Peripartum cardiomyopathy: a contemporary review

Peripartum cardiomyopathy is a rare and potentially fatal disease. Though approximately half of the patients recover, the clinical course is highly variable and some patients develop refractory heart failure and persistent left ventricular systolic dysfunction. It is diagnosed when women present with heart failure secondary to left ventricular systolic dysfunction towards the end of pregnancy or in the months following delivery, where no other cause of heart failure is found. Etiology remains unclear, and treatment is similar to other cardiomyopathies and includes evidence-based standard heart failure management strategies. Experimental strategies such as intravenous immunoglobulin and bromocriptine await further clinical validation.

Evaluation of necessity for mechanical bowel preparation before Milligan-Morgan hemorrhoidectomy: a randomized prospective clinical study

AIM

In this randomized prospective clinical study, we aimed to evaluate the effect of mechanical bowel preparation (MBP) before Milligan-Morgan hemorrhoidectomy on intraoperative procedures and postoperative complication rates to determine whether MBP is adventageous or not before elective anorectal surgeries.

METHODS

Forty patients who had internal grade III or IV hemorrhoidal disease and who would underwent open hemorrhoidectomy were randomized into two groups: non-MBP group (female:male, 11:9; mean age, 33.8±9.57 years) that would not receive MBP before the surgery, and MBP group (female:male, 12:8; mean age, 34.7±11.37 years) that would be given one Fleet enema on the morning of Milligan-Morgan hemorrhoidectomy. Intraoperative variables and postoperative complications were compared between two groups.

RESULTS

MPB had no effect on both intraoperative and postoperative variables, such as operating time, intraoperative bleeding, visual analogue scale (VAS) score for the comfort of the surgeon during operation, the presence of stool or enema remnants in anal canal, the presence of mucosal edema of the anal canal intraoperatively, the rates of postoperative bleeding and infection, VAS score for the pain on third day postoperatively, time to first stool after the operation, VAS score for the pain during first stool after the operation, and number of analgesics during one week postoperatively (P>0.05 for all).

CONCLUSION

MBP performed before surgery does not provide introperative or postoperative benefit for Milligan-Morgan hemorrhoidectomy, thus MBP is not necessary before elective anorectal surgeries.

Cardiovascular function and treatment in β-thalassemia major: a consensus statement from the American Heart Association

This aim of this statement is to report an expert consensus on the diagnosis and treatment of cardiac dysfunction in β-thalassemia major (TM). This consensus statement does not cover other hemoglobinopathies, including thalassemia intermedia and sickle cell anemia, in which a different spectrum of cardiovascular complications is typical. There are considerable uncertainties in this field, with a few randomized controlled trials relating to treatment of chronic myocardial siderosis but none relating to treatment of acute heart failure. The principles of diagnosis and treatment of cardiac iron loading in TM are directly relevant to other iron-overload conditions, including in particular Diamond-Blackfan anemia, sideroblastic anemia, and hereditary hemochromatosis. Heart failure is the most common cause of death in TM and primarily results from cardiac iron accumulation. The diagnosis of ventricular dysfunction in TM patients differs from that in nonanemic patients because of the cardiovascular adaptation to chronic anemia in non-cardiac-loaded TM patients, which includes resting tachycardia, low blood pressure, enlarged end-diastolic volume, high ejection fraction, and high cardiac output. Chronic anemia also leads to background symptomatology such as dyspnea, which can mask the clinical diagnosis of cardiac dysfunction. Central to early identification of cardiac iron overload in TM is the estimation of cardiac iron by cardiac T2* magnetic resonance. Cardiac T2* <10 ms is the most important predictor of development of heart failure. Serum ferritin and liver iron concentration are not adequate surrogates for cardiac iron measurement. Assessment of cardiac function by noninvasive techniques can also be valuable clinically, but serial measurements to establish trends are usually required because interpretation of single absolute values is complicated by the abnormal cardiovascular hemodynamics in TM and measurement imprecision. Acute decompensated heart failure is a medical emergency and requires urgent consultation with a center with expertise in its management. The first principle of management of acute heart failure is control of cardiac toxicity related to free iron by urgent commencement of a continuous, uninterrupted infusion of high-dose intravenous deferoxamine, augmented by oral deferiprone. Considerable care is required to not exacerbate cardiovascular problems from overuse of diuretics or inotropes because of the unusual loading conditions in TM. The current knowledge on the efficacy of removal of cardiac iron by the 3 commercially available iron chelators is summarized for cardiac iron overload without overt cardiac dysfunction. Evidence from well-conducted randomized controlled trials shows superior efficacy of deferiprone versus deferoxamine, the superiority of combined deferiprone with deferoxamine versus deferoxamine alone, and the equivalence of deferasirox versus deferoxamine.