Single versus double Perclose techniques for vascular closure during transfemoral transcatheter aortic valve replacement.

INTRODUCTION: The preferred approach for transcatheter aortic valve replacement (TAVR) is transfemoral. There has been widespread adoption of the Perclose ProglideTM device for vascular closure. Typically, two devices are deployed before upsizing the access sheath in the "preclose technique." Prior investigations have compared the use of a single device versus double device technique, but none have shown significant clinical benefit to either approach. METHODS: Five hundred and six patients underwent transfemoral TAVR (TF-TAVR) with single or double Perclose devices for vascular closure from July 2015 to February 2020. A retrospective review was conducted, and propensity-matched analyses were used to account for differences in baseline characteristics. RESULTS: In the matched analysis, there were 251 patients in the single Perclose group and 238 in the double. There was a statistically significant improvement in overall procedural success using the single closure device (94.6% vs. 88.5%, p = 0.009) This was defined as intraprocedural hemostatic control, lack of contrast extravasation, arterial dissection, occlusion, or stenosis >50% in the final crossover angiogram, as well as unimpaired limb perfusion without claudication throughout the index hospitalization. There was also a significant improvement in arterial dissection rates (0.6% vs. 4.6%, p = 0.004), stenosis >50% (1.3% vs. 4.4%, p = 0.028), and Valve Academic Research Consortium major vascular complications (1.8% vs. 4.9%, p = 0.038). CONCLUSION: A single Perclose device is a safe means of vascular closure during TF-TAVR and may have important clinical benefits compared to the commonly used two-device technique.

Mechanical circulatory support in acute myocardial infarction and cardiogenic shock: Challenges and importance of randomized control trials.

BACKGROUND: Acute myocardial infarction (AMI) complicated by cardiogenic shock (CS) is associated with significant morbidity and mortality. METHODS: We provide an overview of previously conducted studies on the use of mechanical circulatory support (MCS) devices in the treatment of AMI-CS and difficulties which may be encountered in conducting such trials in the United States. RESULTS: Well powered randomized control trials are difficult to conduct in a critically ill patient population due to physician preferences, perceived lack of equipoise and challenges obtaining informed consent. CONCLUSIONS: With growth in utilization of MCS devices in patients with AMI-CS, efforts to perform well-powered, randomized control trials must be undertaken.

Application of transcatheter valves for aortic valve replacement in pediatric patients: A case series.

OBJECTIVES: To describe our initial experience with pediatric transcatheter aortic valve replacement. BACKGROUND: Transcatheter aortic valve replacement (TAVR) has been approved and used to treat calcific aortic stenosis in adult patients. Select pediatric patients with congenital heart disease (CHD) who are poor candidates for conventional surgical aortic valve replacement can benefit from TAVR. METHODS: A retrospective review was performed to identify and describe pediatric patients with CHD who underwent transcatheter or hybrid aortic valve replacement using a Melody Valve (Medtronic, Minneapolis, MN), or Sapien S3/XT valve (Edwards Life sciences LLC, Irvine, CA). Patients in whom transcatheter valves were implanted on cardiopulmonary bypass were included. Imaging data, procedural elements, and clinical follow-up data were collected to evaluate acute and short-term results. RESULTS: A total of eight pediatric patients underwent treatment of aortic valvular disease using balloon expandable valves and delivery systems. Two patients had Melody valve implantation and six received a Sapien valve (one XT/five S3). In one patient, a Melody valve was placed surgically, failed, and was replaced with a Sapien valve 2 years later. Two patients were treated using a standard transfemoral route, four had the valve delivered on cardiopulmonary bypass via a median sternotomy, one was placed with a transapical approach, and one via a carotid cut down. Patients were followed for an average 16 months (range 1-208 weeks). There were no early or late deaths in this cohort. There were no embolic events, and all valves worked well in the immediate postoperative period. Both Melody implants developed moderate to severe regurgitation at 2 years and 4 years, respectively, and both required replacement at that time. One Sapien 3 valve developed a paravalvular leak that required reintervention within 6 months of implantation. CONCLUSIONS: Transcatheter valves offer a reasonable alternative to traditional surgical aortic valve replacement in certain pediatric patients who are suboptimal surgical candidates. Hybrid approaches and valve delivery on cardiopulmonary bypass has been used in smaller patients. Long-term performance of these valves in young patients has not been studied.

Strategic implementation of phosphorus repletion strategy in continuous two-stage cultivation of Chlorella sp. HS2: Evaluation for biofuel applications.

