Chronic thromboembolic pulmonary hypertension is a rare form of pulmonary hypertension in patients who have evidence of chronic thromboembolic occlusion of the pulmonary vasculature. Historically, surgical pulmonary thromboendarterectomy has been the treatment of choice. However, with up to 40% of patients deemed inoperable, balloon pulmonary angioplasty has emerged as an additional treatment strategy. Balloon pulmonary angioplasty is a complementary strategy alongside surgical pulmonary thromboendarterectomy and offers the opportunity for pulmonary revascularization in patients who have more distal disease, higher comorbidities, or residual obstruction following operative intervention. This review examines the history of balloon pulmonary angioplasty, highlights its effectiveness, discusses important complications and risk reduction strategies, and emphasizes the importance of centers forming a multidisciplinary team of providers to manage the complexity of patients with chronic thromboembolic pulmonary hypertension.

A 53-year-old male presented with worsening fever, chest pain, and dyspnea during the past 2 weeks. He was hypoxic, tachycardic, and hypotensive on admission. Labs were notable for high-sensitivity troponin of 657 pg/mL and B-type natriuretic peptide of 1,648 pg/mL. Chest imaging was consistent with acute respiratory distress syndrome. Transthoracic echocardiography revealed an ejection fraction of 30% to 35% and a mobile 1.5 cm x 1.6 cm hyperechoic mass on the ventricular surface of the aortic valve (AV) with left ventricular outflow obstruction and mean pressure gradient of 38.7 mm Hg and maximum velocity of 3.64 m/s. The patient was initiated on empiric antibiotic and antifungal therapy. Cardiothoracic surgery was consulted for urgent AV repair. Blood cultures were positive for Candida metapsilosis, and intravenous fluconazole and micafungin were initiated. Despite aggressive and prompt medical management, the patient sustained cerebral embolic events in the middle cerebral artery territory and passed away.

Blood pressure goals in the intensive care unit (ICU) have been extensively investigated in large datasets and have been associated with various harm thresholds at or greater than a mean pressure of 65 mm Hg. While it is difficult to perform interventional randomized trials of blood pressure in the ICU, important evidence does not support defense of a higher pressure, except in retrospective database analyses. Perfusion pressure may be a more important target than mean pressure, even more so in the vulnerable patient population. In the cardiac ICU, blood pressure targets are tailored to specific cardiac pathophysiology and patient characteristics. Generally, the goal is to maintain adequate blood pressure within a certain range to support cardiac function and to ensure end organ perfusion. Individualized targets demand the use of both invasive and noninvasive monitoring modalities and frequent titration of medications and/or mechanical circulatory support where necessary. In this review, we aim to identify appropriate blood pressure targets in the ICU, recognizing special patient populations and outlining the risk factors and predictors of end organ failure.

Truman Capote (1924-1984) was a fascinating, entertaining, and much ballyhooed American character who came of age in the mid-Twentieth Century. Some would say he led a tragic life. Often described as a notable novelist, he was more generally a polymath dabbling in nonfiction between his parties. He also was a screenwriter, playwright, actor, and short-story writer. His literary classics include the novella Breakfast at Tiffany's (1958, movie 1961) and true crime nonfiction "novel" (as Capote described it) In Cold Blood (1965, movie 1967). These two efforts became his most famous. But what about his poetry? Was this one of his creative passions?

Left ventricular assist devices (LVAD) can be utilized for heart failure patients as a bridge to transplant, bridge to destination, or bridge to recovery. Given the lack of a universally accepted consensus for assessing myocardial recovery, techniques and strategies in LVAD explantation also vary. In addition, the incidence of LVAD explantation remains relatively low, and surgical techniques of explantation continue to be areas of interest. Our approach using a felt-plug Dacron technique is an effective way to preserve left ventricular geometry and cardiac function.

We report a case of a 55-year-old male with a history of methicillin-resistant staphylococcus aureus bacteremia whose initial transesophageal echocardiography revealed a cardiac mass attached to the right atrium. Because of the uncommon location of the mass, 18F-fluorodeoxyglucose-PET was used to confirm the diagnosis of infective endocarditis.

