Mitral Valve Transcatheter Edge-to-Edge Repair Volumes and Trends.

Background: Despite an association between operator volumes and procedural success, there remains an incomplete understanding of the contemporary utilization and procedural volumes for mitral valve transcatheter edge-to-edge repair (MTEER). We aimed to identify annual operator procedural volumes, temporal trends, and geographic variability for MTEER among Medicare patients in the United States (US). Methods: We queried the National Medicare Provider Utilization and Payment Database for a CPT code (33418) specific for MitraClip device from 2015 through 2019. We analyzed annual operator procedural volumes and incidence and identified longitudinal and geographic trends in MTEER utilization. Results: From 2015 through 2019, a total of 27,034 MTEER procedures were performed among Medicare patients in the US. The nationwide incidence increased from 6.2 per 100,000 patients in 2015 to 23.8 per 100,000 patients in 2019, a 283% increase over the study period (Ptrend < 0.001). The incidence of MTEER by state varied by nearly 900% (range 5.5 to 54.9 per 100,000 person-years). In 2019, the mean annual MTEER operator annual volume was 9.1 MTEER procedures and had grown from 6.2 per year in 2015. Conclusions: In this nationwide study of Medicare beneficiaries in the United States, we identified a significant and sustained increase in the utilization of MTEER devices and operators and growth in annual procedural volumes from 2015 through 2019 with considerable variability in utilization by state. Further studies are needed to understand the clinical impact of variability in utilization and the optimal procedural volumes to ensure high efficacy outcomes and maintain critical access to MTEER therapies.

Association of heart failure with procedural complications and in-hospital outcomes from left atrial appendage occlusion device implantation in patients with atrial fibrillation: insights from the national inpatient sample of 62 980 procedures.

AIMS: To determine outcomes in atrial fibrillation (AF) patients undergoing percutaneous left atrial appendage occlusion (LAAO) with concomitant heart failure with preserved ejection fraction (HFpEF) and heart failure with reduced ejection fraction (HFrEF). METHODS AND RESULTS: Data were extracted from National Inpatient Sample for calendar years 2015-2019. LAAO device implantations were identified on the basis of ICD-10-CM code of 02L73DK. The outcomes assessed in our study included complications, in-patient mortality, and resource utilization. A total of 62 980 LAAO device implantations were studied. HFpEF (14.4%, n = 9040) and HFrEF (11.2%, n = 7100) were associated with a higher prevalence of major complications and in-patient mortality in crude analysis. In the multivariate model adjusted for potential confounders, HFpEF and HFrEF were not associated with major complications [adjusted odds ratio (aOR) 1.04, 95% confidence interval (CI) 0.93-1.16 and aOR 1.07, 95% CI 0.95-1.21] or in-patient mortality (aOR 1.48, 95% CI 0.85-2.55 and aOR 1.26, 95% CI 0.67-2.38). HFpEF and HFrEF were associated with prolonged length of stay (LOS) > 1 day (aOR 1.41, 95% CI 1.31-1.53 and aOR 1.66, 95% CI 1.53-1.80) and increased hospitalization costs > median cost 24 752$ (aOR 1.26, 95% CI 1.19-1.34 and aOR 1.21, 95% CI 1.13-1.29). CONCLUSION: The prevalence of HF in AF patients undergoing percutaneous LAAO was approximately 26%. HF was not independently associated with major complications and in-patient mortality but was associated with prolonged LOS and higher hospitalization costs.

Selective Valve Removal for Melody Valve Endocarditis: Practice Variations in a Multicenter Experience.