Lipid production in microalgae under nitrogen (N) starved condition can be enhanced by excess phosphorus (P) supply in the second stage of two-stage cultivation strategy. However, implementing two-stage cultivation is difficult in large-scale cultivation system as it requires high energy of transferring large algal biomass from first stage to second stage. To address this problem, we have optimized a continuous two-stage (CTS) cultivation strategy using Chlorella sp. HS2, where nitrogen in the growth environment is depleted naturally via consumption. To enhance both biomass and lipid productivity this strategy explored supplementation of additional P from 50% to 2500% of the initial concentration at the start of N-limited second stage of growth. The results of the optimization study in photobioreactor (PBR) showed that supplementing 500% of initial P and 100% of initial other nutrients (O) (N0-P500-O100) on 5th day showed the maximum biomass productivity of 774.4 mg L-1 d-1. It was observed that Chlorella sp. HS2 grown in PBR yielded higher biomass (3.8 times), lipid (6.1 times) and carbohydrate (5.5 times) productivity in comparison to the open raceway ponds (ORP) study, under optimum nutrient and carbon supply condition. The maximum lipid (289.6 mg L-1 d-1) and carbohydrate (219.2 mg L-1 d-1) productivities were obtained in TPBR-3, which were 1.9 and 1.3 times higher than that of TPBR-2 (+ve control) and 9.6 and 3.7 times higher than that of TPBR-1 (-ve control), respectively. Fatty acid mainly composed of C16/C18 (84.5%-85.7%), which makes the microalgal oil suitable for biofuel production. This study concluded that feeding excess amount of P is an effective and scalable strategy to improve the biomass and lipid productivity of CTS cultivation.

Ferumoxytol-enhanced MR Angiography for Vascular Access Mapping before Transcatheter Aortic Valve Replacement in Patients with Renal Impairment: A Step Toward Patient-specific Care.

Purpose To assess the technical feasibility of the use of ferumoxytol-enhanced (FE) magnetic resonance (MR) angiography for vascular mapping before transcatheter aortic valve replacement in patients with renal impairment. Materials and Methods This was an institutional review board-approved and HIPAA-compliant study. FE MR angiography was performed at 3.0 T or 1.5 T. Unenhanced computed tomographic (CT) images were used to overlay vascular calcification on FE MR angiographic images as composite fused three-dimensional data. Image quality of the subclavian and aortoiliofemoral arterial tree and confidence in the assessment of calcification were evaluated by using a four-point scale (4 = excellent vascular definition or strong confidence). Signal intensity nonuniformity as reflected by the heterogeneity index (ratio between the mean standard deviation of luminal signal intensity and the mean luminal signal intensity), signal-to-noise ratio, and consistency of luminal diameter measurements were quantified. Findings at FE MR angiography were compared with pelvic angiograms. Results Twenty-six patients underwent FE MR angiography without adverse events. A total of 286 named vascular segments were scored. The image quality score was 4 for 99% (283 of 286) of the segments (κ = 0.9). There was moderate to strong confidence in the ability to assess vascular calcific morphology in all studies with complementary unenhanced CT. The steady-state luminal heterogeneity index was low, and signal-to-noise ratio was high. Interobserver luminal measurements were reliable (intraclass correlation coefficient, 0.98; 95% confidence interval: 0.98, 0.99). FE MR angiographic findings were consistent with correlative pelvic angiograms in all 16 patients for whom the latter were available. Conclusion In patients with renal impairment undergoing transcatheter aortic valve replacement, FE MR angiography is technically feasible and offers reliable vascular mapping without exposure to iodine- or gadolinium-based contrast agents. Thus, the total cumulative dose of iodine-based contrast material is minimized and the risk of acute nephropathy is reduced. © RSNA, 2017 Online supplemental material is available for this article.

Myocardial functional changes in transfemoral versus transapical aortic valve replacement.

