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Background Rotational atherectomy (RA) during PCI is linked to a higher likelihood coronary perforations (CP). However, the evidence base on incidence, predictors and outcomes of this complication in RA-PCI remains limited. Methods Using the British Cardiac Intervention Society database, data were analysed on all RA-PCI procedures in UK 2007–2014. Descriptive statistics and multivariate logistic regressions were used to examine baseline, procedural and outcome associations. Results During 10,980 RA-PCI procedures, 167 CPs were recorded (1.52%) with a stable annual incidence. Baseline and procedural covariates associated with higher rates of RA perforation were number of stents used, female gender, smoking, and left-main stenosis. CP was significantly associated with shock, DC cardioversion, heart block, transfusion, emergency surgery, periprocedural MI, in-hospital major bleed, acute kidney injury, dissection, side branch loss and in-hospital death. CP was also associated with higher rates of in-hospital MACCE (OR 12.22, 95% CI 7.67–19.47), 30-day mortality (OR 10.02, 95% CI 5.87–17.09) and 12-month mortality (OR 3.90, 95% CI 2.53–6.02). Conclusions CP is more frequent in RA-PCI than all-comer PCI and is associated with a significant burden of morbidity and mortality. There are a limited number of baseline and procedural co-variates associated with CP in RA-PCI, making it difficult to predict.

Background\ud \ud Percutaneous coronary intervention (PCI) is increasingly utilized for treatment of coronary disease involving the unprotected left main stem (ULMS). However, no studies to date have examined the outcomes of such interventions when complicated by coronary perforation (CP).\ud Methods\ud \ud Using the British Cardiovascular Intervention society (BCIS) database, data were analyzed on all ULMS‐PCI procedures complicated by CP in England and Wales between 2007 and 2014. Multivariate logistic regressions were used to identify predictors of ULMS CP and to evaluate the association between this complication and outcomes.\ud Results\ud \ud During 10,373 ULMS‐PCI procedures, CP occurred more frequently than in non‐ULMS‐PCI (0.9 vs. 0.4%, p

ObjectivesCongestion can worsen outcomes after transcatheter aortic valve implantation (TAVI), but can be difficult to quantify non-invasively. We hypothesised that preprocedural plasma volume status (PVS), estimated using a validated formula that enumerates percentage change from ideal PV, would provide prognostic utility post-TAVI.MethodsThis retrospective cohort study identified patients who underwent TAVI (2007–2017) from a prospectively collected database. Actual ([1-haematocrit] × [a + (b × weight (Kg))] and ideal (c × weight (Kg)) PV were quantified from equations where a, b and c are sex-dependent constants. Calculated PVS was then derived (100% x [(actual – ideal PV)/ideal PV]).ResultsIn 564 patients (mean age 82±7 years, 49% male), mean PVS was −2.7±10.2%, with PV expansion (PVS >0%) evident in 39%. Only logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) independently predicted a PVS >0% (OR 1.85, p=0.002). On Cox analyses, a PVS >0% was associated with greater mortality at 3 (HR 2.29, 95% CI 1.11 to 4.74, p=0.03) and 12 months (HR 2.00, 95% CI 1.23 to 3.26, p=0.006) after TAVI, independently of, and incremental to, the EuroSCORE and New York Heart Association class. A PVS >0% was also independently associated with more days in intensive care (coefficient: 0.41, 95% CI 0.04 to 0.78, p=0.03) and in hospital (coefficient: 1.95, 95% CI 0.48 to 3.41, p=0.009).ConclusionHigher PVS values, calculated simply from weight and haematocrit, are associated with greater mortality and longer hospitalisation post-TAVI. PVS could help refine risk stratification and further investigations into the utility of PVS-guided management in TAVI patients is warranted.