Guidelines for management of Melody transcatheter pulmonary valve (TPV) infective endocarditis (IE) are lacking. We aimed to identify factors associated with surgical valve removal versus antimicrobial therapy in Melody TPV IE. Multicenter retrospective analysis of all patients receiving Melody TPV from 10/2010 to 3/2019 was performed to identify cases of IE. Surgical explants versus non-surgical cases were compared. Of the 663 Melody TPV implants, there were 66 cases of IE in 59 patients (59/663, 8.8%). 39/66 (59%) were treated with IV antimicrobials and 27/66(41%) underwent valve explantation. 26/59 patients (44%) were treated medically without explantation or recurrence with average follow-up time of 3.5 years (range:1-9). 32% of Streptococcus cases, 53% of MSSA, and all MRSA cases were explanted. 2 of the 4 deaths had MSSA. CART analysis demonstrated two important parameters associated with explantation: a peak echo gradient ≥ 47 mmHg at IE diagnosis(OR 10.6, p < 0.001) and a peak echo gradient increase of > 24 mmHg compared to baseline (OR 6.7, p = 0.01). Rates of explantation varied by institution (27 to 64%). In our multicenter experience, 44% of patients with Melody IE were successfully medically treated without valve explantation or recurrence. The degree of valve stenosis at time of IE diagnosis was strongly associated with explantation. Rates of explantation varied significantly among the institutions.

Contemporary procedural trends of Watchman percutaneous left atrial appendage occlusion in the United States.

OBJECTIVE: To determine trends in real-world utilization and in-hospital adverse events from Watchman implantation since its approval by the Food and Drug Administration in 2015. BACKGROUND: The risk of embolic stroke caused by atrial fibrillation is reduced by oral anticoagulants, but not all patients can tolerate long-term anticoagulation. Left atrial appendage occlusion with the Watchman device has emerged as an alternative therapy. METHODS: This was a retrospective cohort study utilizing data from National Inpatient Sample for calendar years 2015-2017. The outcomes assessed in this study were associated complications, in-hospital mortality, and resource utilization trends after Watchman implantation. Trends analysis were performed using analysis of variance. Multivariable adjusted logistic regression analysis was performed to determine predictors of mortality. RESULTS: A total of 17 700 patients underwent Watchman implantation during the study period. There was a significantly increased trend in the number of Watchman procedures performed over the study years (from 1195 in 2015 to 11 165 devices in 2017, p < .01). A significant decline in the rate of complications (from 26.4% in 2015% to 7.9% in 2017, p < .01) and inpatient mortality (from 1.3% in 2015% to 0.1% in 2017, p < .01) were noted. Predictors of in-hospital mortality included a higher CHA2 DS2 -VASc score (odds ratio [OR]: 2.61 per 1-point increase, 95% confidence interval [CI]: 1.91-3.57), chronic blood loss anemia (OR: 3.63, 95% CI: 1.37-9.61) and coagulopathy (OR: 4.90, 95% CI: 2.32-10.35). CONCLUSION: In contemporary United States clinical practice, Watchman utilization has increased significantly since approval in 2015, while complications and in-patient mortality have declined.

Percutaneous mitral valve repair in adults with congenital heart disease: Report of the first case-series.

BACKGROUND: Systemic atrioventricular valve regurgitation (AVVR) is frequently encountered in adults with congenital heart disease (CHD). Surgical intervention is the mainstay of therapy, but in a specific high-risk subset, percutaneous valve repair might offer a lower-risk alternative. METHODS: Three patients with complex CHD and severe symptomatic AVVR underwent percutaneous mitral valve repair at a single center. All were deemed to be high-risk for surgery by a multidisciplinary CHD team and provided informed consent for the compassionate use of the MitraClip (Abbott, Santa Clara, CA). Three-dimensional heart models were generated for the procedure, which was performed by an adult CHD cardiologist (who provided imaging support) and an interventional cardiologist with expertise in CHD and percutaneous mitral valve repair. RESULTS: The first case was a 39 year-old-woman with [S,L,D] dextrocardia, double outlet right ventricle, mild tricuspid hypoplasia, and a secundum atrial septal defect, who was palliated at age 35 with a right bidirectional Glenn and later developed severe, symptomatic mitral regurgitation, and underwent placement of one MitraClip XTR device. Two patients with L-loop transposition of the great arteries each successfully underwent placement of two MitraClip XTR devices; one patient had a single-leaflet detachment of one of the clips with no change in regurgitation or clip position on follow-up. All patients had significant reduction of AVVR and improvement in NYHA functional class. CONCLUSIONS: Percutaneous atrioventricular valve repair in adults with CHD is feasible with the MitraClip but requires significant preprocedural planning and a multidisciplinary team that combines CHD and interventional therapeutic expertise.

Left internal mammary artery side branch intervention in the management of coronary steal syndrome following coronary artery bypass grafting.

