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Heart failure represents a dynamic clinical challenge with the continuous rise of a multi‐morbid and ageing population. Yet, the evolving nature of mechanical circulatory support offers a variety of means to manage candidates who might benefit from such interventions. This narrative review focuses on the role of the main mechanical circulatory support devices, such as ventricular assist device, extracorporeal membrane oxygenation, Impella and TandemHeart, in the physiological process of ventricular unloading and remodelling in heart failure, highlighting their characteristics, mechanism and clinical outcomes. The outcome measures described include physiological changes (i.e., stroke volume or preload and afterload), intracardiac pressure (i.e., end‐diastolic pressure) and extracardiac pressure (i.e., pulmonary capillary wedge pressure). Overall, all the above mechanical circulatory support strategies can facilitate the unloading of the ventricular failure through different mechanisms, which subsequently affects the ventricular remodelling process. These physiological changes start immediately after ventricular assist device implantation. The devices are indicated in different but overlapping populations and operate in distinctive ways; yet, they have evidenced performance to a favourable standard to improve cardiac function in heart failure, although this proved variable for different devices, and further high‐quality trials are vital to assess their clinical outcomes further. Both Impella and TandemHeart are indicated mainly in cardiogenic shock and high‐risk percutaneous coronary intervention patients; at the time the literature was evaluated, both devices were found to yield a significant improvement in haemodynamics but not in survival. Nevertheless, the choice of device strategy should be based on individual patient factors, including indication, to optimize clinical outcomes. What is the topic of this review? This narrative review focuses on the role of the main mechanical circulatory support devices in the physiological process of ventricular unloading and remodelling in heart failure. What advances does it highlight? This narrative review presents a comprehensive overview of the main mechanical circulatory support devices in heart failure, highlighting their characteristics, mechanisms and clinical outcomes. These devices can facilitate the unloading of ventricular failure to varying extents and through different mechanisms, which subsequently affects the ventricular remodelling process. Nevertheless, the choice of device strategy should be based on individual patient factors, including indication, to optimize clinical outcomes.

This article provides a narrative review of the current literature and our expert opinion concerning the iliac branch endoprosthesis (IBE) and its use in the treatment of complex abdominal aortic aneurysm (AAA) cases with concomitant aneurysmal involvement of the common iliac artery (CIA) and/or the internal iliac artery (IIA). Up to 25% of those with an AAA may present with extension of the aneurysmal disease into the iliac vessels. This anatomy may complicate the standard endovascular aortic repair (EVAR) procedure, as the available length of distal landing zones is altered. The optimum treatment requires both the adequate sealing of the distal landing zone as well as the preservation of the pelvic circulation through the IIA. Extensive preoperative assessment of the anatomy, as well as an accurate deployment following all procedural steps, enables endovascular treatment of complex aorto‐iliac aneurysms safe with excellent midterm clinical outcomes. The current literature shows that the utilization of the IBE offers a durable treatment of these complicated cases with results equal to those of the open repair, without the associated morbidity. Preservation of the pelvic circulation is recommended to prevent pelvic ischaemic symptoms and can also be carried out on both sides provided certain anatomical requirements are met. What is the topic of this review? How iliac branch devices (IBD) can extend technical options for endovascular treatment of aortoiliac aneurysms and whether lifelong dual antiplatelet therapy (DAPT) is routinely required for increasing patency rates after implantation of IBD. What advances does it highlight? IBD are versatile devices that can safely be implanted also outside standard instructions‐for‐use such as in cases with hypogastric aneurysms. While lifelong DAPT may not be routinely advised following IBD implantation, its use is usually recommended in the first 3–6 months but may be extended in selected circumstances.

Fenestrated/branched endovascular aortic repair emerges as the primary therapeutic modality for intricate aortic pathologies encompassing the paravisceral and thoracoabdominal segments, where bridging stent grafts (BSGs) play a vital role in linking the primary aortic endograft with target vessels. Bridging stent grafts can be categorized mainly into self‐expanding stent grafts (SESGs) and balloon‐expandable stent grafts (BESGs). Physiological factors significantly influence post‐complex endovascular aortic repair BSG behaviour, impacting clinical outcomes of SESGs and BESGs in different but overlapping ways. Crucial prerequisites for BSGs encompass not only flexibility but also resilience against mechanical stress and compliance mismatch, especially when bridging the rigid aortic main body with dynamic target vessels. The significance of considering these physiological factors in clinical decision‐making is underscored by recognizing the interplay between SESG and BESG characteristics, vessel physiology and patient haemorheology. Such factors include the anatomy and tortuosity of the vessel, diameter of the vessel and BSG, deployment and durability, extrinsic stenosis and respiratory motion. Haemorheological factors, such as anti‐thrombotic therapy and hydration status, need to be considered. This narrative review examines both in vitro and in vivo evidence regarding the impact of physiological factors on the behaviour of BSGs and assesses the consequences for clinical outcomes following complex endovascular aortic repair. What is the topic of this review? The narrative review aims to examine both in vitro and in vivo evidence regarding the impact of physiological factors on the behaviour of bridging stent grafts (BSGs) and to assess the consequences for clinical outcomes following fenestrated/branched endovascular aortic repair (F/BEVAR). What advances does it highlight? Bridging stent grafts play a major role in F/BEVAR. Physiological factors significantly influence post‐F/BEVAR BSG behaviour, impacting clinical outcomes. The significance of considering these physiological factors in clinical decision‐making is underscored by recognizing the interplay between BSG characteristics, vessel physiology and patient haemorheology.