Introduction Excimer laser coronary atherectomy (ELCA) is a recognized adjunctive therapy utilized in the percutaneous management of complex coronary lesions. Studies examining its safety and utility have been limited by small sample sizes. Our study examines the determinants and outcomes of ELCA. Methods Using the British Cardiac Intervention Society database, data were analyzed on all PCI procedures in the UK between 2006-2016. Descriptive statistics and multivariate logistic regressions were used to examine baseline, procedural and outcome associations with ELCA. Results We identified 1,471 (0.21%) ELCA cases out of 686,358 PCI procedures. Baseline covariates associated with ELCA use were age, BMI, number of lesions, CTO or restenosis attempted and history of prior MI, CABG or PCI. Procedural co-variates associated with ELCA were the use of glycoprotein inhibitors, intravascular imaging, rotational atherectomy, cutting balloons, microcatheters and intra-aortic balloon pumps. Adjusted rates of in-hospital major adverse cardiac/cerebrovascular events (MACCE) or its individual components (death, peri-procedural MI, stroke and major bleed) were not significantly altered by the use of ELCA. However, there were higher odds of dissection (OR 1.52, 95% CI 1.17-1.98), perforation (OR 2.18, 95% CI 1.44-3.30), slow flow (OR: 1.67, 95% CI 1.18-2.36), reintervention (OR: 2.12, 95% CI 1.14-3.93) and arterial complications (OR: 1.63, 95% CI 1.21-2.21). Conclusions ELCA use during complex PCI is associated with higher risk baseline and procedural characteristics. Although increased rates of acute procedural complications were observed, ELCA does not increase likelihood of in-hospital MACCE or its individual components.

Introduction Due to the demographics of our patient population our institution has a high incidence of very elderly (>85 years) patients with severe symptomatic aortic stenosis. We examined the outcomes of these patients following trans-catheter aortic valve implantation (TAVI), surgical aortic valve replacement (SAVR) or medical therapy. Methods We included all patients >85 years of age with symptomatic severe aortic stenosis referred to our tertiary centre for consideration of aortic valve intervention between 2009 and 2016. Following assessment by the TAVI team (2 cardiologists and 2 cardiac surgeons) patients underwent SAVR or TAVI. Patients deemed unsuitable or refusing intervention had medical therapy. Data was obtained from electronic databases and clinical case notes. Results 309 patients were included (86 TAVI, 133 SAVR and 90 medical). Comparing patients undergoing TAVI and SAVR, TAVI patients were older (mean age 89.4 years vs. 86.9, p All TAVI patients had surgical access (86% trans-femoral, 8% trans-apical, 6% direct aortic), an Edwards (XT or Sapien 3) valve and general anaesthetic in 69% of cases. There were no intraoperative deaths but 3 conversions to sternotomy for bleeding. 68% of the surgical patients underwent isolated AVR and 32% AVR+CABG with 1 surgical intraoperative death. Medically managed patients had poor outcomes with a mortality of 49% at 1 year and 77% at 3 years. Survival of patients with either intervention was better, with no significant difference in 30-day mortality of SAVR and TAVI (5.3% vs 2.3%, p=049) or 3-year mortality (33% vs. 36%, p=0.66) respectively (figure 1). Compared with TAVI, SAVR patients spent significantly more days on ITU/HDU (8.31±12 vs. 0.96 ±1.7, p Conclusion The prognosis of patients >85 years of age with symptomatic severe aortic stenosis without intervention is poor. Aortic valve intervention in very elderly patients has acceptable mortality out to 3 years. In our early experience, using surgical access and high rates of general anaesthesia, TAVI in this group had similar mortality to SAVR but with significant reductions in both ITU and overall hospital stay. Conflict of Interest none

Background The durability of TAVR prostheses has come under major scrutiny since the move towards lower risk patients. We sought to compare the rate of structural valve deterioration (SVD) over time between transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR). Methods We included all TAVR and SAVR patients (age ≥ 75 years) that were performed in our centre from 2005 until 2015. Applying the internationally “agreed on” definitions of SVD, we surveyed all available serial echocardiographic follow-ups. Results We included 269 TAVR and 174 SAVR cases. Post-intervention, TAVR patients had lower mean and peak gradients but higher rate of mild aortic regurgitation. SAVR patients had longer follow-up (in months, SAVR: 53 (30, 85) Vs TAVR: 33.4 (23, 52)). SVD as per Valve Academic Research Consortium-2 (VARC-2) was similar between the two groups (TAVR 28% Vs SAVR 31%; P = 0.593) but moderate haemodynamic SVD (European Association of Percutaneous Cardiovascular Intervention (EAPCI) criteria) was more common among SAVR cases (TAVR 11.5% Vs SAVR 20.7%; P = 0.007). Using Kaplan-Meier estimates, the rate of SVD over time was not different between the two groups as per VARC-2 criteria but different when moderate haemodynamic SVD criteria were applied (Log Rank P = 0.022) in favour of TAVR. The mean gradient rose steadily over time but more so post-SAVR (β = 0.52 ± 0.24 in comparison to TAVR at every given time point; P = 0.032). Conclusion Structural valve deterioration is common on long-term follow-up post-TAVR. The rate is similar to post-SAVR cases according to VARC-2 criteria but less according to the moderate haemodynamic SVD criteria.