OBJECTIVE: The objective of this qualitative review is to summarize the pathophysiological and clinical data behind the clinical entity of left internal mammary artery (LIMA) side branch coronary steal as well as the potential diagnostic and therapeutic modalities available. BACKGROUND: The presence of persistent unligated LIMA side branches following coronary artery bypass grafting has previously been associated with stable angina and acute coronary syndromes. However, despite numerous attempts to objectively demonstrate a coronary steal phenomenon, the pathophysiology of LIMA side branch flow diversion remains elusive and the clinical utility of intervention is not well elucidated. METHODS: A review of literature and available data including case reports, case series, and investigational studies was performed. RESULTS: Therapeutic closure of LIMA side branches has been reported in at least 44 patients and in at least 31 publications since 1990 and is associated with an 87.5% rate of freedom from angina amongst technically successful initial interventions. In all patients with pre- and post- stress testing, intervention was associated with an improvement and/or resolution of previously observed reversible ischemia. CONCLUSIONS: LIMA side branch coronary steal should remain an ongoing consideration in symptomatic patients with large unligated side branches on angiography, particularly when there is clear evidence of reversible ischemic on perfusion imaging.

Outcomes of fractional flow reserve-guided percutaneous coronary interventions in patients with acute coronary syndrome.

INTRODUCTION: Fractional flow reserve (FFR) assessment has been validated as an effective tool to guide revascularization of stable coronary artery disease. The role of utilizing FFR in acute coronary syndrome (ACS) is less established. METHODS: The study population was extracted from the National Readmissions Data (NRD) 2014 using International Classification of Diseases, ninth edition, clinical modification (ICD-9-CM) codes for ACS, percutaneous coronary intervention (PCI), FFR, and periprocedural complications. Study endpoints included all-cause of in-hospital mortality, length of index hospital stay (LOS), acute kidney injury (AKI), bleeding, coronary dissection, total number of stents used, stroke, vascular complications (VCs), and the total charges of index hospitalization. RESULTS: A total of 304,548 discharges that had the diagnosis of ACS and treated invasively within the same index hospitalization (average age 65.1 years; 64% male) were identified. Among these, 7,832 had FFR guided invasive treatment (2.6%) which was associated with significantly lower in-hospital all-cause mortality (1.1 vs. 3.1%, p < .01), shorter LOS (4.6 vs. 5.3 days, p < .01), less AKI (12.5 vs. 14.6%, p < .01), less bleeding (7.0 vs. 8.5%, p < .01), and lower total charges ($99,805 vs. $105,736). There was no significant difference between both groups in terms of stroke (2.2 vs. 2.3%, p = .41), coronary dissection (0.7 vs. 0.8%, p = .34), VC (1.3 vs. 1.0% p = .01) or the total number of stents used (55.5 vs. 54.5% p = .34). CONCLUSION: In patients presenting with an ACS FFR- guided PCI, as compared to angiography guided PCI, was associated with lower rates of in-hospital mortality, shorter LOS, less AKI, bleeding and lower hospital charges. There was no significant difference in terms of the incidence of stroke, coronary dissection, VC or the total number of stents used.

Complex robotic compared to manual coronary interventions: 6- and 12-month outcomes.

OBJECTIVES: To assess the long-term safety and efficacy of robotic percutaneous coronary revascularization for use in complex coronary lesions. BACKGROUND: Robotically assisted percutaneous coronary intervention (PCI) is safe and feasible in simple coronary lesions and has excellent short-term procedural and clinical outcomes for complex lesions; however, long-term safety and efficacy outcomes are unknown. METHODS: A total of 103 consecutive patients underwent a total of 108 robotic (R)-PCI procedures (age 68.1; 78.3% male) over 18 months, and 210 patients underwent a total of 226 manual (M)-PCI procedures (age 67.5; 78.1% male) during the same period. Patients were subsequently followed and both 6-month and 12-month major adverse cardiovascular events (MACE), comprised of any death, stroke, myocardial infarction, or target vessel revascularization, are reported and compared. RESULTS: There was no difference between the two groups with regard to overall MACE at 6 months (R-PCI 5.8% vs. M-PCI 3.3%, P = 0.51) or at 12 months (R-PCI 7.8% vs. M-PCI 8.1%, P = 0.92). There was no difference between the individual components of the primary combined endpoint at either time point. No access site complications occurred in either cohort that met BARC III or higher criteria. CONCLUSIONS: At the 6- and 12-month time points following R-PCI, no difference in clinical outcomes or safety measures was observed as compared to M-PCI.

