Testing for myocardial ischemia is the single-most relevant one for diagnosis and appropriate management of coronary artery disease (CAD). The clinical challenge for a physician diagnosing and taking care of the patients is which tests should be necessary for whom. The diagnostic work-up of suspected CAD includes choosing the most appropriate modality for the individual patient to achieve a conclusive and clinical helpful diagnosis and to minimize use of personal and financial resources. In addition, myocardial ischemia testing has to be the most important tool for deciding whether or not to revascularize. Therefore, this review outlines the current clinical work-up including the appropriate selection of ischemia testing in the diagnosis of suspected obstructive CAD, as well as when making a decision of revascularization therapy.

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Cardiogenic shock (CS) complicates acute myocardial infarction (AMI) with an incidence from 5% to 10%, and is a main cause of death in patients with acute cardiovascular disease including AMI. Short-term mortality associated with CS may approach nearly 30% to 45% in the contemporary era. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) may represent the final option for severe CS that is refractory to medical therapy. Peripheral VA-ECMO can be initiated percutaneously and promptly via femoral artery and femoral vein access, and is widely used for CS and CA in emergency situations. In this review, we describe the role and efficacy of peripheral VA-ECMO in treating CS and CA.

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Ischemic mitral regurgitation (MR) is defined as functional MR caused by myocardial ischemia. Apical and posterior displacement of papillary muscles , referred to as tethering, positively correlates with maximal regurgitation area. Surgical intervention for patients with moderately ischemic MR at the time of coronary artery bypass (CABG) remains controversial. However, patients with uncorrected mild or moderate MR who undergo CABG are at increased risk of death and hospitalization. Restrictive MV annuloplasty and coronary artery bypass surgery has become accepted as the standard technique for severe functional MR. However, even after downsizing simple annuloplasty by two sizes, MR persists or recurs in >20% of patient. Furthermore, recurrent and progressive MR after MV plasty is associated with high mortality rates. Predictors for recurrent mitral regurgitation are flexible ring usage, left ventricle diameter, continuous LV remodeling, sphericity index at end-systole and end-diastole, and preoperative posterior leaflet angle >45°. Second chordal cutting, papillary muscle approximation and so on are recommended as additional procedures. Whether to replace or repair severe chronic ischemic MV regurgitation has remained controversial. Replacement results in long-term secure MV sufficiency, whereas mitral repair still confers some risk of MR recurrence. Percutaneous MV repair using the MitraClip procedure can offer clinical improvement even in patients with high surgical risk and severe functional MR. The long-term outcomes of the this procedure should be determined. Ischemic MR remains a significant complication of myocardial infarction, and deeper understanding of the mechanism of ischemic MR has led to continuous improvements in surgical treatment. Complex mechanisms involving the mitral annulus, chordae tendinea, papillary muscle, and LV are involved, and optimal surgical repair should consider the overall pathology of each patient.

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When ventricular septal rupture (VSR) occurs following acute myocardial infarction, the mortality is still high. To save the patient, prompt diagnosis, proper management and satisfactory surgical closure are mandatory. This discussion of VSR management describes information of epidemiology, pathogenesis, diagnosis, management, and repair procedures of the septal rupture with a surgeon's point of view. Although definitive surgery remains the treatment of choice, it remains a challenging operation carrying high early mortality. Percutaneous closure may provide option for patients whose conditions preclude surgical repair, and may be useful to close residual shunt. Prompt diagnosis of VSR with referral to experienced heart team is important for the improvement of the clinical outcomes.

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