Sean M. Conte

Background: Protein-losing enteropathy (PLE) is seen in up to 15% of patients with Fontan circulation and has important nutritional, immunologic, and haemodynamic consequences especially in the context of advanced heart failure. Midodrine, an alpha-1-receptor agonist, increases lymphatic tone, mitigating leak of lymph into the bowel, and has been shown to have clinical and biochemical benefit in patients with Fontan failure. Case summary: A young woman with Fontan circulation, end-stage heart failure, and PLE developed progressive hypoalbuminaemia, deconditioning, and frailty prohibitive to transplantation candidacy. Three months after commencing oral midodrine therapy, she experienced normalization of her serum albumin and improvements in her oedema, exercise tolerance, and frailty enabling candidacy and eventual successful heart transplantation. Discussion: The development of PLE in patients with Fontan circulations is an indication for cardiac transplantation, but there are often significant barriers due to the many complications. We performed a comprehensive Medline search, and this is the first case demonstrating the use of midodrine to bridge a frail patient with PLE and advanced Fontan heart failure to heart transplantation candidacy and eventual transplant.

A best evidence topic was written addressing the question ‘in patients with saphenous vein graft lesions requiring percutaneous coronary intervention, do long‐term clinical outcomes differ between drug‐eluting and bare‐metal stents?’ Altogether 1466 papers were found, of which seven represented the best evidence. Although one major recent randomised trial was neutral, the weight of earlier evidence supports drug‐eluting stents as standard of care. Bare‐metal stents may represent a reasonable, efficacious, and less expensive alternative to drug‐eluting stents in well selected patient groups.

A best evidence topic in cardiac surgery was written according to a structured protocol addressing the question ‘for post‐cardiac surgery atrial fibrillation (AF), do clinical outcomes differ between rate or rhythm control strategies?’ Altogether, 2174 papers were found using the reported searches, of which 5 represented the best evidence to answer the clinical question. Hospital length of stay ranged from 5.0 to 13.2 days for rate control and 5.2 to 10.3 days for rhythm control. Freedom from AF at follow up was achieved in 84.2–91 and 84.2–96% in rate and rhythm control groups respectively. Minimal serious adverse events were noted in all studies analysed and there was no difference between rate and rhythm control groups. We conclude that in the management of post‐cardiac surgery, AF, rate control and rhythm control are equivalent in terms of hospital length of stay, freedom from arrhythmia at follow up and complication rates.