Renal artery stenosis and ambulatory blood pressure monitoring: A case report and review of the literature.

Renal artery stenosis (RAS) is a prevalent cause of secondary hypertension. Elderly patients with atherosclerosis and young women with fibromuscular dysplasia (FMD) are particularly at risk. Blood pressure screening is often key to this diagnosis, although the reliability of clinical screening has been questioned, and ambulatory blood pressure monitoring (ABPM) likely offers superior ability to diagnose poorly controlled hypertension. In patients with RAS, medical management should be the primary means of therapy; however, in a select group of these patients, renal revascularization may be considered, and has been shown to reduce blood pressure and stabilize chronic kidney disease. In this report, we present a patient diagnosed with RAS due to FMD, found to have significant hypertension via ABPM, and treated successfully with percutaneous renal artery angioplasty; importantly, continuous 24-hr ambulatory monitoring after pressure gradient guided renal angioplasty confirmed reduction in blood pressure.

Percutaneous left atrial appendage occlusion in atrial fibrillation patients with a contraindication to oral anticoagulation: a focused review.

Stroke is the most feared complication of atrial fibrillation (AF). Although oral anticoagulation with non-vitamin K antagonist and non-vitamin K antagonist oral anticoagulants (NOACs) have been established to significantly reduce risk of stroke, real-world use of these agents are often suboptimal due to concerns for adverse events including bleeding from both patients and clinicians. Particularly in patients with previous serious bleeding, oral anticoagulation may be contraindicated. Left atrial appendage occlusion (LAAO), mechanically targeting the source of most of the thrombi in AF, holds an immense potential as an alternative to OAC in management of stroke prophylaxis. In this focused review, we describe the available evidence of various LAAO devices, detailing data regarding their use in patients with a contraindication for oral anticoagulation. Although some questions of safety and appropriate use of these new devices in patients who cannot tolerate anticoagulation remain, LAAO devices offer a significant step forward in the management of patients with AF, including those patients who may not be able to be prescribed OAC at all. Future studies involving patients fully contraindicated to OAC are warranted in the era of LAAO devices for stroke risk reduction.

Robotic technology in interventional cardiology: Current status and future perspectives.

Robotic technology has been utilized in cardiovascular medicine for over a decade, and over that period, its use has been expanded to percutaneous coronary and peripheral vascular interventions. The safety and feasibility of robotically assisted percutaneous cardiovascular interventions has been demonstrated in studies including simple to complex coronary lesions, and both iliac and femoropopliteal lesions. These reports have shown that robotically assisted PCI significantly reduces operator exposure to harmful ionizing radiation without a detrimental effect on procedural success or clinical efficacy. Additionally, the use of robotics has the intuitive benefit of alleviating the risk of orthopedic injuries faced by interventional operators. In addition to the interventional operator benefits, robotically assisted intervention has the potential for patient level benefit by allowing more accurate lesion length measurement, precise stent placement, and lower patient radiation exposure. However, further investigation is required to fully elucidate these potential benefits.

Thermoelectric property enhancement via pore confinement in template grown bismuth telluride nanowire arrays.

Nanostructuring of thermoelectric materials can lead to thermal-to-electrical conversion efficiencies comparable with mechanical energy conversion. Theory predicts that characteristic length scales of <10 nm are necessary to achieve high thermoelectric figures of merit (zT > 3). While sub-10 nm diameter nanowire arrays have been difficult to fabricate, we present here a novel template for sub-10 nm thermoelectric nanowire array fabrication using anodized aluminum oxide followed by silica wall coating for pore confinement. Electrodeposited bismuth telluride nanowires displayed increasing electrical-to-thermal conductivity ratio as the pore diameter decreased, in agreement with theoretical predictions. Achieving the desired stoichiometric ratio of Bi2Te3 through electrodeposition was non-trivial, which limited the Seebeck coefficient of the nanowires. However, hydrolysis of the nanopore walls led to improved electrodeposition, achieving near stoichiometric bismuth-to-tellurium ratios and ultimately p-type thermoelectric nanowire arrays with a Seebeck coefficient of up to 79 µV K-1.

