventricular assist device or OHT at a large Canadian center were reviewed (n = 421; 1988 to 2015) and subjects with clinical and pathologic evidence of AIC were included (n = 17, 4.0%). A comparison cohort with idiopathic NIC from the same database, matched 3:1 for age, gender, ethnicity, and year of heart failure onset was selected. The Mann-Whitney rank-sum and Fisher's exact tests were used for comparisons. Patients with AIC were predominantly women (70.6%) with heart failure diagnosed at age 40.2 ± 15.8 and 8.3 ± 8.9 years after anthracycline treatment. Compared with NIC, no differences were seen in co-morbidities, echocardiographic measures, the proportion of patients receiving a defibrillator, ventricular assist device, or OHT, the incidence of graft failure, and all-cause mortality. In contrast to other studies, AIC was not associated with a higher incidence of right ventricular dysfunction. A greater proportion of patients with AIC developed cancer (recurrence or new primary) post-OHT (21.4% vs 2.3%, p = 0.042). In conclusion, we demonstrate that when matched cohorts of patients with end-stage heart failure secondary to AIC and idiopathic NIC are compared, they are similar with respect to co-morbidities, degree of ventricular dysfunction, and advanced therapeutics used. The prognosis with OHT is also similar., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Current available treatment options for advanced heart failure include heart transplantation and ventricular assist device (VAD) therapy. This project aimed to evaluate the cost-effectiveness of a bridge-to-transplantation (BTT)-VAD approach relative to direct heart transplantation in transplant-eligible patients., Methods and Results: A Markov model was used to evaluate survival benefits and costs for BTT-VAD versus nonbridged heart transplant recipients. Three different scenarios were considered according to severity of patients' baseline hemodynamic status (high, medium, and low risk). Results are presented in terms of survival, costs, and cost-effectiveness ratio. Sensitivity analyses were used to analyze uncertainty in model estimates. Over a 20-year time horizon, BTT-VAD therapy increased survival at an increased cost relative to nonbridged heart transplant recipients: $100 841more in costs and 1.19 increased life years (LYs) in high-risk patients ($84 964/LY), $112 779 more in costs and 1.14 more LYs ($99 039/LY) in medium-risk patients, and an additional cost of $144 334 and incremental clinical benefit of 1.21 more LYs ($119 574/LY) in low-risk patients. The sensitivity analysis estimated a 59%, 54%, and 43% chance of BTT-VAD therapy being cost-effective for high-, medium-, and low-risk patients at a willingness-to-pay level of $100 000/LY. Subgroup analyses indicated that risk of post-VAD and transplantation complications, waiting time, renal dysfunction, and patient age substantially affected the cost-effectiveness ratio., Conclusions: BTT-VAD therapy is associated with improved survival and increased costs. On the basis of commonly accepted willingness-to-pay thresholds, BTT-VAD therapy is likely to be cost-effective relative to nonbridged heart transplantation in specific circumstances.

Immune activation and inflammation play critical roles in the development of heart failure (HF). Human leukocyte antigen-G (HLA-G) is a nonclassical, major histocompatibility complex class I (MHC-I) protein, upregulated in the context of transplantation, malignancy, and inflammation, and has been correlated with various clinical outcomes. We sought to evaluate the utility of plasma HLA-G in identifying patients with HF. We conducted a single-center, cross-sectional pilot study involving 82 patients diagnosed with HF and 10 healthy controls. Concentrations of circulating HLA-G and inflammatory markers were detected with specific enzyme-linked immunosorbent assay kits and quantified according to purified protein standards. The mean age of the patients was 49.1 ± 12.0 years and 62.2% were male. The median and interquartile range of HLA-G levels (U/ml) were significantly higher (p < 0.001) in HF patients (63, 36-98) compared with controls (28, 22-40). Moreover, HLA-G levels that were similarly (p = 0.766) upregulated across all New York Heart Association functional classes. There was no significant correlation between serum HLA-G and other biomarkers. In conclusion, HLA-G is upregulated in patients diagnosed with HF. Its marked elevation even in New York Heart Association class I patients might indicate that serum HLA-G is a more sensitive marker than other classical HF biomarkers., (Copyright © 2011 American Society for Histocompatibility and Immunogenetics. All rights reserved.)