Background: The mitral valve orifice area (MVOA) is difficult to assess accurately by 2D echocardiography because of geometric assumptions; therefore, 3D planimetry may offer advantages. We studied the differences in MVOA measurements between the most frequently used methods, to determine if 3D planimetry would result in the re-grading of severity in any cases, and whether it was a more accurate predictor of clinical outcomes. Methods: This was a head-to-head comparison of the three most commonly used techniques to grade mitral stenosis (MS) by orifice area and to assess their impact on clinical outcomes. 2D measurements (pressure half-time (PHT), planimetry) and 3D planimetry were performed retrospectively on patients with at least mild MS. The clinical primary endpoint was defined as a composite of MV balloon valvotomy, mitral valve repair or replacement (MVR) and/or acute heart failure (HF) admissions. Results: Forty-one consecutive patients were included; the majority were female (35; 85.4%), average age 55 (17) years. Mean and peak MV gradients were 9.4 (4) mmHg and 19 (6) mmHg, respectively. 2D and 3D measures of MVOA differed significantly; mean 2D planimetry MVOA was 1.28 (0.40) cm2, mean 3D planimetry MVOA 1.15 (0.29) cm2 (P = 0.003). Mean PHT MVOA was 1.43 (0.44) cm2 (P = 0.046 and P < 0.001 in comparison to 2D and 3D planimetry methods, respectively). 3D planimetry reclassified 7 (17%) patients from mild-tomoderate MS, and 1 (2.4%) from moderate to severe. Overall, differences between the two methods were significant (X 2, P < 0.001). Only cases graded as severe by 3D predicted the primary outcome measure compared with mild or moderate cases (odds ratio 5.7). Conclusion: 3D planimetry in MS returns significantly smaller measurements, which in some cases results in the reclassification of severity. Routine use of 3D may significantly influence the management of MS, with a degree of prediction of clinical outcomes.

We report the first-in-man implantation of the Mitra-Spacer. The device was implanted transapically. FMR was reduced to moderate. At two months, while in NYHA Class II, LVEF had improved, but FMR increased and 2 mL was added, reducing FMR to mild. Despite anticoagulation, thrombi developed around the device and the valve was replaced at eight months. The Mitra-Spacer successfully bridged this patient to surgery after LVEF had recovered.

Bone marrow mesenchymal stromal cells (MSCs) have shown therapeutic potential in the treatment of myocardial infarction patients. However, bone marrow requires invasive harvesting techniques. Therefore, the aim was to carry out a feasibility study of using autologous peripheral blood (PB) as a source for MSCs and platelet lysate (PL), a potential novel therapeutic intervention in acute ST elevation myocardial infarction (STEMI) patients. Autologous PL and MSCs were prepared from STEMI patient and healthy control blood. MSCs were analyzed by trilineage differentiation and flow cytometry. PB MSCs were isolated from 83% of patients (n = 6) but not from controls. The use of PL was feasible in the first passage but not in subsequent ones due to volume. To conclude, PB is a promising alternative to bone marrow. It negates the need for invasive harvesting techniques, and reduces hemorrhagic risk in this patient population routinely managed with anticoagulant and antiplatelet agents.

Angiodyplasia and aortic stenosis are both conditions that are highly prevalent in elderly people and can often co-exist. Recent studies suggest that this association is related to subtle alterations in plasma coagulation factors. The von Willebrand factor is the strongest link between aortic stenosis and bleeding associated with gastrointestinal angiodysplasia. With an ageing population, the disease burden of aortic stenosis and its association with angiodysplasia of the bowel makes this an incredibly underdiagnosed yet important condition. Clinicians should be aware of this association when dealing with elderly patients presenting either with unexplained anemia, gastrointestinal bleeding or with aortic stenosis. A high index of suspicion and appropriate diagnostic techniques followed by appropriate and prompt treatment could be life-saving. No clear guidelines exist on management but surgical aortic valve replacement is thought to offer the best hope for long-term resolution of bleeding. With a growing number of technological armamentarium in the management of such patients, especially with the advent of transcatheter aortic valve implantation, new options can be offered even to elderly patients with comorbidities for whom conventional surgery would have been impossible.

