Women with a Fontan circulation have a high rate of miscarriage and, even if pregnancy progresses to a viable gestational age, a high rate of obstetric and neonatal complications.

Exercise electrocardiography has low sensitivity for detection of myocardial ischemia. However, when combined with cardiopulmonary exercise testing (CPEX), the sensitivity and specificity of ischemia detection improves significantly. CPEX offers unique advantages over imaging techniques in tricky situations such as balanced ischemia. Early abnormal oxygen uptake would point toward profound coronary stenosis that could be missed in perfusion imaging. CPEX could be an invaluable tool in asymptomatic left bundle branch block pattern, without exposing patients to the risks of computerized tomography or invasive coronary angiography. Normal oxygen uptake curves would rule out significant coronary stenosis as the cause of left bundle branch block pattern. Elseways, abnormal oxygen uptake in patients with normal coronary arteries could indicate microvascular angina. Furthermore, exercise capacity is an excellent predictor of cardiovascular risk in those with and without heart disease. Using two clinical cases we introduce the concept of gas-exchange and hemodynamic changes encountered in ischemic heart disease.

The direct examination of waste water is difficult due to low and fluctuating concentrations of microorganisms and because concentration procedures are usually organism and/or matrix specific and most techniques have high or unknown variability parameters. One-step skimmed milk flocculation (SMF) has been proposed as an efficient method to concentrate viruses in all types of environmental water matrices such as river water, seawater, groundwater and wastewater. The organic flocculation procedure is easy and fast to be carried out; it requires a simple laboratory infrastructure, thus eliminating costly equipment, in addition to the low cost of the inputs necessary to be performed. The aim of this study is to perform skimmed milk flocculation procedure in order to detect SARS-CoV-2 recovery from the waste water.

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Background: Long-term outcomes for women with Fontan repairs have improved, meaning more women will embark upon pregnancy. Counseling women remains challenging, as pregnancies are relatively uncommon. Recent reports suggest favourable maternal outcomes but poorer fetal and neonatal outcomes. Purpose: To evaluate fetal, neonatal and maternal outcome in women with Fontan physiology Methods: A retrospective multicentre study of pregnancy in women with a Fontan circulation between 2000-2016.All identified pregnancies were reviewed, including those resulting in miscarriage or termination, as well as live births. Results: 45 women had 112 pregnancies resulting in one termination, 63 miscarriages (54-1st trimester, 9 2nd trimester),49 livebirths and one intra-uterine death at 30 weeks gestation. Age at first pregnancy was 28 [range 21-34] years and gestation of delivery was 33 [range [25][26][27][28][29][30][31][32][33][34][35][36][37][38][39][40] weeks. 68% of babies were born before 37 weeks; two thirds of these as a result of medical intervention due to concerns regarding fetal wellbeing. Median birth weight centile (corrected for sex and birth order) was nine. Women with ventricular impairment had babies with lower birth weight (p=0.045, two sided t test). Maternal saturations and booking haemoglobin were not associated with birthweight, however all 8 women (100%) with baseline oxygen saturations <85% miscarried, compared with 49 of 105 (47%) with baseline saturations at or above 85% (p=0.006 Fisher's exact test). There were three neonatal deaths (all preterm). There were no cases of fetal congenital heart disease. Blood loss was lowest with spontaneous vaginal birth (median 400ml, 30% Post Partum Hemorrhage (PPH)) and elective caesarean section (CS) (median 600ml, PPH 20%) followed by emergency CS (median 775ml, PPH 28%) and assisted delivery (median 900ml, PPH 82%) (PPH defined as ≥500ml vaginal delivery and ≥1000ml caesarean section (p=0.01, Pearson Chi square). On linear regression including maternal age, height, weight, smoking, NYHA class, mode of delivery and use of aspirin and low molecular weight heparin, the only significant additional correlation with estimated blood loss was prior use of warfarin (p=0.035). Maternal morbidity was low; 7 women required diuretics during pregnancy for symptoms of heart failure, 6 had episodes of arrhythmia (4 atrial arrhythmia, 2 episodes SVT (one patient both pregnancies) and one woman suffered a post natal venous thromboembolism (poor compliance LMWH). There was no maternal mortality. Median follow up was 4.5 years (range 6 months-11 years) years; no women had increased NHYA class at follow up review. Conclusions: Rates of fetal and neonatal complications are high in Fontan pregnancies and this is substantiated by our findings. Maternal health is well maintained during and early after pregnancy when women are managed in specialist obstetric cardiac services. It is unknown whether pregnancy accelerates failure of Fontan physiology over longer term. Background/Introduction...