Fractured pericardial drain sheath: Removal technique.

Pericardiocentesis with drain placement provides relief of symptomatic pericardial tamponade. The use of a pericardial sheath preserves access to the pericardial space in the event a drain may need to be replaced or manipulated. Although rare, sheath fracture and migration into the pericardial space may be a complication of prolonged sheath maintenance. Prompt action may allow percutaneous retrieval of the foreign body and avoid the need for surgical exploration. We report a case of successful percutaneous retrieval of a fractured pericardial sheath. © 2015 Wiley Periodicals, Inc.

Renal frame count: a measure of renal flow that predicts success of renal artery stenting in hypertensive patients.

OBJECTIVES: Renal artery (RA) stenting can improve control of hypertension yet predicting clinical response remains difficult. We sought to determine the role of the renal frame count (RFC) (number of angiographic frames for contrast to reach distal renal parenchyma after initial RA opacification) as a predictor of improvement in blood pressure (BP) after RA stenting. METHODS: Renal flow was quantified in 68 consecutive patients (age 72.5 ± 9.1 years, 72% male) undergoing RA stenting for refractory hypertension (BP ≥ 140/90 mm Hg despite treatment with two or more antihypertensive medications) by measuring RFC pre-RA stenting. Significant renal artery stenosis (RAS) was defined as a stenosis ≥ 70% by visual estimation on angiography. Baseline and 6-month follow-up BP was recorded. Clinical response was defined by a drop in systolic blood pressure (SBP) >10 mm Hg on the same or fewer number of anti-hypertensive medications. RESULTS: Patients with RFC > 30 had SBP reduction (43.2 ± 25.7 mm Hg vs. 30.1 ± 31.3 mm Hg, P = 0.067), diastolic blood pressure reduction (9.1 ± 19.0 vs. -0.2 ± 13.4 mm Hg, P = 0.02), and mean arterial pressure reduction (23.8 ± 19.4 vs. 11.8 ± 16.1 mm Hg, P < 0.001) compared to patients with RFC ≤ 30. Furthermore, baseline RFC >30 was associated with a higher rate of clinical response to RA stenting (93.5% vs. 73%, P = 0.027). CONCLUSIONS: RFC can be used as a clinical predictor of response to RA stenting. RFC > 30 was associated with reduction in BP after RA stenting and was predictive of clinical response. RFC provides a useful intraprocedural tool in assessing the severity of RAS and predicts the likelihood of clinical response following RA stenting.

Angiographic characteristics of definite stent thrombosis: role of thrombus grade, collaterals, epicardial coronary flow, and myocardial perfusion.

OBJECTIVES: To characterize the prevalence of thrombus burden, collateral vessels to the infarct-related artery, epicardial coronary artery flow, and myocardial perfusion in patients with angiographically confirmed definite stent thrombosis (ST), and to define their relationship with associated treatments and outcomes. BACKGROUND: Angiographic characteristics of ST are not well defined. METHODS: All cases of angiographically determined ST at five academic hospitals from 2005 to 2012 were reviewed. Demographic, procedural, and angiographic characteristics were recorded. In-hospital and 1-year follow-up data were obtained. RESULTS: Among 205 cases of angiographic definite ST (60 ± 8 years; 87% male), the majority presented with late/very late ST (69%) and STEMI (66%). High-risk angiographic findings at presentation included thrombus grade 4-5 (87%), absence of collateral vessels (76%), and reduced initial TIMI 3 flow (90%). Final TIMI 3 flow was achieved in 90% of patients and was associated with greater use of aspiration thrombectomy (60% vs. 25%; P = 0.003), glycoprotein IIb/IIIa inhibitors (80% vs. 30%, P < 0.001), and repeat stenting (67% vs. 10%, P < 0.001). A final myocardial perfusion grade of 2-3 was achieved in 79% of patients and was associated with greater use of aspiration thrombectomy (61% vs. 36%, P = 0.003). After multivariable logistic regression, aspiration thrombectomy (AOR 2.6, 95% CI 1.3-5.2) and implantation of a new stent (AOR 2.1, 95% CI 1.1-4.3) were associated with optimal combined epicardial flow and myocardial perfusion. At 1-year follow-up, significantly lower risk of repeat ST (HR 0.1; 95% CI 0.1,0.2; P < 0.001) among patients with initial TIMI 3 flow at index ST was observed. CONCLUSIONS: The majority of ST patients present with late/very late ST with high thrombus burden and STEMI. Presence of collateral vessels and low thrombus burden is cardioprotective, while reduced initial TIMI flow is associated with larger infarct size and recurrent ST. Aspiration thrombectomy and repeat stenting are associated with improved epicardial coronary artery flow and myocardial perfusion among patients treated for ST. © 2014 Wiley Periodicals, Inc.