Background Very little is known about long-termvalvedurability aftertranscatheter aortic valve replacement(TAVR). Objectives This study sought to evaluate the incidence of structural valvedegeneration(SVD) 5 to 10 years post-procedure. Methods Demographic, procedural, and in-hospital outcome data on patients who underwent TAVR from 2007 to 2011 were obtained from the U.K.TAVI(United Kingdom Transcatheter Aortic Valve Implantation) registry. Patients in whom echocardiographic data were available both at baseline and≥5 years post-TAVR were included.HemodynamicSVD was determined according to European task force committeeguidelines. Results A total of 241 patients (79.3 ± 7.5 years ofage; 46% female) with paired post-procedure and late echocardiographicfollow-up(median 5.8 years, range 5 to 10 years) were included. A total of 149 patients (64%) were treated with a self-expandable valve and 80 (34.7%) with a balloon-expandable valve. Peakaortic valvegradientatfollow-upwas lower than post-procedure (17.1 vs. 19.1mmHg; p=0.002). More patients had none/trivialaortic regurgitation(AR) (47.5% vs. 33%), and fewer had mild AR (42.5% vs. 57%) at follow-up (p=0.02). There was 1 case (0.4%) of severe SVD 5.3 years afterimplantation(new severe AR). There were 21 cases (8.7%) of moderate SVD (mean 6.1 years post-implantation; range 4.9 to 8.6 years). Twelve of these (57%) were due to new AR and 9 (43%) torestenosis. Conclusions Long-term transcatheter aortic valve function is excellent. In the authors’ study, 91% of patients remained free of SVD between 5 and 10 years post-implantation. The incidence of severe SVD was&nbsp

Aim: To evaluate the safety profile during a 3-year transition from default transfemoral access to default transradial access (TRA) for percutaneous coronary interventions in a tertiary cardiac center. Methods: Data were collected from electronic databases on all percutaneous coronary interventions from 2007 to 2009. Results: Two thousand eight hundred and forty-five procedures were recorded. TRA increased from 36 to 58% of procedures over the study period. Postprocedure blood transfusion requirements, incidence of hematoma and hospital length of stay were less among TRA cases. Fluoroscopy time, procedure time and mortality were similar in both groups. Access site crossover was higher among TRA cases but not prohibitive. Conclusion: Transitioning from a default transfemoral access to TRA unit was not associated with an adverse clinical or safety profile.

ObjectivePerforming transfemoral transcatheter aortic valve implantation (TAVI) without general anaesthesia (GA) has been increasingly adopted. We sought to study the impact of GA and non-GA approaches on procedural outcome and 30-day and 1-year mortality in transfemoral TAVI.MethodsThe UK TAVI registry holds information for every TAVI procedure in the UK. We analysed the data for patients implanted during 2013–2014 using either an Edwards Sapien or a Medtronic CoreValve prosthesis. Propensity score-matching analysis was performed to adjust for confounding factors.Results2243 patients were studied (aged 81.4±7.5 years, 1195 males). 1816 (81%) underwent TAVI with GA and 427 (19%) without GA. Transoesophageal echocardiography (TOE) was used in 92.3% of GA and 12.4% of non-GA cases (pConclusionProcedure outcome, and 30-day and 1-year mortality are not influenced by mode of anaesthesia. However, GA is associated with longer procedure duration and greater length of stay.

Background: As transcatheter aortic valve implantation (TAVI) becomes more straightforward, a larger proportion of patients will be well enough to be discharged early. This study sought to charac­terise the clinical features that allowed patients to be discharged early after TAVI and to evaluate the safety of an early discharge policy. Methods: All patients undergoing TAVI at the above cited center from August 2007 to March 2015 were included in this study. Baseline characteristics, in-hospital outcomes, re-admissions and mortality were compared. Results: Three hundred thirty-seven TAVIs were performed during the study period, and 18 died in-hospital (18/337, 5.3%). Of the remaining patients, 56 were discharged within 3 days of the index procedure (‘early discharge group’ 56/319, 17.5%). There was no difference between the early discharge and late discharge group in terms of Valve Academic Research Consortium-2 (VARC-2) criteria out­comes, all-cause re-admission rates and the need for permanent pacemaker implantation. Mortality at 1 year was better among the early discharge group (3.6% vs. 15.6%, p = 0.014); a reflection of baseline clinical differences. Conclusion: Early discharge of clinically selected TAVI patients is safe and appropriate . Lower logistic EuroSCORE, smaller delta creatinine and not developing any complications are factors associated with early discharge. (Cardiol J 2018; 25, 1: 14–23)

