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Bioprosthetic aortic valves are increasingly being utilized in a younger population due to improved durability and possibility for future valve-in-valve replacement. This has resulted in a larger population of patients with bioprosthetic aortic valve degeneration requiring re-intervention. Despite no head-to-head comparisons between redo surgical aortic valve replacement (SAVR) and valve-in-valve transcatheter aortic valve replacement (ViV TAVR), observational studies suggest a comparable long-term risk between which led to the incorporation of ViV TAVR to current guidelines.This article summarizes the comparative performance of redo SAVR versus ViV TAVR in patients with bioprosthetic valve dysfunction and provides a guide to better understand which procedure is best for which patient.With the rising use of TAVR, we will be confronted with more bioprosthetic aortic valve degeneration requiring re-intervention. Based on the available evidence and expert consensus, we propose that patients with bioprosthetic aortic valve degeneration be treated with ViV TAVR if they have a history of radiation heart disease, prohibitive surgical risk, and multiple sternotomies; while patients with small prostheses, history of infective endocarditis, those at high risk for coronary obstruction, and those with need for other cardiac surgery will be managed with redo SAVR.

Globally, family-owned businesses are the oldest and most predominant form of an enterprise, forming an integral part of the organised and unorganised sectors of free economies. Over the years, with the greater longevity of family businesses in India, there has been a dynamic and strategic shift in Indian families from being ‘family businesses’ to ‘business families’. This shift has come with its own set of challenges, most critical among them being the challenges related to ‘human capital’ for these businesses. The need to balance familial relationships with the pragmatism of business is a unique interplay which creates multiple complexities and inter-related issues for all family members alike. With close to 75 per cent of the Indian workforce employed by family-owned businesses, it is important to dive deeper into the human resources (HRs) function in Indian Family businesses. Our endeavour is to understand the challenges of HRs in a family business and how this differs from larger corporations or non-family businesses.

Atrial fibrillation (AF) is the most prevalent sustained arrhythmia affecting over 30 million patients worldwide with astronomical figures for progression over the next few decades. In this comprehensive review, we have sought to accumulate the factors that determine outcomes of AF. Patient factors such as age, sex, and ethnicity have a vital impact on the incidence and progression of AF, including outcomes of catheter ablation. While the above are non-modifiable, we also provide detailed associations of potentially modifiable comorbidities such as hypertension, congestive heart failure, valvular heart disease, diabetes mellitus, obesity, obstructive sleep apnea, conduction system disorders, and substance abuse with AF. Beyond patient factors, some parameters related to the AF itself can determine outcomes—such as duration of AF, whether it is paroxysmal or persistent AF and certain critical electrocardiographic patterns that suggest a higher risk of AF recurrence. Imaging modalities such as echocardiography, computed tomography, and cardiac magnetic resonance provide invaluable insights into the progression of AF. We describe the various pharmacological and non-pharmacological strategies for AF management with a peek at some futuristic approaches. While each one of these variables could lend themselves for a separate review, we attempted to provide an overview of the most critical predictors of AF outcomes to equip the readers with the latest know-how of the management of AF.

Supraventricular tachycardia (SVT) can occur in pregnant women with or without structural heart disease. SVT remains uncommon in pregnancy, and atrial fibrillation is now the most frequent supraventricular arrhythmia in pregnancy. Maternal physiologic changes such as increased intravascular volume can predispose to SVT and other arrhythmias in pregnancy. Although considered benign, SVT can be associated with adverse maternal and fetal outcome, especially among those with pre-existing structural heart disease. The clinical evaluation of SVT in pregnancy includes detailed history and physical examination. Important investigations include 12 lead ECG during SVT and sinus rhythm and echocardiography. The general management centers on arrhythmia avoidance during pregnancy by ablation of known SVT before pregnancy and involving a multidisciplinary care team for patients presenting 1st time during pregnancy. Acute management of SVT includes vagal maneuvers, pharmacotherapy and cardioversion for patients with hemodynamically unstable SVT. Chronic management includes pharmacotherapy with AV nodal blocking agents, anti-arrhythmic therapy, or catheter ablation in tertiary care centers after extensive consideration of risks and benefits to the mother and the fetus.

Introduction The ablation of outflow tract premature ventricular contractions (PVCs) is generally safe and effective. In some patients, successful ablation sites may not correlate with the earliest activation. We sought to evaluate mechanistic and anatomic relevance of the region below the left sinus of Valsalva in variable morphology outflow tract ventricular arrhythmias. Methods PVC cases where ablation was in the region inferior to the left sinus of Valsalva were identified. Procedural and demographic information and long-term outcomes were obtained. Cadaver dissections to evaluate regional anatomy were done as well. Results A total of 51 cases were included (age 53 ± 10; 37 [73%] males). Ablation was done for high PVC burden (>20%; mean 27% ± 8%) and presence of symptoms (73%) or ejection fraction less than 50% (78%). QRS morphology included either R wave (8; 16%), Rs (9; 18%), or rS (67%) in lead I, no precordial transition (40; 78%), V2 transition, (7; 14%), or V3 transition (4; 8%). In 31 (61%), the site just below the left coronary cusp was the earliest site, while the remainder had another site earlier. Ablation was acutely successful in 50 of 51 (98%). After 3 months, success was noted in 48 of 51 (94%). In two patients, repeat ablation in the same region resulted in durable suppression. Conclusion The cases presented emphasize the importance of a region centered below the left sinus of Valsalva, where multivariable morphology QRS may be successfully ablated. Consideration of mapping and ablation even when signals are late in this region may be warranted in previously failed ablation attempts or first-line evaluation.