Introduction: The use of mechanical circulatory support (MCS) in nontransplant eligible candidates remains controversial. Our decision to offer MCS for nontransplant candidates has led to their reevaluation after a period of left ventricular assist device (LVAD) support., Methods: From 2001 to September 2009, we had 37 patients who received an implantable LVAD, 22 (59%) were not deemed to be transplant eligible at the time of LVAD insertion (bridge to candidacy, BTC group)., Results: Fifteen (41%) patients were considered transplant eligible (bridge to transplant, BTT group) at the time of device insertion and received a HeartMate XVE (n = 7), HeartMate 2 (n = 7), or a Novacor LVAS (n = 1). In the BTC group, patients received the HeartMate XVE device (n = 11), HeartMate 2 (n = 5), or the Novacor LVAS (n = 6). The primary criterion for transplant ineligibility was refractory pulmonary hypertension (PH) in 18 patients, 3 patients did not meet our body mass index criteria (>35 kg/m(2)), and 2 patients were dialysis-dependent. Six (27%) BTC patients died on support. Overall, 16/22 patients (73%) were subsequently listed for transplantation, with one listed for combined heart-lung due to refractory PH. Twelve patients (75%) underwent successful heart transplantation. Three patients died during their transplant. Overall posttransplant survival at one year shows lower survival in the BTC group compared to the BTT group (67% vs. 100%, p = 0.05). At two years and three years the survival was lower, but not statistically different (BTC vs. BTT: 67% vs. 90% and 64% vs. 87%, respectively, p = NS)., Conclusions: MCS can successfully convert a large proportion of transplant-ineligible patients into acceptable candidates. , (© 2011 Wiley Periodicals, Inc.)

Aims: Ventricular assist device (VAD) therapy is widely used as a bridge to cardiac transplant. Studies addressing the effect of VADs on post-transplant outcomes have shown conflicting results. It is imperative to review this evidence to inform clinical decision making and future research. Our aim was to systematically evaluate the effect of VAD therapy on long-term post-transplant outcomes in heart transplant recipients., Methods and Results: We searched online databases (Medline, PubMed, Embase, and CINAHL) and references of included articles. Comparative studies evaluating the effect of VADs on post-transplant outcomes in adults were included and study results were meta-analysed using random-effects models. We conducted subgroup analyses to assess the effect estimate of extra- vs. intra-corporeal VADs and to evaluate the impact of transplant era and listing status. Overall, we identified 31 observational studies. One-year post-transplant mortality in recipients bridged with an extra-corporeal VAD was significantly higher than in non-bridged recipients (RR 1.8, 95% CI 1.53-2.13, I(2)= 1%), while patients supported with an intra-corporeal VAD had similar mortality to non-bridged recipients (RR 1.08, 95% CI 0.95-1.22, I(2)= 0%). The risks of rejection within the first post-transplant year and coronary allograft vasculopathy were not significantly different between patients with or without VAD support prior to transplant. Publication bias was low; however, the risk of bias across studies was moderate to high., Conclusion: Intra-corporeal VAD support does not have a deleterious impact on post-transplant outcomes. However, post-transplant survival may be poorer in the subgroup of patients supported with extra-corporeal devices. Studies with greater methodological rigour are warranted.

Background: The increasing prevalence of heart failure and its unpredictable trajectory highlight the need for patients to make their end-of-life care wishes known using advanced care directives (ACDs). The paucity of literature addressing heart failure patients' decision-making processes and knowledge of ACDs underscores the need for investigation. The purposes of this study were to (1) determine patients' awareness, comprehension, and utilization of ACDs and (2) determine their knowledge of the process of cardiopulmonary resuscitation and their current resuscitation preference., Methods: A prospective, single-centre study was designed to collect quantitative data addressing patients' understanding of ACDs and cardiopulmonary resuscitation as well as their current resuscitation preference. Patients who consented were interviewed using a semistructured questionnaire. Data were analyzed using descriptive statistics., Results: Of the 41 participants, 76% did not know what ACDs were and fewer recalled discussing them with their physician. Nearly 80% of the 37 queried participants would have preferred to discuss ACDs. More than 75% of participants wanted full resuscitation if they were to require it at this time. Most participants had not documented their resuscitation preference, and only slightly over half said their substitute decision maker was aware of their preference. Among the 19 with an implantable cardioverter-defibrillator, nearly half would want it deactivated should their condition worsen. Only 2 participants recalled having discussed this option with their physician., Conclusions: There remains a lack of knowledge and utilization of ACDs among this heart failure population. Participants' preferences highlight the importance of discussing ACDs and exploring resuscitation preferences early and often in heart failure., (Copyright © 2011 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Background: Fixed pulmonary hypertension (FPH) is considered a contraindication to cardiac transplantation. Ventricular assist device (VAD) therapy through prolonged left ventricular unloading may reverse FPH. Our aim was to assess post-transplant outcomes and survival in patients with and without FPH undergoing VAD implantation as bridge to transplant., Methods: Fifty-four patients received an intracorporeal left VAD (LVAD) as a bridge to transplant from 2000 to 2008 at two institutions (Rigshospitalet, Denmark, and the Toronto General Hospital, Canada). Twenty-two (41%) patients had fixed FPH (defined as pulmonary vascular resistance [PVR] >3 Wood units and resistant to pulmonary vasodilators) prior to VAD implant (FPH group) and were compared with 32 patients without FPH (NoFPH group). Baseline characteristics, pre- and post-transplant pulmonary pressures, incidence of complications and post-transplant survival were analyzed., Results: Baseline characteristics were similar except that patients in the FPH group were older (46 ± 11 years vs 39 ± 13 years in the NoFPH group, p < 0.05). The mean pre-VAD PVR was 4.3 ± 1.7 Wood units in the FPH group and 1.7 ± 0.5 Wood units in the NoFPH group (p < 0.001). Pulmonary pressures were higher in the FPH group immediately prior to VAD implant, but they were comparable immediately pre-transplant and during the first year post-transplant. The incidence of post-transplant RV failure was not significantly different between groups. Post-transplant survival was similar between groups., Conclusions: VAD therapy successfully decreases pulmonary hypertension, even in patients with "fixed" FPH, allowing candidacy for heart transplantation. Among bridge-to-transplant candidates, the presence of FPH does not reduce post-transplant survival., (Copyright © 2010 International Society for Heart and Lung Transplantation. Published by Elsevier Inc. All rights reserved.)