With increasing life expectancy, the epidemic of valvular heart disease, especially aortic stenosis (AS), is becoming more prevalent. Transcatheter aortic valve implantation (TAVI) has emerged as an alternative therapy for patients with significant aortic valve disease. It offers a less invasive procedure in comparison to surgical aortic valve replacement (sAVR) and an attractive substitute from the patient’s perspective. The evidence for TAVI in inoperable and high risk surgical patients is now established and in the intermediate risk group has been accumulating rapidly and is looking favourable for TAVI. However, the full ‘TAVI story’ is still unfolding. Technological advances in devices and delivery systems are evolving with the aim to improve the function and durability of TAVI and to simplify the procedure while enhancing safety. The incidence of vascular injury and pacemaker requirement post TAVI remains an issue and further development in this regard is therefore of utmost importance, particularly as lower risk and potentially younger patients are treated. Moreover, the evidence concerning long-term durability of the TAVI prostheses continues to accumulate. Whilst TAVI is proving to be an invaluable tool for inoperable and high risk patients, more trial evidence is needed before it encompases lower risk populations and moreover, its use as a first line treatment worldwide in most healthcare systems is limited by the costs associated with the prosthesis.

Bone marrow mesenchymal stromal cells (MSCs) have shown therapeutic potential in the treatment of myocardial infarction patients. However, bone marrow requires invasive harvesting techniques. Therefore, the aim was to carry out a feasibility study of using autologous peripheral blood (PB) as a source for MSCs and platelet lysate (PL), a potential novel therapeutic intervention in acute ST elevation myocardial infarction (STEMI) patients. Autologous PL and MSCs were prepared from STEMI patient and healthy control blood. MSCs were analyzed by trilineage differentiation and flow cytometry. PB MSCs were isolated from 83% of patients (n = 6) but not from controls. The use of PL was feasible in the first passage but not in subsequent ones due to volume. To conclude, PB is a promising alternative to bone marrow. It negates the need for invasive harvesting techniques, and reduces hemorrhagic risk in this patient population routinely managed with anticoagulant and antiplatelet agents.

Little is known about the long-term durability of trans-catheter aortic heart valves, particularly beyond 5 years. In the UK 100% of cases are recorded on the UK TAVI database, and annual follow-up trans-thoracic echocardiography (TTE) is recommended. Data on all patients undergoing TAVI in the UK

Objectives: Determine the real-world difference\ud between 2 groups of patients with severe aortic\ud stenosis and similar baseline comorbidities: surgical\ud turn down (STD) patients, who were managed\ud medically prior to the availability of transcatheter aortic\ud valve implantation (TAVI) following formal surgical\ud outpatient assessment, and patients managed with a\ud TAVI implant.\ud Design: Retrospective cohort study from real-world\ud data.\ud Setting: Electronic patient letters were searched for\ud patients with a diagnosis of severe aortic stenosis and\ud a formal outpatient STD prior to the availability of TAVI\ud (1999–2009). The second group comprised the first 90\ud cases of TAVI in South Wales (2009 onwards). 2 years\ud prior to and 5 years following TAVI/STD were assessed.\ud Patient data were pseudoanonymised, using the Secure\ud Anonymized Information Linkage (SAIL) databank, and\ud extracted from Office National Statistics (ONS), PatientEpisode\ud Database for Wales (PEDW) and general\ud practitioner databases.\ud Population: 90 patients who had undergone TAVI in\ud South Wales, and 65 STD patients who were medically\ud managed.\ud Main outcome measures: Survival, hospital\ud admission frequency and length of stay, primary care\ud visits, and cost-effectiveness.\ud Results: TAVI patients were significantly older (81.8 vs\ud 79.2), more likely to be male (59.1% vs 49.3%),\ud baseline comorbidities were balanced. Mortality in TAVI\ud versus STD was 28% vs 70% at 1000 days follow-up.\ud There were significantly more hospital admissions per\ud year in the TAVI group prior to TAVI/STD (1.5 (IQR 1.0–\ud 2.4) vs 1.0 IQR (0.5–1.5)). Post TAVI/STD, the TAVI\ud group had significantly lower hospital admissions (0.3\ud (IQR 0.0–1.0) vs 1.2 (IQR 0.7–3.0)) and lengths of stay\ud (0.4 (IQR 0.0–13.8) vs 11.0 (IQR 2.5–28.5), p