Dr. Oliver Wendell Holmes Sr. was a 19th century elite physician, curmudgeon, essayist, and poet. His works were numerous, insightful, entertaining, and characteristic of the pre-Civil War, Civil War, and Gilded age eras. Many of his shorter poems are taught in high school as examples of late 19th century works, as they are relatively easy to memorize and understand. Holmes and the Fireside Poets (Emerson, Longfellow, and Lowell, among others) created works that, in their time, were read aloud by fathers and mothers to their family because the poems often centered around values, morals, and historic events. "Old Ironsides" is characteristic of the type of work for which the Fireside Poets became famous. It is an entertaining poem to read, study, and hear, particularly when linking it to the oldest ship in the world, still afloat and sailing around Boston Bay.

The Spectrum of Care for Aortic Disease Aortic diseases have varied pathologies and, increasingly, new options for treatment.The causes of aortic disease may vary from congenital or genetic conditions to infection, traumatic accidents, degenerative or inflammatory disorders.Environmental influences clearly contribute to increased occurrence, with known risk factors including hypertension, aging, smoking, and trauma.While preventive and pharmacological interventions have been explored in recent years, surgery or Endovascular intervention continues as the recommended solution when treating most cases.This issue of the Methodist DeBakey Cardiovascular Journal explores the major types of aortic disease and their various options for treatment and repair.We open with a review of dynamic imaging of aortic pathologies by Drs.Dipan J. Shah, Alan B. Lumsden, Peter Osztrogonacz, and colleagues, who note that today's vascular surgeons can choose from a wide array of imaging modalities to evaluate different aortic pathologies.Despite the fact that newer dynamic imaging techniques provide time-resolved information in various aortic pathologies compared to the standard imaging modalities of vascular ultrasound and aortography, these newer techniques have not seen widespread adoption.To help readers decipher the role of emerging modalities, the authors provide an overview of dynamic imaging techniques for aortic pathologies and describe various dynamic computed tomography and magnetic resonance imaging protocols, clinical applications, and potential future directions.Next, we explore the topic of branched and fenestrated aortic endovascular grafts with Dr. Marvin D. Atkins and coauthor Aidan D. Atkins.Although improvements in morbidity and mortality have made endovascular repair of abdominal and descending thoracic aortic aneurysms the standard of care, late durability is problematic due to persistent endoleaks that may lead to aneurysm expansion and eventual rupture.The authors explore the current state of branched, fenestrated, and physician-modified endografts used in complex aortic pathologies-including early results of such technologies that show at least similar shortterm outcomes compared with open repair-as well as issues such as late branch endograft failure and acute periprocedural stroke.From here, Drs.Valeria Duarte, Michael Singh, and Raman Yousefzai discuss the increase in genetically triggered thoracic aortic disease.Up to 25% of patients with thoracic aortic disease have an underlying genetic predisposition, which makes diagnosis critical from both a medical management perspective and to identify at-risk family members.The authors explain the genetic etiology of thoracic aortic disease, identify aortic diseases associated with genetic syndromes, review the recent ACC/AHA guidelines, and discuss specific testing protocols for patients predisposed with heritable thoracic aortic disease.

An 81-year-old female patient with a history of severe secondary mitral regurgitation, hypertension, and paroxysmal atrial fibrillation was seen by the valve team to determine candidacy for transcatheter edge-to-edge repair of the mitral valve. Two-dimensional biplane imaging showed a transverse basal left ventricle false tendon attached to papillary muscles. The position was concerning for interference during deployment of the mitral clip.

Evidence for cardiovascular outcomes with older-generation antihyperglycemic drugs in the management of type 2 diabetes is based on aggregated data from prior randomized controlled trials and observational studies that were not focused on prespecified cardiovascular end points. Newer antihyperglycemic medications have undergone a rigorous evaluation of cardiovascular outcomes through randomized controlled trials since the US Food and Drug Administration imposed a mandatory requirement for all glucose-lowering drugs in 2008. The three classes of drugs that have been most extensively studied are dipeptidyl peptidase 4 inhibitors, glucagon-like peptide 1 receptor agonists, and sodium-glucose cotransporter-2 (SGLT2) inhibitors, the latter two reporting significant reductions in adverse cardiovascular outcomes independent of their glycemic effect. Remarkably, it was the evidence from SGLT2 inhibitors cardiovascular outcome trials that prompted further evaluation of the drug class in patients with heart failure irrespective of their diabetes status, demonstrating a broader cardiometabolic effect of these drugs. In this review, we assess the evidence for cardiovascular outcomes with common older- and newer-generation glucose-lowering drugs in the management of type 2 diabetes. We also discuss emerging glucose-lowering drugs with novel metabolic targets that influence the risk of adverse cardiovascular events and expand on the role of these drugs beyond the management of type 2 diabetes.