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The aim of this report is to explore the direct and long-term outcome in a high risk patient who was treated with rotational atherectomy to assist the placement of drug eluting stents in heavily calcified lesions.

New persistent left bundle branch block (NP-LBBB) has been associated with adverse outcomes after TAVI but few predictors thus far reported. We sought to identify predictors of NP-LBBB after TAVI with EvolutR/PRO (ER/EP). From 1/2016 to 4/2019, 544 patients from 2 centers underwent TAVI with Evolut (54% ER, 46% EP) for severe native aortic stenosis. Patients with previous LBBB and pacemaker were excluded. Aortic root analysis was performed using 3Mensio Valves Software and membranous septal length (MSL) was determined using the standard coronal view. Clinical, anatomic and procedural characteristics of 396 Evolut were analyzed and predictors of NP-LBBB were identified. Valve Academic Research Consortium-2 outcomes were reported. At discharge, NP-LBBB was seen in 76(19.2%) patients. NP-LBBB in Evolut was associated with implant depth at left coronary cusp (p = 0.004) and 34 mm ER (p = 0.026). Independent predictors of NP-LBBB in Evolut were shorter MSL (odds ratio [OR] = 0.82 per mm septum, 95% confidence interval [CI] = 0.68 to 0.98,p = 0.030), left ventricular outflow tract (LVOT) eccentricity (OR = 1.04 per %, 95% CI = 1.01 to 1.06,p = 0.002), implant depth at noncoronary cusp (NCC) (OR = 1.28 per mm ventricular, 95% CI = 1.11 to 1.48,p = 0.001) and annular perimeter oversizing ≥20% (OR = 2.38, 95% CI = 1.20 to 4.72, p = 0.013). On ROC curve analysis, MSL ≤6.5 mm, NCC depth ≥3 mm and LVOT eccentricity ≥35% were optimal threshold values to predict NP-LBBB. In Conclusion, shorter MSL, LVOT eccentricity, annular oversizing and deeper implant depth are novel predictors of NP-LBBB in Evolut TAVI. Preprocedural CT assessment of aortic root anatomy may help identify patients at risk for NP-LBBB. In such patients, modifying procedural factors such as higher implant and less annular oversizing may reduce the risk of NP-LBBB. Further evaluation of our hypothesis is warranted.

Backgrounds/aims Pancreatic leak and fistula formation following pancreatic resection is a dreaded complication associated with significant morbidity and mortality. The perioperative use of inotropes has been implicated in anastomotic dehiscence in other types of gastrointestinal surgery but their impact in pancreatic surgery remains unclear and a potentially modifiable risk factor for pancreatic leak. This study aims to assess the impact of perioperative inotrope infusion on the incidence of pancreatic leak following pancreaticoduodenectomy. Methods Retrospective data analysis of all patients undergoing pancreaticoduodenectomy at a tertiary HPB institute. Multivariate analysis and regression models assessed the impact of inotrope use against other known risk factors such as pancreatic duct size and gland texture. Pancreatic fistulae were graded as per ISGPF as Grade A (biochemical leak), Grade B and Grade C fistula. Results One-hundred and twenty-three (123) patients were included. A total of 52 patients (42%) developed a leak (29 grade A, 15 grade B, and 8 Grade C). In the fistula group, 28 patients (55%) received perioperative inotropes compared to 26 (35%) in the no fistula group. On univariate analysis, patients receiving inotropes (p=0.04) and patients with a soft pancreatic texture (p=0.003) had a statistically higher incidence of developing a pancreatic fistula of any grade. On multivariate analysis, only inotrope use was associated with an increased risk of developing a pancreatic fistula of any grade (OR 2.46, p=0.026), independent of pancreatic texture and pancreatic duct size. Conclusions Perioperative inotrope use is associated with an increase incidence of pancreatic leak following pancreaticoduodenectomy and should therefore be used judiciously.

Sudoku is a very popular pass-time game that had gained a lot of popularity when it was published by The Times in London. We have used Java Server Faces (JSF) as a tool for Full-Stack development of the Sudoku as a web browser based game. By building this project we had gained a better understanding of the framework. In this work we present an algorithm for solving the Sudoku problem and a safe way of validating the results keeping scalability in mind.

Treatment of bifurcation lesions remains technically challenging for interventional cardiologists. Previous idealized in vitro bench models have shown that kissing balloon inflation (KBI) might result in a less circular stent shape, worse stent apposition and lower endothelial shear stress (ESS)

The anatomic interplay between aortic valve, ascending aorta, left ventricular outflow tract and peripheral vasculature play a major role in determining device related outcomes in transcatheter aortic valve replacement. Factors such as the alignment angle (prosthesis-ascending aorta), pre-dilatation, operating team experience and chronic kidney disease may play a role in valve displacement. Careful analysis of all imaging modalities while sizing and selecting a valve type, and attention to newer deployment techniques may improve outcomes.