Procedural success and long-term outcomes of aspiration thrombectomy for the treatment of stent thrombosis.

BACKGROUND: Stent thrombosis (ST) is associated with a significant burden of coronary thrombus and potential microvascular obstruction. Aspiration thrombectomy may decrease the extent of microvascular obstruction in patients with acute myocardial infarction but its role in the treatment of ST is uncertain. The present study sought to evaluate the association between aspiration thrombectomy, procedural success and long-term outcomes among patients presenting with ST. METHODS: In a multicenter cohort of patients with definite ST, procedural success, long-term mortality, and major adverse cardiovascular events (death, stroke, re-infarction, revascularization) were ascertained. Propensity weighting was used to determine the association between aspiration thrombectomy and long-term outcomes. RESULTS: A total of 205 patients with ST were identified. Among these, 115 (56%) patients underwent adjunctive aspiration thrombectomy during percutaneous coronary intervention. Patients undergoing aspiration thrombectomy were more likely to present with ST-elevation myocardial infarction (75% vs. 52%, P < 0.003) and require hemodynamic support (19% vs. 10%, P = 0.07). Aspiration thrombectomy was associated with improved procedural outcomes including postprocedural TIMI 3 flow, resulting in higher angiographic and procedural success (each 96% vs. 83%, P < 0.001). Despite improved angiographic outcomes, the use of aspiration thrombectomy was not associated with a difference in long-term mortality (adjusted HR 0.99, 95% CI 0.44-2.24) or major adverse cardiovascular events (adjusted HR 1.06, 95% CI 0.45-2.48). CONCLUSIONS: Aspiration thrombectomy is associated with improved coronary flow and procedural success but is not associated with improved long-term outcomes among patients undergoing percutaneous intervention for definite ST. CLINICAL TRIAL REGISTRATION: NCT00931502 (http://www.clinicaltrials.gov/ct2/show/NCT00931502)

Simultaneous Stenting With Edwards SAPIEN Transcatheter Pulmonary Valve Replacement.

Background: Prestenting of the landing zone for transcatheter pulmonary valve replacement (TPVR) with a balloon-expandable valve can dilate a stenotic right ventricular outflow tract (RVOT), prevent paravalvar leak (PVL), and protect against conduit tear. Simultaneous stenting (SS) with the Melody valve has been described, but to our knowledge, SS with a SAPIEN valve has not been reported. We report our experience with this novel technique. Methods: A retrospective chart review of patients who underwent TPVR at Rady Children's hospital and UCSD Medical Center was performed. Patients were included if they had underwent SAPIEN TPVR with SS. Rationale for stent choice was a bare metal stent to relieve long-segment stenosis and covered stents to prevent PVL or to protect against conduit tear. Results: A total of 17 cases were identified. The majority of RVOTs were transannular patches (n = 9, 56%), with a minimum diameter of 19.6 ± 5.2 mm, and the most common valve placed was an Edwards SAPIEN 26.0 mm (n = 10, 59%). All SAPIEN valves placed were of the S3 generation. The procedure was successful in all patients, with no conduit tears. Minor complications occurred in 3 patients (17.6%). Conclusions: Simultaneous stent deployment with a SAPIEN TPVR is an alternative 1-step technique for patients who require prestenting. SS simplifies the procedure, has low complication rates, and offers the benefits of a longer landing zone and decreased PVL.

Intravascularly infused extracellular matrix as a biomaterial for targeting and treating inflamed tissues.