BACKGROUND: Transcatheter aortic valve replacement (TAVR) has greatly expanded the treatment options available for patients with severe aortic stenosis at high surgical risk. MATERIALS AND METHODS: We compared changes in myocardial function in TAVR with a transfemoral (TF) versus a transapical (TA) approach at a major tertiary hospital from 2012-2016. Traditional echocardiographic measures of cardiac structure and function were tracked, alongside the use of two-dimensional speckle tracking echocardiography to measure myocardial strain and strain rates. RESULTS: For the entire cohort with complete data at all time points (n = 42), between the pre-TAVR baseline (mean: 20.1 d) and the post-TAVR 1-mo follow-up (mean: 32.7 d), global longitudinal strain significantly increased (from -15.6% to -18.2%, P < 0.001). When comparing the TF (n = 31) and TA (n = 11) groups, TA patients showed persistently impaired apical longitudinal strain at the 1-mo follow-up (-15.9% versus -22.3%, P < 0.05). In terms of clinical outcomes, both groups (n = 131 for TF, n = 53 for TA) were similar in terms of 30-d mortality, readmission rate, and risk of post-TAVR acute kidney injury. However, TA patients experienced significantly longer length of hospitalization (7.58 versus 3.92 d, P = 0.02), intensive care unit hours (105.4 versus 47.1 h, P = 0.02), and were at a greater risk of long-term (>72 h) intensive care unit stay (45% versus 25%, P = 0.01). CONCLUSIONS: Patients undergoing TA-TAVR exhibit impaired apical longitudinal strain, although global myocardial function is similar to TF-TAVR otherwise. Myocardial strain measured by two-dimensional speckle tracking echocardiography appears to be a sensitive method to detect subtle cardiac remodeling after TAVR.

Defining the common femoral artery: Insights from the femoral arterial access with ultrasound trial.

OBJECTIVE: We sought to establish the typical location of the common femoral artery (CFA) bifurcation, the origin and most inferior reflection of the inferior epigastric artery (IEA) relative to the femoral head (FH) and whether patient demographics predicted anatomical variations. BACKGROUND: In the absence of ultrasound guidance or prior imaging, the precise location of the CFA bifurcation and IEA can only be determined following access site angiography. Fluoroscopic landmarks are commonly used to estimate the location of the CFA bifurcation, but the position of the IEA is less well characterized. METHODS: Prospectively collected data on 989 patients with femoral angiography in the FAUST trial were analyzed. The level of CFA bifurcation and the origin and most inferior reflection of the IEA were classified by angiography. Logistic regression was used to explore whether baseline demographics were associated with anatomic variations. RESULTS: The CFA bifurcation occurs below the middle 1/3rd of the femoral head in 95% of patients, and no patient factors are predictive of a high bifurcation. The IEA origin has a more variable anatomically pattern, with high BSA, male gender, and white race associated with a low IEA origin. CONCLUSION: Operators should attempt to access the CFA at the level of the middle 1/3rd of the FH to maximize the chance of CFA cannulation. However, this location carries an 11% risk of being at or above the IEA origin. Baseline demographics were of limited utility for predicting anatomic variants of the CFA bifurcation and the course of the IEA. © 2016 Wiley Periodicals, Inc.

Transcatheter closure of an iatrogenic ventricular septal defect after SAPIEN valve implantation.

A 57-year-old woman developed progressive calcific mitral and aortic valve disease with a porcelain aorta secondary to a history of radiation therapy. She was considered a very poor operative candidate and referred for transcatheter aortic valve replacement (TAVR). Four weeks after extensive coronary artery stenting, a TAVR was performed with a 23 mm Edwards SAPIEN valve (Edwards Life Sciences, Irvine, CA) through a transapical approach. Post-operatively, her symptoms of dyspnea persisted and worsened. She was found to have an acquired ventricular septal defect (VSD) measuring 8 mm by 5 mm by transesophageal echocardiogram and by a CT angiogram. Percutaneous VSD closure was accomplished with an 8 mm Muscular VSD Occluder (St. Jude Medical, St. Paul, MN) with elimination of her shunt, improvement of her dyspnea, and marked improvement in exercise tolerance.

Comparison of near-infrared spectroscopy and optical coherence tomography for detection of lipid.