Background: Acute renal dysfunction (ARD) is a frequent complication after ventricular assist device (VAD) implantation. The purpose was to identify predictors associated with ARD after VAD implantation., Methods and Results: ARD was defined using the risk of renal dysfunction, injury to the kidney, failure of kidney function, loss of kidney function, end-stage kidney disease (RIFLE) criteria. Patients who developed ARD during VAD support (ARD, n=24) were compared with patients who did not (NoARD, n=29). Patients with ARD before implant were excluded. Patient characteristics pre-VAD implant, incidence of complications during support and survival were analyzed. Baseline characteristics were similar. The ARD group had longer cardiopulmonary bypass (CPB) time, greater need for reoperation and higher risk of bleeding (>1 L) intraoperatively (P < .05). The ARD group had a higher incidence of infections (17% vs. 50%, OR 5, 95%CI 1.3-17), liver injury (58% vs. 17%, OR 7, 95%CI 2-24), ventricular arrhythmias (42% vs. 14%, OR 4, 95%CI 1.1-16), and right ventricular failure (73% vs. 30%, OR 7, 95%CI 2-24). Need for dialysis was associated with higher pre-VAD creatinine and worse outcomes. Survival was significantly lower in the ARD group (HR 8.5, 95%CI 2-29)., Conclusions: Acute renal dysfunction is a common and serious complication post-VAD implantation and is associated with reduced survival. Longer CPB time, higher intraoperative blood loss, and reoperation are associated factors with the development of this disease.

Mechanical circulatory support is an important adjunct to the management of patients with advanced heart failure. Technological advances in this area have improved overall survival and decreased the incidence of complications. In addition, they have expanded the population suitable for this therapy. The challenge for clinicians is to translate the clinical evidence into the selection of the most appropriate device that will benefit an individual patient. This paper will review ventricular assist devices currently available and their clinical indications.

Background: The Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) scale classifies advanced heart failure patients according to hemodynamic status. This study assessed the usefulness of the INTERMACS scale to predict outcomes in advanced heart failure patients undergoing mechanical circulatory support (MCS)., Methods: Fifty-four patients underwent MCS implantation from 2001 to 2007. Group A included 27 patients at INTERMACS level 1 and 2. Group B included 27 at INTERMACS level 3 and 4. Patient characteristics pre-MCS implant, incidence of complications during support, and survival between groups were compared., Results: Before MCS implantation, Group A had significantly lower cardiac index, mean arterial blood pressure, systolic pulmonary pressure, higher central venous pressure, and lower urine output (p < .05). After MCS, Group A had a lower incidence of infections (17% vs 46%; odds ratio [OR], 0.25, 95% confidence interval [CI], 0.06-0.6) and a higher incidence of liver injury (39% vs 11%; OR 5, 95% CI, 1.15-25). Mortality at 30 days was higher in Group A (38% vs 11%; OR, 4.8; 95% CI, 1.1-21); however, the mortality after 30 days post-MCS support was significantly higher in Group B (0% vs 18%, p < .05). Cox model showed overall survival was poorer in Group A (hazard ratio, 2.7; 95% CI, 1.1-7)., Conclusion: INTERMACS levels identified patients at risk for developing complications after MCS support. INTERMACS is a valid score system that should be considered as a tool to assess patient profile and predict complications and mortality after MCS implantation.