Use of bioprosthetic implants for surgical aortic valve replacements (SAVR) has been increasing in the recent years Surgical redo AVRs for failed surgical aortic bioprostheses have been traditionally considered the standard practice; however, in patients with higher surgical risk scores, transcatheter valve-in-valve aortic valve replacements are being commonly performed There is scarcity of data comparing these two approaches in this complex patient cohort Available data suggest that transcatheter ViV aortic valve replacement is generally a safe approach once some caveats are accounted for.

New permanent pacemaker Implantation (PPI) after TAVR has been associated with impaired ventricular recovery and increased heart failure readmissions but few predictors have been reported. We sought to identify predictors of new PPI after TAVR with Sapien3 (S3). From 10/2015 to 4/2019, 613 patients

Anemia and thrombocytopenia are common in patients undergoing percutaneous coronary intervention (PCI) and often associated with a variety of comorbid conditions. We sought to evaluate their impact on periprocedural and long-term outcomes after PCI. Data from 14,993 PCI patients were prospectively

Drug-eluting stents (DES) remain the most widely used treatment for in-stent restenosis (ISR). In this analysis we sought to determine the proportion, characteristics, and outcomes of patients who do or do not receive DES for ISR. We included all patients undergoing percutaneous coronary

New permanent pacemaker implantation (PPI) after transcatheter aortic valve replacement (TAVR) has been associated with impaired ventricular recovery and increased heart failure readmissions, but few predictors have been reported. We sought to identify predictors of new-PPI after TAVR with EvolutR/

New persistent left bundle branch block (NP-LBBB) has been associated with adverse outcomes after transcatheter aortic valve replacement (TAVR), but few predictors have thus far been reported. We sought to identify predictors of NP-LBBB after TAVR with the Edwards Sapien3 (S3) valve. From October

Retroperitoneal hemorrhage (RPH) and other femoral artery access site complications are associated with "high" arterial punctures. Using the nadir of inferior epigastric artery (IEA) as the landmark for identifying the inguinal ligament and high punctures can reduce access site complications. Traditional teaching of aiming for the middle of the femoral head while obtaining femoral access can result in higher than desired puncture site more frequently than aiming for the lower quarter. Enhanced understanding of anatomical landmarks, use of imaging guidance and strict adherence to safe access practices can help improve outcomes.

Repeat surgery is the ideal choice for degenerated bioprosthetic mitral valves. Percutaneous valve-in-valve (ViV) replacement for the treatment of degenerated bioprostheses has emerged as an alternative to open surgery in patients who are at high risk of surgical complications. Joseph et al have described the feasibility and long-term outcomes of Melody ViV Implantation for bioprosthetic mitral valve dysfunction in high-risk population.

ObjectiveThe prevalence of heart failure (HF) among adult patients with congenital heart disease (ACHD) is rising. Right ventricle (RV) exercise reserve and its relationship to outcomes have not been characterised. We aim to evaluate the prognostic impact of impaired RV reserve in an ACHD population referred for cardiopulmonary exercise testing (CPET).MethodsThis retrospective study evaluates patients with ACHD who underwent CPET (n=147) with first-pass radionuclide ventriculography at a single tertiary care centre. RV reserve was categorised as normal, mild to moderately or severely impaired. The primary composite clinical outcome included clinical right HF, arrhythmia, transplantation or death.ResultsPatients were median age 41±13 years, 50% were female and median follow-up was 1.1 (IQR: 0.7–2.0) years. Exercise RV reserve was impaired in 103 patients (70%), of whom 32% were asymptomatic. Resting RV systolic function poorly predicted RV reserve, with 52% of patients with severe impairment having a qualitatively normal echocardiographic assessment. The severely impaired reserve group had lower peak oxygen consumption (VO2)(17.2 vs 22.5 mL/kg/min, p2, age, sex, RV pathology, QRS duration, New York Heart Association class, resting RV ejection fraction and RV dilation by echocardiography or MRI (HR 3.7, 95% CI 1.1 to 13.0, p=0.039).ConclusionImpaired RV reserve, occurred in asymptomatic patients, was not well predicted by resting systolic function assessment, and strongly predicted adverse cardiovascular outcomes.

ABSTRACT: Calcific aortic valve stenosis is common in the elderly. While history and examination can establish the diagnosis, determination of its severity typically requires echocardiography to define valve anatomy, measure stenosis severity and assess left ventricular response. The purpose of this review is to describe some of the commonly encountered challenges in the echocardiographic assessment of aortic stenosis. These include errors in the calculation of aortic valve area, assessment of aortic stenosis during atrial fibrillation, determining the presence of aortic stenosis in the setting of low transvalvular pressure gradients and discriminating other forms of obstruction to left ventricular ejection from aortic stenosis. Lastly, a review of how echocardiography is utilized to select patients for transcatheter aortic valve replacement is presented.