OBJECTIVES: To compare intracoronary near-infrared spectroscopy (NIRS) and optical coherence tomography (OCT) for the detection of lipid, to identify NIRS signals to differentiate superficial lipid, and to characterize the plaque with yellow block (YB) chemograms on NIRS. BACKGROUND: Intracoronary NIRS has been developed to detect lipid core plaque (LCP). METHODS: We investigated a total of 17 patients who underwent both OCT and NIRS. NIRS analysis included plaque lipid core burden index (LCBI), LCP length, and the presence of YB on the block chemogram. OCT analysis included maximum lipid arc (LA), the length of lipid (LL), lipid index, and the thinnest fibrous cap thickness (FCT). RESULTS: Twenty-five plaques with >40% plaque burden were analyzed. LCP, showing LCBI > 0, was observed in 20 plaques (80%) and YB was detected in seven plaques (28%). Plaque LCBI showed modest correlations with maximum LA and lipid index by OCT (r(2) = 0.319, P = 0.003 and r(2) = 0. 404, P = 0.001, respectively). Lipid length showed a significant correlation between NIRS and OCT measurements (r(2) = 0.581, P < 0.001). There was no significant difference in NIRS parameters between superficial and deep lipid. Plaques with YB compared with those without YB showed a larger LA, longer LL, and thinner FCT (185 ± 29° vs. 105 ± 76°, P = 0.014; 8.5 ± 3.3 mm vs. 3.3 ± 2.7 mm, P = 0.001; 112 ± 42 vs. 166 ± 61 µm, P = 0.033). CONCLUSIONS: NIRS and OCT parameters showed modest linear correlations in the measurement of lipid. The accurate depth of lipid in the vessel wall could not be identified by quantitative NIRS parameters. YB chemograms represented more vulnerable features on OCT.

Fractional Flow Reserve in End-Stage Liver Disease.

Fractional flow reserve (FFR) determines the functional significance of epicardial stenoses assuming negligible venous pressure (Pv) and microvascular resistance. However, these assumptions may be invalid in end-stage liver disease (ESLD) because of fluctuating Pv and vasodilation. Accordingly, all patients with ESLD who underwent right-sided cardiac catheterization and coronary angiography with FFR as part of their orthotopic liver transplantation evaluation between 2013 and 2018 were included in the present study. Resting mean distal coronary pressure (Pd)/mean aortic pressure (Pa), FFR, and Pv were measured. FFR accounting for Pv (FFR - Pv) was defined as (Pd - Pv)/(Pa - Pv). The hyperemic effect of adenosine was defined as resting Pd/Pa - FFR. The primary outcome was all-cause mortality at 1 year. In 42 patients with ESLD, 49 stenoses were interrogated by FFR (90% were <70% diameter stenosis). Overall, the median model for ESLD score was 16.5 (10.8 to 25.5), FFR was 0.87 (0.81 to 0.94), Pv was 8 mm Hg (4 to 14), FFR-Pv was 0.86 (0.80 to 0.94), and hyperemic effect of adenosine was 0.06 (0.02 to 0.08). FFR-Pv led to the reclassification of 1 stenosis as functionally significant. There was no significant correlation between the median model for ESLD score and the hyperemic effect of adenosine (R = 0.10). At 1 year, 13 patients had died (92% noncardiac in etiology), and patients with FFR ≤0.80 had significantly higher all-cause mortality (73% vs 17%, p = 0.001. In conclusion, in patients with ESLD who underwent orthotopic liver transplantation evaluation, Pv has minimal impact on FFR, and the hyperemic effect of adenosine is preserved. Furthermore, even in patients with the predominantly angiographically-intermediate disease, FFR ≤0.80 was an independent predictor of all-cause mortality.

Acute myocardial infarction caused by multivessel coronary spasm due to calcium channel blocker withdrawal.

Calcium channel blockers are a commonly used class of medications for the management of hypertension, angina, and superventricular tachyarrhythmias. Abrupt withdrawal of these agents can precipitate coronary vasospasm, which may result in myocardial infarction. We present the case of a 47-year-old woman who sustained an acute myocardial infarction mediated by multivessel coronary vasospasm secondary to verapamil withdrawal and the associated interventional management.

Suicide left ventricle following transcatheter aortic valve implantation.

In some patients with aortic stenosis, dynamic intraventricular gradients like those seen in hypertrophic obstructive cardiomyopathy may develop secondary to left ventricular hypertrophy from chronic pressure overload. With the advent of transcatheter aortic valve implantation, many patients with aortic stenosis and advanced age who formerly would be considered "too high risk" for aortic valve replacement are getting treatment for their aortic stenosis. This case highlights the hemodynamic aberrations that can occur with TAVI leading to a cautionary note regarding implementation of this rapidly emerging technique in patients with left ventricles that may be at risk for suicide left ventricle.

Transcatheter closure of a traumatic VSD in an adult requiring an ASD occluder device.

Traumatic ventricular septal defects (VSD) can occur after blunt or penetrating chest trauma or cardiac procedures. There are few publications reporting the safety and efficacy of transcatheter closure of traumatic VSDs. We report a case of a large VSD resulting from penetrating chest trauma that was not repaired at the initial surgical procedure on the disrupted right ventricle. Because of the late identification of the VSD postoperatively, transcatheter closure after the original surgical procedure was recommended and performed requiring an Amplatzer atrial septal defect occluder device because of defect size and configuration. This case describes the technique and postprocedure imaging leading to a cautionary note regarding VSD closure device techniques.

