Update: cardiac xenotransplantation

Novel therapies in childhood heart failure: today and tomorrow

Heart failure is an important cause of morbidity and mortality in individuals of all ages. The many-faceted nature of the clinical heart failure syndrome has historically frustrated attempts to develop an overarching explanative theory. However, much useful information has been gained by basic and clinical investigation, even though a comprehensive understanding of heart failure has been elusive. Heart failure is a growing problem, in both adult and pediatric populations, for which standard medical therapy, as of 2010, can have positive effects, but these are usually limited and progressively diminish with time in most patients. If we want curative or near-curative therapy that will return patients to a normal state of health at a feasible cost, much better diagnostic and therapeutic technologies need to be developed. This review addresses the vexing group of heart failure etiologies that include cardiomyopathies and other ventricular dysfunctions of various types, for which current therapy is only modestly effective. Although there are many unique aspects to heart failure in patients with pediatric and congenital heart disease, many of the innovative approaches that are being developed for the care of adults with heart failure will be applicable to heart failure in childhood.

Myocardial infarction: a paradigm of success in modern medicine

Hospital mortality for acute myocardial infarction declined from 30% to 10% in the last 30 years, thanks to coronary care units and early revascularization with thrombolysis, angioplasty, and stent implantation. Pathologists played a major role by establishing plaque rupture and coronary thrombosis as the major cause of acute myocardial infarction and by discovering that ischemic myocardium necrosis progresses from endocardium to epicardium as a "wave front" phenomenon, with potential reversible injury if the reperfusion is accomplished within 3 h. Long-term mortality following myocardial infarction is mostly due to sudden electrical death, which may be prevented by pharmacologic (antiarrhythmic drugs) and nonpharmacologic (implantable cardioverter defibrillator, pacemaker) therapy. Ventricular assist devices may support the left ventricle as a bridge to transplantation. Long-term mortality at distance from acute myocardial infarction declined from 10% to 2% per year. Despite these indisputable achievements, there are still pending questions: in vivo identification of vulnerable plaque, mechanisms of thrombosis by plaque erosion, prompt treatment on the spot of instantaneous cardiac arrest by external defibrillation, adverse effect of myocardial reperfusion, fate of bare- and drug-eluting coronary stents. With these limitations and challenges well in mind, nowadays myocardial infarction does not represent a nightmare as it was in the past. The achievements in its prevention, diagnosis, and treatment should be considered as a pride of cardiovascular medicine.