Coronary heart disease is the most common cause of heart failure. Its prevalence has increased mainly owing to the improved survival of patients after acute myocardial infarction. In patients with heart failure, the presence of coronary heart disease has been shown to be independently associated with worsened long-term outcomes, including hospitalizations and poor mortality. Coronary heart disease frequently coexists with several major risk factors for the onset and progression of heart failure, such as hypertension, diabetes, obesity and metabolic syndrome, among others. Medical efforts to reduce the incidence of heart failure burden in patients with coronary heart disease and other types of cardiomyopathies must be directed at the prevention of heart failure and coronary risk factors themselves, and not just at the improvement of the management of established disease. This article will address the impact of known risk factors in the development of coronary heart disease and heart failure.

Background: The purpose of this study is to describe the treatment preferences of patients with heart failure among three distinct treatment options--optimal medical management, oral inotropes or left ventricular device (LVAD) support--to determine if there were differences in preferences between patients with mild heart failure (New York Heart Association [NYHA] Class II) and severe heart failure (NYHA Class IV), and also to determine whether quality of life, perceived severity of symptoms and overall health influenced treatment preferences., Methods: We enrolled 91 patients who completed the Minnesota Living with Heart Failure Questionnaire (MLHFQ); visual analog scales for depicting their perceived severity of overall health, dyspnea and fatigue; and a treatment trade-off tool., Results: The most preferred treatment options were oral inotropes, LVAD and standard medical management. There were no differences in treatment preferences between NYHA II and NYHA IV patients. Patient preferences correlated poorly with MLHFQ, symptom and overall health scores. Although not statistically significant, there was a trend toward patients with worse quality of life and symptom scores preferring more aggressive treatment., Conclusions: The results of our study identified two distinct groups of patients: one group preferring treatments that prolonged survival time and another group that favored strategies that improved quality of life but reduced survival time. Treatment preferences were independent of functional or symptom status, suggesting that preferences may be decided early in the course of illness.

Background: Left ventricular assist devices (LVADs) are an important adjunct to the management of end-stage heart failure patients. Uncertainty remains regarding whether to remove an LVAD in a clinically stable, asymptomatic patient who displays signs of ventricular recovery., Objectives: To evaluate, from a patient's perspective, the quality-adjusted life expectancy of an LVAD explantation., Methods: A Markov state transition model was used to assess the benefits of two strategies: remove an LVAD or continue the LVAD support. Effectiveness was measured in quality-adjusted life months. Utility and probability scores were derived from the literature and expert opinion. The base case focused on a 35-year-old man with dilated cardiomyopathy, an implantable LVAD and signs of ventricular recovery, with New York Heart Association class I heart failure symptoms., Results: In the base case, continuing LVAD support was strongly preferred and improved quality-adjusted life expectancy by nine quality-adjusted life months. In sensitivity analyses for the utility post-transplant, removal of the device would have been preferred if the utility was less than 0.7. The model was also sensitive to the probability of late complications post-LVAD implantation. As the probability of complications increased (greater than 28%), the preferred strategy was to remove the LVAD., Conclusions: Continuing LVAD support in asymptomatic patients with signs of ventricular recovery appears to be the preferred strategy for conveying greater quality-adjusted life months compared with LVAD explantation. As the probability of complications after LVAD implantation increases, the preferred strategy is to remove the LVAD.

In October of 2002, a workshop was held as part of the Canadian Cardiovascular Congress in Edmonton, Canada, entitled "Under-Utilization of Mechanical Circulatory Support in Canada. Why and What Can Be Done?" The workshop examined various issues related to the use of mechanical circulatory support devices in the Canadian context. Representatives from all Canadian centers with active mechanical circulatory support programs were invited to participate and participants included surgeons and cardiologists, as well as other affiliated health professionals. Opinions were solicited from the workshop participants and a series of recommendations were formulated.

Reliable predictors of myocardial recovery post-mechanical assist device implantation are not well defined. We report the case of a 29-year-old woman with refractory congestive heart failure due to acute myocarditis of unknown etiology. The patient was supported with a HeartMate (Thoratec Corp., Woburn, MI) left ventricular assist device for 100 days showing improvement in clinical status. Hemodynamic monitoring, dobutamine stress echocardiography, and cardiopulmonary testing were performed to identify myocardial recovery. Improvements in myocardial reserve, hemodynamic parameters, and myocardial oxygen consumption were identified prior to explantation. The patient was successfully explanted. This case confirms that myocardial recovery is feasible with the use of a mechanical assist device. This article describes our current left ventricular assist device weaning protocol.

