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Coarctation of the Aorta

The 2020 ESC guidelines suggest stenting is appropriate if the patient is normotensive but has a peak gradient of > 20 mm Hg (class IIa) or if angiography shows stenosis is > 50% (class IIb).

Atrial Septal Defect & Patent Foramen Ovale

The 2020 ESC guidelines add the PVR to their criteria and consider it a class IIa indication if the PVR is between 3 Wood units and 5 Wood units, and the guidelines preclude the use of closure if the PVR is ≥ 5 Wood units.

ESC guidelines favor bringing the patient back to the catheterization laboratory for retesting on pulmonary vasodilators, rather than using acute testing, to see if the PVR can be reduced below 5 Wood units.

The ESC guidelines also suggest considering fenestrated closure in the face of pulmonary hypertension.

The use of bosentan or sildenafil is recommended if the PVR is over 5 Wood units and there is a right to left shunt.

A 2020 update from the guideline subcommittee of the American Academy of Neurology reaffirms no change in the policy that states patients < 55 years with cryptogenic stroke/TIA and no other identifiable cause except for the presence of a PFO should still be considered for PFO closure.

The presence of a “floppy atrial septum - atrial septal aneurysm” has been associated with a higher risk of recurrent stroke/TIA in patients with cryptogenic stroke/TIA.

Mitral Regurgitation

Transcatheter edge-to-edge repair is an option in symptomatic patients at higher surgical risk regardless of whether the mitral regurgitation is primary or secondary.

Patients with functional chronic mitral regurgitation may improve with biventricular pacing and guideline-directed management and therapy.

Aortic Stenosis

Surgery is recommended for patients < 65 years or with a life expectancy of > 20 years.

Transcatheter AVR is recommended for all patients > 80 years.

Either surgical AVR or transcatheter AVR can be considered for all patients between 65 and 80 years.

Atrial Fibrillation

In patients with recent-onset atrial fibrillation (< 1 year), the EAST-AFNET 4 trial found that rhythm control with antiarrhythmic medication or catheter ablation is associated with a lower risk of death from cardiovascular causes, stroke, or hospitalization for heart failure.

Heart Failure

Two large clinical trials of patients with type 2 diabetes have shown that inhibitors of SGLT2 substantially reduce the risk of cardiovascular death and hospitalization for heart failure for patients with reduced EF, with or without diabetes.

Dapagliflozin also reduced all-cause mortality and has been approved for treating heart failure with reduced EF. Empagliflozin is under FDA review.

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