The extent to which patients with an abdominal aortic aneurysm (AAA) should exercise remains unclear, given theoretical concerns over the perceived risk of blood pressure‐induced rupture, which is often catastrophic. This is especially pertinent during cardiopulmonary exercise testing, when patients are required to perform incremental exercise to symptom‐limited exhaustion for the determination of cardiorespiratory fitness. This multimodal metric is being used increasingly as a complementary diagnostic tool to inform risk stratification and subsequent management of patients undergoing AAA surgery. In this review, we bring together a multidisciplinary group of physiologists, exercise scientists, anaesthetists, radiologists and surgeons to challenge the enduring ‘myth’ that AAA patients should be fearful of and avoid rigorous exercise. On the contrary, by appraising fundamental vascular mechanobiological forces associated with exercise, in conjunction with ‘methodological’ recommendations for risk mitigation specific to this patient population, we highlight that the benefits conferred by cardiopulmonary exercise testing and exercise training across the continuum of intensity far outweigh the short‐term risks posed by potential AAA rupture.

More recent interest has included assessment of physiological parameters including heart rate variability and measuring biological markers such as cortisol (both in blood and hair) (Arora et al., 2009). [...]from the very first day of clinical work “burnout“ stimulus may begin. [...]awareness of the underlying problem is critical and in the future it is likely to assume greater importance not least of which concerns the employer expectations in an environment of fewer hours and less employees.

Background Fingolimod (Gilenya®) is approved for relapsing forms of multiple sclerosis in the USA. Owing to transient heart-rate effects when initiating fingolimod, eligible patients undergo precautionary baseline assessment and first-dose observation (FDO) for ≥6 h. Prior to 2014, FDO was undertaken only in clinics. As the FDO period is short, and fingolimod has accumulated evidence of a positive benefit:risk ratio, an in-home treatment-initiation program, Gilenya@Home, was developed to offer a convenient alternative. Methods Cardiac parameters and adverse events (AEs) were recorded by healthcare professionals performing fingolimod FDOs in the US Gilenya@Home program or in US Gilenya Assessment Network clinics. Anonymized data were collated retrospectively from the first 34 months in the home setting and from 78 months in clinics; data are reported descriptively. Satisfaction with Gilenya@Home was rated by patients using a 7-item questionnaire that considered aspects such as ease of scheduling, courtesy, and competency. Results Data were captured as part of standard care from 5573 patients initiating fingolimod in-home (October 2014 to July 2017) and from 15,025 patients initiating in-clinic (July 2010 to December 2016). In the Gilenya@Home questionnaire, 91.7% of 1848 respondents rated their overall satisfaction as “very good,” and 7.6% rated their satisfaction as “good.” AEs were reported for 30.7 and 32.6% of in-home and in-clinic patients, respectively. In total, 557 in-home (10.0%) and 398 in-clinic (2.6%) patients were monitored for > 6 h; 15 (0.3%) in-home and 129 (0.9%) in-clinic patients were transferred to an emergency room for overnight monitoring. The mean (standard deviation) heart rate (HR; bpm) pre-FDO was 74.8 (12.2) in-home and 74.2 (11.3) in-clinic; reduction in HR at 6 h postdose was 10.6 (12.0) and 6.3 (9.6), respectively. New-onset first-degree atrioventricular block was experienced by 132 (2.4%) in-home and 74 (0.5%) in-clinic patients, and Wenckebach (Mobitz type I) second-degree atrioventricular block by four (0.07%) and nine (0.1%) patients, with no cases of third-degree atrioventricular block. Conclusions A substantial number of patients have initiated fingolimod at home, reporting very high levels of satisfaction. Gilenya@Home was as rigorous as the clinic setting in detecting cardiovascular events. Overall, FDO safety outcomes were similar with Gilenya@Home and in-clinic.

The aim of this study was to identify risk factors for abdominal aortic aneurysm (AAA) from the largest Welsh screening cohort to date. Patients were recruited from 1993 (to 2015) as part of the South East Wales AAA screening programme through general practitioners. Demographic data and risk factors were collected by means of a self‐report questionnaire. Statistical tests were performed to determine whether associations could be observed between AAA and potential risk factors. Odds ratios (OR) were also calculated for each of the risk factors identified. A total of 6879 patients were included in the study. Two hundred and seventy‐five patients (4.0%) presented with AAA, of which 16% were female and 84% were male. Patients with AAA were older than the (no AAA) control group ( p  < 0.0001). The following risk factors were identified for AAA: family history of AAA ( p  < 0.0001); history of vascular surgery ( p  < 0.0001), cerebrovascular accident ( p  < 0.0001), coronary heart disease ( p  < 0.0001), diabetes ( p  < 0.0001), medication ( p  = 0.0018), claudication ( p  < 0.0001), smoking history ( p  = 0.0001) and chronic obstructive pulmonary disorder ( p  = 0.0007). AAA is associated with classical vascular risk factors, in addition to other less‐well‐documented risk factors including previous vascular surgery. These findings have practical implications with the potential to improve future clinical screening of patients in order to reduce AAA mortality.

Following publication of the original article [1], the authors reported a mistake regarding the year found in the paragraph of the Background section.Following publication of the original article [1], the authors reported a mistake regarding the year found in the paragraph of the Background section.