Several chronic total occlusions (CTOs) may be undilatable despite successful wire passage; several techniques can be used for lesion preparation, such as high-pressure balloon inflations, rotational atherectomy laser, cutting balloon, and scoring balloons. Presence of moderate to severe calcification and lesion length over 40 mm in association with comorbidities, such as diabetes mellitus and reduced ejection fraction, may contribute to making a CTO lesion undilatable. Still, appropriate therapy selection for a patient with CTO should be individualized and procedure safety attended to.

New persistent Left Bundle Branch Block(NP-LBBB) and permanent pacemaker(PPM) implantation after TAVR is not benign. We aim to identify predictors of NP-LBBB and new-PPM after Medtronic EvolutR(ER) TAVR. From 3/2014 to 12/2017, 294 patients from 3 centers with severe native aortic stenosis

Impact of transcatheter heart valve(THV) selection on prosthesis-patient mismatch(PPM) remains unknown. We aimed to compare incidence of moderate and severe PPM between Sapien3(S3) and EvolutR/Pro(ERP) in a theoretical model. From 10/2015 to 9/2018, standardized effective orifice area(EOA) of 1401

Expanding indication and use of Transcatheter aortic valve replacement (TAVR) poses a unique problem of coronary access after valve implantation. Even though, troubleshooting tools and techniques have been published but are not available at the fingertips of the user at all the times. We tried to

New Persistent Left Bundle Branch Block(NP-LBBB) and permanent pacemaker(PPM) implantation after TAVR is not benign. We aim to identify novel predictors of new-LBBB and NP-PPM after Edwards Sapien3(S3) TAVR From 3/2014 to 12/2017, 407 patients from 3 centers with severe native aortic stenosis

Transcatheter aortic valve replacement (TAVR) is expanding to younger patients, but the feasibility of TAVR in failing transcatheter aortic valves (TAV) remains unknown. We determine the feasibility of TAV-in-TAV after SAPIEN 3 (S3) TAVR. From October 2015 to April 2019 at 2 centers, 610 S3 TAVRs

Athletic heart syndrome refers to the physiological and morphological changes that occur in a human heart after repetitive strenuous physical exercise. Examples of exercise-induced changes in the heart include increases in heart cavity dimensions, augmentation of cardiac output, and increases in heart muscle mass. These cardiac adaptations vary based on the type of exercise performed and are often referred to as sport-specific cardiac remodeling. The hemodynamic effects of endurance and strength training exercise lead to these adaptations. Any abnormalities in chamber dilatation and left ventricular function usually normalize with cessation of exercise. Athletic heart syndrome is rare and should be differentiated from pathologic conditions such as hypertrophic cardiomyopathy, left ventricular noncompaction, and arrhythmogenic right ventricular dysplasia when assessing a patient for athletic heart syndrome. This paper describes specific adaptations that occur in athletic heart syndrome and tools to distinguish between healthy alterations versus underlying pathology.

The aorta is the major arterial conduit which transports blood from the heart to the systemic circulation. It originates immediately beyond the aortic valve and is divided into an ascending aorta (initial ascending part) followed by the aortic arch (middle curve) and descending aorta (terminal descending part). The descending part continues through the hiatus of the diaphragm to become the abdominal aorta. The normal aorta is small, with a mean diameter of 3.2 cm (ascending aorta at the level of the right pulmonary artery).

Left atrial pressure (LAP) and V-wave reduction are markers of successful transcatheter mitral repair but no simple method of continuous monitoring exists. We report our multicenter experience on continuous LAP monitoring during MitraClip repair. From 11/2016 to 8/2017, 74 prohibitive risk patients

Impact of transcatheter valve choice on prosthesis-patient mismatch (PPM) remains unknown. We compared moderate and severe PPM among Edwards Sapien (ES), Medtronic CoreValve (MC) and BostonScientific Lotus (BL) in a theoretical model. From 6/2014 to 9/2017, 471 patients had TAVR for severe native

Flash pulmonary edema is characteristically sudden in onset with rapid resolution once appropriate therapy has been instituted (Messerli et al., 2011). Acute increase of left ventricular (LV) end diastolic pressure is the usual cause of sudden decompensated cardiac failure in this patient population. Presence of bilateral renal artery stenosis or unilateral stenosis in combination with a single functional kidney in the susceptible cohort is usually blamed for this condition. We describe a patient who presented with flash pulmonary edema in the setting of normal coronary arteries. Our case is distinct as our patient developed flash pulmonary edema secondary to unilateral renal artery stenosis in the presence of bilateral functioning kidneys. Percutaneous stent implantation in the affected renal artery resulted in rapid resolution of pulmonary edema.

Stress echocardiography is deemed diagnostic with achievement of target heart rate (HR) (> 85% maximum predicted) or double product (DP) for exercise (ESE) and dobutamine (DSE). However both modalities affect the left ventricle (LV) differently. Exercise increases HR physiologically to increase