Idiopathic ventricular arrhythmias originating from the aortic sinus of Valsalva often show preferential conduction to the right‐ventricular outflow tract, which may render radiofrequency ablation more difficult. We describe a patient with symptomatic premature ventricular contractions of left‐ventricular outflow tract origin presenting with a variation of QRS morphology during ablation. The correlation between the characteristics of local voltage potentials and the real origin site of the ventricular arrhythmia is discussed.

Knowledge of relevant cardiac anatomy is crucial in understanding the pathophysiology and treatment of arrhythmias, and helps avoid potential complications in mapping and ablation. This article explores the anatomy, relevant to electrophysiologists, relating to atrial flutter and atrial fibrillation, ventricular tachycardia relating to the outflow tracts as well as endocardial structure, and also epicardial considerations for mapping and ablation.

Background Premature coronary artery disease ( CAD ) is common in patients with coarctation of aorta ( COA ), but there are limited data about any direct relationship (or lack thereof) between COA and CAD . We hypothesized that atherosclerotic cardiovascular disease risk factors, rather than COA diagnosis, was the primary determinant of CAD occurrence in patients with COA . Methods and Results This is a retrospective study of 654 COA patients and a control group of 876 patients with valvular pulmonic stenosis and tetralogy of Fallot to determine prevalence and independent risk factors for CAD . There was no evidence of a difference in the unadjusted CAD prevalence between the COA and control groups (7.8% versus 6.3%, P =0.247), but premature CAD was more common in COA patients (4.4% versus 1.8%, P =0.002). In the analysis of a propensity‐matched cohort of 126 COA and 126 control patients, there was no evidence of a difference in overall CAD prevalence (6.3% versus 5.6% versus P =0.742) and premature CAD prevalence (4.8% versus 3.2%, P =0.518). The multivariable risk factors for CAD were hypertension (odds ratio [ OR ] 2.14; 95% CI 1.36–3.38), hyperlipidemia ( OR 3.33; 95% CI 2.02–5.47), diabetes mellitus ( OR 1.98; 95% CI 1.31–3.61), male sex ( OR 2.05; 95% CI 1.33–3.17), and older age per year ( OR 1.06; 95% CI 1.04–1.07). Conclusions After adjusting for atherosclerotic cardiovascular disease risk factors, we did not find evidence of a difference in CAD risk between the patients with COA and other patients with congenital heart disease.

Background Patients with tetralogy of Fallot ( TOF ) remain at risk for cardiovascular events despite successful repair. Some of the current risk stratification tools require advanced imaging and invasive studies, and hence are difficult to apply to routine patient care. A recent study showed that QRS fragmentation ( QRS ‐f) is predictive of mortality in patients with TOF. The current study aims to validate this result by assessing whether severity of QRS ‐f could predict all‐cause mortality in a different TOF population. Methods and Results The authors reviewed the Mayo Adult Congenital Heart Disease database for patients with TOF who had ECG from 1990–2017. QRS ‐f was defined as notches in QRS complex in ≥2 contiguous leads on ECG , not related to bundle branch block, and classified as none, mild (≤3 leads), moderate (4 leads), or severe (≥5 leads). Of 465 patients (age 37±14 years) in the study, QRS ‐f was present in 161 (35%): mild (n=43, 9%), moderate (n=77, 17%), and severe (n=41, 9%). There were 55 deaths (12%) during 13.6±8.2 years of follow‐up. Severity of QRS ‐f remained an independent predictor of all‐cause mortality after adjustment for other ECG parameters, patient demographics, and atrial and ventricular arrhythmia (hazard ratio, 1.74 per class; 95% confidence interval, 1.08–2.93 [ P =0.041]). Conclusions The presence of severe QRS ‐f may be used as complementary data to the usual clinical indices to determine whether interventions such as invasive electrophysiology study should be performed in patients with nonsustained ventricular tachycardia or to proceed with pulmonary valve replacement in patients with severe pulmonary regurgitation with ventricular volumes below the guideline‐directed threshold for intervention.

Squamous cell carcinoma (SCC) of the penis is a rare cancer in the industrialized countries, including the United States. Risk factors for these cancers include inflammatory conditions as well as infection with the human papilloma virus (HPV). Treatment modalities are based on TNM staging and may include surgical management or chemoradiation. Patients with local or some regional disease can have a favorable prognosis; however, with extranodal metastasis, survival decreases sharply. Here, we present a case of long-term disease-free survival in a patient with widely metastatic SCC of the penis., Highlights • Penile cancer is a rare malignancy associated with high mortality when metastatic. • HPV-related cancer accounts for nearly half of all cases and may respond differently to therapy. • New evidence suggests that patients with HPV-related penile cancer have better survival outcomes. • Aggressive and persistent treatment may be appropriate for carefully selected patients. • We suggest that HPV could serve as a biomarker to help select patients for more aggressive treatment.

Left ventricular apical aneurysm (LVAA) in hypertrophic cardiomyopathy (HCM) is a rare subset of this disease. It is associated with regional scarring/fibrosis, a higher risk for arrhythmic sudden death, and thromboembolic events. Surgical resection is often considered in severely symptomatic

Cardiocutaneous fistula is a very rare complication with unclear management strategies [(1)][1]. Herein, we present a case of recalcitrant right ventricular (RV) fistula that was successfully treated with endocardial radiofrequency ablation (RFA). The patient had severe mitral valve regurgitation