Exploration of two-stage cultivation strategies using nitrogen starvation to maximize the lipid productivity in Chlorella sp. HS2.

In this work, the two-stage cultivation of Chlorella sp. HS2 for enhancing the lipid productivity was optimized by adjusting the duration of nitrogen-replete (N+) and -deplete (N-) stages within a 9 day period using urea as nitrogen source. The highest lipid content of 36.7% and productivity of 216.9 mg L-1 d-1 were obtained under five days of N+ followed by four days of N- conditions. Replenishing phosphorus and other nutrients (N-P+O+) at the beginning of the nutrient-starvation resulted in 1.55 and 1.68-folds improvement in lipid productivities compared to the single stage and zero nutrient controls (N-P-O-), respectively. The estimated biodiesel properties based on the fatty acid profiles met all criteria of international standards. The findings of this study indicate that properly adjusting the period of nitrogen availability as well as the presence of other nutrients is highly important in order to maximize the biofuel productivity in two-stage microalgal cultivation.

Efficient microalgae removal from aqueous medium through auto-flocculation: investigating growth-dependent role of organic matter.

This study investigated the growth-dependent role of algal organic matters (AOMs) to achieve high removal efficiency (R.E) of microalgae. The results showed that the microalgae cells produced 96 ± 2% of total AOMs as loose bound AOMSS (LB-AOMs) and 4 ± 1% as cell-bound (CB-AOMs) in exponential phase. In stationary phase, LB-AOMs and CB-AOMs were 46 ± 0.7percentage and 54 ± 0.2 percentage, respectively. The R.Es in exponential and stationary phase were 83 ± 2.6% and 66 ± 1.2%, respectively. It is found that the difference of biomass concentration (between exponential and stationary phase) had no significant impact on the R.E (P > 0.01). Further investigations revealed that LB-AOMs inhibit flocculation in exponential and CB-AOMs in stationary phase; however, CB-AOMs showed stronger inhibition than the LB-AOMs (P < 0.01). The provision of calcium (17 ± 0.9 mg/L) to the culture reduced the AOMs inhibition and improved the R.E from 66 ± 1.2% (in control) to 90 ± 4.2%. An increase in R.E was attributed to the interaction of calcium with AOMs and subsequently acting as a flocculant. The findings of this study can be valuable to improve the performance of auto-flocculation technology, which is mainly limited by the presence of AOMs. Graphical Abstract.

Biological Carbon Recovery from Sugar Refinery Washing Water into Microalgal DHA: Medium Optimization and Stress Induction.

Sugar refinery washing water (SRWW) contains abundant levels of carbon sources and lower levels of contaminants than other types of wastewater, which makes it ideal for heterotrophic cultivation of microalgae. Here, carbon sources in SRWW were utilized for conversion into the form of value-added docosahexaenoic acid (DHA) using Aurantiochytrium sp. KRS101. Since SRWW is not a defined medium, serial optimizations were performed to maximize the biomass, lipid, and DHA yields by adjusting the nutrient (carbon, nitrogen, and phosphorus) concentrations as well as the application of salt stress. Optimum growth performance was achieved with 30% dilution of SRWW containing a total organic carbon of 95,488 mg L-1. Increasing the nutrient level in the medium by supplementation of 9 g L-1 KH2PO4 and 20 g L-1 yeast extract further improved the biomass yield by an additional 14%, albeit at the expense of a decrease in the lipid content. Maximum biomass, lipid, and DHA yields (22.9, 6.33, and 2.03 g L-1, respectively) were achieved when 35 g L-1 sea salt was applied on a stationary phase for osmotic stress. These results demonstrate the potential of carbon-rich sugar refinery washing water for DHA production using Aurantiochytrium sp. KRS101 and proper cultivation strategy.

Optimization of heterotrophic cultivation of Chlorella sp. HS2 using screening, statistical assessment, and validation.

