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Right ventricular dysfunction presents unique challenges in patients with cardiopulmonary disease. When optimal medical therapy fails, mechanical circulatory support is considered. Devices can by classified according to whether they are deployed percutaneously or surgically, whether the pump is axial or centrifugal, whether the right ventricle is bypassed directly or indirectly, and whether the support is short term or long term. Each device has advantages and disadvantages. Acute mechanical circulatory support is a suitable temporizing strategy in advanced heart failure. Future research in right ventricular mechanical circulatory support will optimize device management, refine patient selection, and ultimately improve clinical outcomes.Mechanical circulatory support devices are increasingly used for the treatment of acute myocardial infarction complicated by cardiogenic shock. These devices provide different levels of univentricular and biventricular support, have different mechanisms of actions, and provide different physiologic effects. Institutions require expert teams to safely implant and manage these devices. This article reviews the mechanism of action, physiologic effects, and data as they relate to the utilization of these devices.Recent advances in the field of interventional cardiology have allowed for more complex procedures to be performed percutaneously. Ability to obtain safe large bore vascular access is frequently the key factor to procedural success. Meticulous technique for successful vascular access incorporates the understanding of anatomic landmarks, ultrasound, fluoroscopy, and micropuncture. Adequate hemostasis at the end of the case can be achieved through careful use of commercially available vascular closure devices. Although access-related vascular complications are uncommon, early recognition is key to successful management. Arterial tortuosity and calcification can present a significant challenge to successful common femoral artery access.Mechanical circulatory support is used widely in acute setting of myocardial infarction, myocarditis, and cardiogenic shock as well as in chronic scenarios with advanced end-stage heart failure. Different algorithmic approaches can help the clinician decide the type of support required in a high morbidity and mortality setting. It is paramount to emphasize the need for a multidisciplinary approach to make steadfast decisions in the acute settings of cardiogenic shock.This article offers an overview of os trigonum syndrome, complications, operative techniques, and the authors' preferred protocol. Os trigonum is an ossicle like many other ossicles in the foot and ankle. Individuals who require repetitive plantarflexion of the ankle for activity may develop symptoms of an enlarged os trigonum. Usually, symptoms will be isolated to the posteriolateral aspect of the ankle. selleck chemicals llc Because of the normal anatomic route of the flexor hallucis longus tendon, its range of motion may also elicit pain to the posterolateral ankle. Conservative, as well as surgical including both endoscopic and open excision, has been described.Achilles tendon ruptures are a common ailment and often missed in upwards of 25% of cases. Neglected Achilles injuries can be treated both conservatively and surgically. Physical therapy, bracing, and custom ankle-foot orthoses are some options to consider. Surgically, there are many options, depending on the quality of the existing tendon, size of the defect, and the surgeon's comfort with the technique. Those procedures include primary repair, V-Y tendon advancement, turndown flap, tendon transfers, and other allografts. These techniques have been shown to have good to excellent outcomes and typically return patients to activities without complaints.Plantar fasciitis has been considered an acute inflammatory disorder. However, the local histologic findings represent a more chronic, degenerative state without inflammation. Patients may be stuck in a chronic state of cyclical inflammation leading to tissue degeneration, refractory symptoms, and disability. This idea process has influenced the treatment approach of some practitioners who have implemented the idea of regenerative medicine and use of biologic adjuvants in the treatment of plantar heel pain. Biologic therapies provide many different cellular components, growth factors, and proteins to restore normal tissue biology and are a useful adjunct in the treatment of recalcitrant plantar fasciitis.The treatment of Achilles tendinitis from conservative to minimally invasive to surgery gives patients a wide range of treatment options for this common pathology. The use and role of biologics to augment this treatment is emerging. The use of biologics may enhance the healing potential of the Achilles tendon when conservative treatment fails. There are a handful of biologics being investigated to obtain if improved outcomes can be maximized.Bone tumors of the foot are an uncommon finding. Most tumors are found incidentally on imaging and are benign. Care must be taken although due to the aggressive nature of malignant bone tumors that can occur in the calcaneus. Malignant lesions will more commonly present with symptoms of pain and swelling. Often misdiagnosed as soft tissue injuries, it is critical to be able to diagnose and treat these lesions early. Imaging plays an important role with plain films and advanced imaging. Surgical treatments can range from curettage with grafting to amputation for more aggressive lesions.There is an ever-evolving debate about the best treatment option for Achilles tendon ruptures. There was a relative consensus that operative treatment yielded the best outcomes. Much of this is based on results in athletic populations. Conservative treatment was considered only for the elderly and those with very inactive lifestyles. There has been an evolution, however, with more surgeons utilizing an aggressive functional rehabilitation with conservative management. Surgical intervention still is the treatment of choice for elite-level athletes. The treatment of choice for patient populations other than elite athletes remains an individual choice between patient and physician.
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