OBJECTIVES To evaluate the opinions of practicing clinicians on medical television dramas and the effects these series have on society as well as their own practice. DESIGN, SETTING AND PARTICIPANTS Observational study using a structured questionnaire disseminated among doctors of all grades and specialties at one tertiary centre and two large secondary care district general hospitals in Wales, United Kingdom. Three hundred and seventy-two questionnaires were distributed over a 3-month period, with 200 completed questionnaires received (response rate, 54%). MAIN OUTCOME MEASURES Frequency and reasons for watching these programs, and opinions regarding realism, educational value and public perception, evaluated by doctors' grades and specialties. Identification of work practice with any observed traits in fictional doctors was also analysed. RESULTS 65% of doctors surveyed admitted to watching these programs on more than one occasion. Junior doctors (interns and resident medical officers) were more regular viewers. Most doctors who admitted to watching medical dramas did so for entertainment purposes (69%); 8% watched for educational purposes and, of these, 100% watched House MD, 82% felt that these dramas were unrepresentative of daily practice, and 10% thought that they accurately portrayed reality. Most of the positive responses were from junior doctors. 61% of doctors identified some aspect of their clinical practice with another doctor (fictional or non-fictional; most junior doctors identified with a fictional doctor, compared with non-fictional role models for more senior practicing clinicians. CONCLUSIONS This survey shows that a large body of the medical workforce watches medical television dramas and that such programs exercise a growing influence on the practice of junior doctors, particularly those in physicianly specialties. The reasons for certain role model selections remain unknown and may require further evaluation.

Aortic stenosis is the most common valvular heart disease, affecting 4.6% of adults older than 75 years. Patients at high risk of surgical complication were historically treated medically. Transcatheter Aortic Valve Implantation (TAVI) allowed access to a therapy that reduced symptoms and mortality

Introduction Transcatheter aortic valve implantation (TAVI) is a therapeutic option for high surgical risk patients with symptomatic aortic stenosis. While improvements in pulmonary artery systolic pressure (PASP) following TAVI have been reported, data regarding the effect of changes in PASP on patient functional status are limited. Methods We performed a retrospective analysis of all consecutive TAVI procedures recorded on the UK TAVI registry from our institution between January 2007 and January 2015. Functional status was defined by the New York Heart Association (NYHA) classification and PASP assessed by transthoracic echocardiography. Repeat measures of PASP and NYHA were performed prior to TAVI and at 1-, 6- and 12-– months following TAVI. Linear mixed model for repeated measures analysis was used to detect changes in PASP and NYHA over the three time points following TAVI and to measure their association. Adjusting for traditional risk factors, we subsequently evaluated whether PASP and NYHA predicted 1-year mortality following TAVI. Results Over eight years, 299 patients (48% male, age 84 ± 8 years) underwent TAVI. During a mean follow-up of 775 days, 114 patients died. One month following TAVI, there was a significant reduction in PASP (37.3 ± 1.7 to 32.4 ± 1.7 mm Hg, p In univariate Cox regression analyses, PASP, NYHA and LVEF, at 1-month following TAVI, all predicted 1-year mortality (p Conclusion These data provide evidence that the reduction in PASP observed following TAVI is closely correlated with an improvement in NYHA functional class along with mortality at 1-year. This study will help enable cardiovascular clinicians to identify those patients likely to have a favourable symptomatic response to TAVI based on the echocardiographic PASP estimate post-procedure.