Background: The Internet is a useful tool for improving communication between patients and their health care providers. However, no study has examined an efficient use of the Internet to improve quality of care for these patients. The purpose of this pilot study is to determine the feasibility of using an Internet-based communication tool with heart failure patients and to assess the effect of this system on the patients' quality of life., Methods and Results: A prospective study was conducted among patients (n=16) attending a university-based heart failure clinic. An Internet communication Web site (www.heartfunction.com) was developed for the pilot study. The system was designed to be an information resource for patients and a daily communication method between patients and health care providers. Quality of life scores based on the Minnesota Living with Heart Failure Questionnaire (MLHFQ) were obtained at baseline and at three months. The mean MLHFQ score was 59.75+/-1.5 at baseline and 49.87+/-1.3 at three months (P=0.093). Significant differences were found at three months in the scale items that measured relationships with friends and family (3.062 versus 2.06; P=0.03), working around the house and yard (3.68 versus 2.81; P=0.008) and side effects of medication (2.81 versus 1.93; P=0.048). All patients reported high levels of satisfaction with the Web site., Conclusions: Internet-based communication is a feasible tool for the management of heart failure patients, providing an effective medium through which health care professionals can interact with their patients. This approach may also improve patient quality of care and quality of life.

The use of cannabis and its derivatives have increased steadily over the past few decades, prompting patients and clinicians to increasingly inquire about its health effects and safety profile. However, despite promising evidence suggesting therapeutic utilization, cannabis remains a controlled substance in most countries and is largely considered to have no medical or recreational benefit; thus, a lack of observational studies and randomized control trials exist to outline positive and negative health implications. Ultimately, this leaves patients, health-care professionals, and policymakers without necessary evidence required to make informed decisions on cannabis use. This review outlines cannabis in a clinical setting and delves into specific effects of cannabinoids on cardiovascular health and disease. It discusses positive and negative health implications associated with cannabis, mechanisms in cardiovascular disease, and reveals methods guiding cannabis use in the clinical setting. Advances in research are necessary to guide decisions regarding cannabinoid use. Countries that have federally legalized cannabis have a unique opportunity to study cardiovascular implications in an unbiased and comprehensive manner. Ultimately, as cannabis use will inevitably increase, researchers, clinicians, and policymakers must work together to ensure cannabis is utilized in a way that is therapeutically beneficial. [ABSTRACT FROM AUTHOR]

Cardiac amyloidosis is a myocardial disease characterized by extracellular amyloid infiltration throughout the heart. Cardiac amyloidosis has a wide spectrum of clinical manifestations but the most frequent presentation is heart failure. Differential diagnoses from other restrictive cardiomyopathies is important. A combination of clinical, electrocardiographic and imaging methods is commonly used to diagnose this disease. Definite diagnosis is based on endomyocardial biopsy and treatment of cardiac amyloidosis is a challenge. Heart transplantation, although controversial, has demonstrated survival benefit. INSET: Key issues. [ABSTRACT FROM AUTHOR]

Severe pectus excavatum, although a rare condition, is likely to be encountered by large transplant centers. The main concerns for transplant centers are the associated cardiopulmonary abnormalities along with the technical details of the transplant. We describe our experience managing a patient with severe pectus excavatum with associated cardiorespiratory abnormalities. This case report demonstrates that orthotopic cardiac transplantation through a left anterior thoracotomy is a feasible method in patients with significant displacement of the heart into the left chest. [ABSTRACT FROM AUTHOR]

The Human Leukocyte Antigen-G (HLA-G) is a MHC-class Ib molecule with robust immunomodulatory properties; in transplant, it inhibits cytotoxic activity of immune cells and thus has a pivotal role in protecting the allograft from immune attack. The present review details a 10-year experience investigating the influence of HLA-G on heart transplantation, allograft rejection and cardiac allograft vasculopathy development. Exploration of HLA-G in transplantation began with the initial findings of its increased expression in allograft hearts. Since then, HLA-G has been recognized as an important factor in transplant immunology. We discuss inducers of HLA-G expression, and the importance of HLA-G as a potential biomarker in allograft rejection and heart failure. We also highlight the importance of polymorphisms and how they may influence both HLA-G expression and clinical outcomes. There remains much to be done in this field, however we hope that findings from our group and other groups will ignite interest and facilitate further expansion of HLA-G research in transplantation. [ABSTRACT FROM AUTHOR]