Decellularized extracellular matrix in the form of patches and locally injected hydrogels has long been used as therapies in animal models of disease. Here we report the safety and feasibility of an intravascularly infused extracellular matrix as a biomaterial for the repair of tissue in animal models of acute myocardial infarction, traumatic brain injury and pulmonary arterial hypertension. The biomaterial consists of decellularized, enzymatically digested and fractionated ventricular myocardium, localizes to injured tissues by binding to leaky microvasculature, and is largely degraded in about 3 d. In rats and pigs with induced acute myocardial infarction followed by intracoronary infusion of the biomaterial, we observed substantially reduced left ventricular volumes and improved wall-motion scores, as well as differential expression of genes associated with tissue repair and inflammation. Delivering pro-healing extracellular matrix by intravascular infusion post injury may provide translational advantages for the healing of inflamed tissues 'from the inside out'.

Injectate volumes needed to reach specific landmarks in s1 transforaminal epidural injections.

OBJECTIVES: We identify the contrast volumes needed to reach specific landmarks during S1 transforaminal epidural injections (S1-TFEIs). DESIGN: Prospective, nonrandomized, observational human study. Setting. Academic/private pain management practice. Subjects. Forty-two patients undergoing S1-TFEIs were investigated. Thirty-seven patients were included in this study. Interventions. S1-TFEIs were performed using contrast-enhanced fluoroscopic visualization. MAIN OUTCOME MEASUREMENTS: After confirming appropriate spinal needle position, up to 5 mL of nonionic contrast was slowly injected. Under biplanar fluoroscopic guidance, contrast volumes were recorded as flow reached specific anatomic landmarks: the ipsilateral S1 pedicle, the superior aspect of the L5-S1 disc space, and across the midline of the spinous process. RESULTS: After injecting 2 mL of contrast, 100% of S1-TFEIs spread to the medial aspect of the ipsilateral superior pedicle of S1. After injecting 3.0 mL of contrast, 92% of S1-TFEIs spread to the superior aspect of the L5-S1 intervertebral disc. After injecting 4 mL of contrast, 27% of S1-TFEIs spread beyond the midline of the spinous process, but by only a few millimeters. CONCLUSIONS: This study demonstrates injectate volumes needed to reach specific anatomic landmarks in S1-TFEIs. A volume of 3.0 mL of contrast reaches the superior aspect of the L5-S1 intervertebral disc 92% of the time.

Right Ventricular and Pulmonary Computed Tomography Assessments in Paradoxical Low-Flow Low-Gradient Aortic Stenosis Undergoing Transcatheter Aortic Valve Replacement.

Background: Patients with paradoxical low-flow low-gradient aortic stenosis (pLFLG-AS) have high mortality and high degree of TAVR futility. Computed tomography (CT) enables accurate simultaneous right ventricular (RV) and parenchymal lung disease evaluation which may provide useful objective markers of AS severity, concomitant pulmonary comorbidities, and transcatheter aortic valve replacement (TAVR) improvement. However, the prevalence of RV dysfunction and its association with pulmonary disease in pLFLG-AS is unknown. The study objective was to test the hypothesis that pLFLG-AS patients undergoing TAVR have decreased RV function without significant parenchymal lung disease. Methods: Between August 2016 and March 2020, 194 consecutive AS patients completed high-resolution computed tomography (CT) imaging for TAVR evaluation. Subjects were stratified based on echocardiographic criteria as the study group, pLFLG (n=27), and two consecutive control groups: classic severe, normal-flow, high-gradient (n=27) and normal-flow, low-gradient (NFLG) (n=27) AS. Blinded biventricular function and lung parenchymal disease assessments were obtained by high-resolution CT imaging. Results: Patient demographics were similar between groups. pLFLG-AS had lower RV ejection fraction (49±10%) compared to both classic severe (58±7%, p<0.001) and NFLG AS (55±65%, p=0.02). There were no significant differences on lung emphysema (p=0.19), air fraction (p=0.58), and pulmonary disease presence (p=0.94) and severity (p=0.67) between groups. Conclusion: pLFLG-AS patients have lower RV ejection fraction, than classic severe and normal-flow low-gradient AS patients in the absence of significant parenchymal lung disease on CT imaging. These findings support the direct importance of RV function in the pathophysiology of aortic valve disease.