The heterotrophic cultivation of microalgae has a number of notable advantages, which include allowing high culture density levels as well as enabling the production of biomass in consistent and predictable quantities. In this study, the full potential of Chlorella sp. HS2 is explored through optimization of the parameters for its heterotrophic cultivation. First, carbon and nitrogen sources were screened in PhotobioBox. Initial screening using the Plackett-Burman design (PBD) was then adopted and the concentrations of the major nutrients (glucose, sodium nitrate, and dipotassium phosphate) were optimized via response surface methodology (RSM) with a central composite design (CCD). Upon validation of the model via flask-scale cultivation, the optimized BG11 medium was found to result in a three-fold improvement in biomass amounts, from 5.85 to 18.13 g/L, in comparison to a non-optimized BG11 medium containing 72 g/L glucose. Scaling up the cultivation to a 5-L fermenter resulted in a greatly improved biomass concentration of 35.3 g/L owing to more efficient oxygenation of the culture. In addition, phosphorus feeding fermentation was employed in an effort to address early depletion of phosphate, and a maximum biomass concentration of 42.95 g/L was achieved, with biomass productivity of 5.37 g/L/D.

Isolation and Characterization of Novel Chlorella Species with Cold Resistance and High Lipid Accumulation for Biodiesel Production.

Chlorella spp. are green algae that are found across wide-ranging habitats from deserts to arctic regions, with various strains having adapted to survive under diverse environmental conditions. In this study, two novel Chlorella strains (ABC-002, ABC-008) were isolated from a freshwater lake in South Korea during the winter season and examined for possible use in the biofuel production process. The comparison of ABC-002 and ABC-008 strains with Chlorella vulgaris UTEX265 under two different temperatures (10°C, 25°C) revealed their cold-tolerant phenotypes as well as high biomass yields. The maximum quantum yields of UTEX25, ABC- 002, and ABC-008 at 10°C were 0.5594, 0.6747, and 0.7150, respectively, providing evidence of the relatively higher cold-resistance capabilities of these two strains. Furthermore, both the biomass yields and lipid content of the two novel strains were found to be higher than those of UTEX265; the overall lipid productivities of ABC-002 and ABC-008 were 1.7 ~ 2.8 fold and 1.6 ~ 4.2 fold higher compared to that of UTEX265, respectively. Thus, the high biomass and lipid productivity over a wide range of temperatures indicate that C. vulgaris ABC-002 and ABC-008 are promising candidates for applications in biofuel productions via outdoor biomass cultivation.

Transcatheter aortic valve replacement outcomes in bicuspid compared to trileaflet aortic valves.

AIM: TAVR in patients with bicuspid aortic valves (BAV) is more challenging compared to individuals with trileaflet aortic valves (TAV). BAV have been excluded from the large randomized clinical trials assessing transcatheter aortic valve replacements (TAVR) and has been considered as a relative contraindication to TAVR. To report the outcomes of TAVR in BAV and compare them to TAV in the National Inpatient Sample (NIS). METHODS AND RESULTS: TAVR procedures were identified between 2011 and 2014 in the NIS dataset. Endpoints assessed included in-hospital mortality, periprocedural complications, length of stay and cost. Of 40,604 identified TAVR procedures, 407 (1%) were BAV and the 40,197 (99%) were TAV. Patients with BAV were younger and had a lower comorbidity burden. In hospital mortality (4.89% vs 4.17%, OR: 1.71, 95%CI: 0.57-5.12, P = 0.21), AMI (3.49% vs 3.58%, OR: 1.12, 95%CI: 0.36-3.54, P = 0.85), stroke and TIA (2.49% vs 3.55%, OR: 0.75, 95%CI: 0.18-3.16, P = 0.70), vascular complications (2.39% vs 5.58%, OR:0.47, 95%CI: 0.11-1.93, P = 0.29), major bleeding (16.96% vs 23.50%, OR: 0.63, 95%CI: 0.34-1.17, P = 0.15) and rates of permanent pacemaker (PPM) (9.88% vs 10.88%, OR: 1.19, 95%CI: 0.57-2.51, P = 0.64) were similar in both cohorts. CONCLUSIONS: With multimodality imaging and further improvement in technology, our study demonstrates off-label TAVR should not be considered prohibitive and can be successfully performed for BAV with similar peri-procedural outcomes compared to those with TAV. However, there is a need for robust large prospective studies.

Addressing the hemodynamic dilemma of combined mitral and aortic stenosis.

Accurate assessment of valvular hemodynamics is essential in the decision-making process when referring a patient for cardiac surgery who has suspected coexistent aortic and mitral valve disease. Often times, one valvular lesion is worse than the other, and the question of "prophylactically" replacing the less severe valve at the time of surgery is controversial. In these situations and because of uncertainty regarding noninvasive assessment, hemodynamic evaluation in the cardiac catheterization laboratory provides critical information in guiding therapy.