Introduction Transcatheter aortic valve implantation (TAVI) has become the standard of care for high risk patients. Perioperative deterioration of left ventricular (LV) contractile function was previously demonstrated after surgical aortic valve replacement. Moreover, there is evidence to suggest that patients with severe LV hypertrophy have diminished contractile reserve. We sought to compare the contractile reserve of aortic stenosis (AS) patients to control and heart failure groups utilising a gold standard load-independent technique. Methods Patients undergoing TAVI under general anesthesia (AS) and control (Ctrl) and heart failure (HF) patients undergoing diagnostic coronary angiography were recruited for invasive pressure-volume loop studies. We measured systolic indices at rest and followed that by assessment of force-frequency relations with atrial pacing. After correction to body surface area, linear mixed model analysis and Friedman test were used to identify differences. Mean values and standard errors are reported. Results Sixteen (16) patients were in AS group Vs 15 and 12 in Ctrl and HF groups (age in years 84.3 ± 1.5, Vs 59.4 ± 2.2 and 48.5 ± 4.2, p Vs 5 (33%) and 8 (66%), p = 0.46, respectively). At rest, ejection fraction (EF) for AS group was 66% ± 4 Vs 64% ± 4, 42% ± 5 for Ctrl and HF respectively (p = 0.006). The maximum first derivative of LV pressure (dP/dt max ) was 1097 ± 77mmHg/s Vs 1327 ± 63 and 1034 ± 58, p = 0.017. The load-independent parameters included end-systolic pressure volume relationship (ESPVR) for AS 1.85 ± 0.25 mmHg/ml Vs 1.95 ± 0.35, 1.06 ± 0.18 (p = 0.14), Starling Contractile Index (SCI) for AS 7.06 ± 0.9 mmHg/ml/s Vs 7.34 ± 0.9, 4.77 ± 0.6 (p = 0.124) and Preload Recruitable Stroke Work (PRSW) for AS 40 ± 4.2 mmHg/ml Vs 39.6 ± 4.9, 22 ± 3.7 for Ctrl and HF respectively (p = 0.03). With incremental pacing, dP/dt max was biphasic in AS patients (1097 to 1300 then 1084, p = 0.24) but upsloping in Ctrl cohort (1327 to 1778, p = 0.045) and flat in HF (1034 to 1356, p = 0.19) (Figure 1). ESPVR declined steadily in AS patients with incremental pacing unlike the other 2 groups however the changes did not reach statistical significance. SCI response was biphasic in AS (7.7 to 11.9 then 8.1, p = 0.18), upsloping in both Ctrl group (5.6 to 11, p Conclusion These data suggest that aortic stenosis patients with preserved EF have diminished contractile reserve, especially during increased heart rate, and may explain why some of these patients have an unfavorable clinical course post TAVI.

Introduction Epidural analgesia improves outcomes after transapical aortic valve implantation (TA-AVI). However, it is rarely used due to the risk of complications in patients on antiplatelet or anticoagulant medication. Spinal analgesia (SA) is associated with fewer complications. We used SA in patients undergoing TA-AVI and report on outcomes. Methods All TA-AVI patients received general anaesthesia. Since 2013, additional single-shot SA using a long acting opioid plus local anaesthetic intrathecally was used (n = 26). We compared results to a control group of patients without SA (n = 110). Results Mean age was 79.3 ± 8.8yrs (SA) vs. 82.6 ± 7.1yrs (non-SA, p = 0.04). No SA related complication occurred. Up to 30-days, no patient died in the SA cohort compared to 18 deaths in the non-SA group (16.4%, p = 0.02). Increase in creatinine was lower in the SA group (18.5 ± 36.3mmol/l vs. 53.2 ± 74.7mmol/l, p = 0.02). After SA, no patient required dialysis vs. 10.0% (p = 0.12). No patient had respiratory failure in the SA group vs. 12.7% in non-SA (p = 0.05). New onset of atrial fibrillation occurred in 3.8% in SA vs. 16.4% (p = 0.09). Length of stay on intensive care unit (1.9 ± 1.7 vs. 2.0 ± 2.9, p = 0.88) and NYHA-class at 30 days (NYHA I/II 80.8% vs. 67.3%, p = 0.56) were not different. Conclusion The use of SA in TA-AVI is safe. In addition to the growing experience with TA-AVI and its peri-procedural management, the introduction of SA improved outcomes after TA-AVI, with lower mortality, renal- and pulmonary complications. The use of SA possibly leads to a reduction of inflammatory response.

Segmental absence of intestinal musculature (SAIM) is a rare entity of uncertain aetiology. A case of SAIM in an adult is presented, and three other adult cases of SAIM are reviewed. Our case concerns a middle-aged man who underwent a Whipple's procedure for a suspected neoplasm in the head of the pancreas. At surgery, a redundant segment of proximal jejunum with multiple large diverticula was incidentally noted and resected. On histological examination, the small bowel segment showed focal extreme thinning of the muscularis propria, focally amounting to complete absence. A peritoneal biopsy was also submitted which showed changes consistent with an old thrombosed vessel.