Correlation of aortic valve annular plane assessment by on-table three-dimensional rotational angiography and preprocedural computed tomography.

OBJECTIVES: To assess the correlation between the aortic valve annular plane (AVAP) obtained by preprocedural computed tomography (CT) with on-table three-dimensional rotational angiography (3DRA), in patients undergoing transcatheter aortic valve replacement (TAVR). BACKGROUND: Accurate assessment of the AVAP is critical during TAVR procedures to enable optimal positioning and minimize complications. Most commonly, preprocedural CT has been used to determine the AVAP. However, this can differ from the actual AVAP obtained during the TAVR procedure. METHODS: Consecutive TAVR patients at a single center undergoing both preprocedural CT and 3DRA were included in the study. The AVAP assessment by CT was performed using 3mensio software (Pie Medical Imaging). 3DRA assessment was performed using DynaCT (Siemens). RESULTS: A total of 100 patients were included in the analysis. A difference of ≥5° and ≥10° in both the LAO/RAO and cranial/caudal components of the AVAP projection angle as assessed by CT and 3DRA was recorded in 39% and 10% of patients, respectively. The concordance correlation coefficient for the LAO/RAO and cranial/caudal implantation angles was 0.519 (95% CI: 0.377-0.661) and 0.558 (95% CI: 0.432-0.684), respectively. CONCLUSION: Correlation between preprocedural CT and on-table 3DRA in the prediction of the actual AVAP at the time of TAVR implantation is moderate.

Cultural implications of late Holocene climate change in the Cuenca Oriental, Mexico.

There is currently no consensus on the importance of climate change in Mesoamerican prehistory. Some invoke drought as a causal factor in major cultural transitions, including the abandonment of many sites at 900 CE, while others conclude that cultural factors were more important. This lack of agreement reflects the fact that the history of climate change in many regions of Mesoamerica is poorly understood. We present paleolimnological evidence suggesting that climate change was important in the abandonment of Cantona between 900 CE and 1050 CE. At its peak, Cantona was one of the largest cities in pre-Columbian Mesoamerica, with a population of 90,000 inhabitants. The site is located in the Cuenca Oriental, a semiarid basin east of Mexico City. We developed a subcentennial reconstruction of regional climate from a nearby maar lake, Aljojuca. The modern climatology of the region suggests that sediments record changes in summer monsoonal precipitation. Elemental geochemistry (X-ray fluorescence) and δ(18)O from authigenic calcite indicate a centennial-scale arid interval between 500 CE and 1150 CE, overlaid on a long-term drying trend. Comparison of this record to Cantona's chronology suggests that both the city's peak population and its abandonment occurred during this arid period. The human response to climate change most likely resulted from the interplay of environmental and political factors. During earlier periods of Cantona's history, increasing aridity and political unrest may have actually increased the city's importance. However, by 1050 CE, this extended arid period, possibly combined with regional political change, contributed to the city's abandonment.

Dynamic left ventricular outflow tract gradient resulting from Takotsubo cardiomyopathy ameliorated by intra-aortic balloon pump counterpulsation: a case report.

BACKGROUND: Takotsubo cardiomyopathy is a variant of acute coronary syndrome with characteristic acute left ventricular apical ballooning. Uncommonly, there can be associated left ventricular outflow tract (LVOT) obstruction causing cardiogenic shock refractory to inotropic support. The use of afterload-reducing mechanical support such as intra-aortic balloon pump (IABP) counterpulsation is not routinely employed in instances of this kind. CASE SUMMARY: In our case report, we describe a 66-year-old female with acute Takotsubo cardiomyopathy and associated LVOT obstruction which failed to respond to high-dose dobutamine and whose clinical trajectory was worsened by fast atrial fibrillation with rapid ventricular response. Within 24 h of admission, the patient had an IABP placed which rapidly improved her haemodynamics. Two days later, IABP was removed and within 6 days of admission, apical ballooning and LVOT obstruction had fully recovered. CONCLUSION: We recommend early use of mechanical support with IABP counterpulsation to expedite recovery in patients with acute Takotsubo cardiomyopathy with associated LVOT obstruction.

Double Anomalies: Brugada Syndrome Presenting with a Persistent Left Superior Vena Cava.

BACKGROUND The presentation of Brugada syndrome (BrS) with a persistent left superior vena cava (PLSVC) is expected to be a rare entity. It is unknown if this venous anomaly is linked to the arrhythmogenesis seen in BrS, or it is coincidental. This case describes a clinical presentation of the 2, in tandem, and displays the anomaly in association with BrS. CASE REPORT A 54-year-old female presented to the Emergency Department with non-prodromal syncope. This was on a background of a number of similar episodes in the past, and a current suspected viral illness comprising fever and diarrhea. Her resting electrocardiogram was suggestive of BrS. The later was confirmed with an ajmaline provocation test after ECG normalization in the subsequent 24 hours post admission. Pre-intracardiac defibrillator (ICD) procedure imaging displayed the PLSVC. An ICD was implanted, and the advancement of the guidewires displayed the venous anomaly. Post-procedure echocardiography confirmed appropriate positioning of the leads. The patient recovered well and is currently symptom free. CONCLUSIONS PLSVC presenting with BrS is a rare occurrence. It is unknown whether or not the PLSVC and BrS are linked in their presentation, or merely a coincidence.

Dynamic Local Activation Time Mapping in Heavily Scarred Left Atrium and Persistent Atrial Fibrillation: A proof of concept case report.

We report the case of a 68-year-old male, presenting with persistent atrial fibrillation (Pe AF) refractory to anti arrhythmic medications and cardioversion, on a background history of ischaemic heart disease. Pre and post standard pulmonary vein isolation (PVI), left atrial (LA) voltageanalyses wereperformed, followed by dynamic local activation time (DLAT) mapping in addition to focal activity identification.Thisdemonstrated a heavily scarred LA, and a number ofareas of focal activity. The patient remained in atrial fibrillation (AF) post rotor (focal activity) targeting,howevernotable changes in AF cycle length (CL)werenotedandslowed by an average of 25.3 milliseconds. Comparison between DLAT mappingpre and post PVI were anatomically similar but not identical. The anatomical distribution of heavy scar areas in the LA did not correspond to the DLAT areas of interest. The patient subsequentlyremained in normal sinus rhythm (SR) for 6 monthson a low dose Beta blockade in a short follow up period. DLAT mapping and its characteristics in heavily scarred LA are reported in this case.

The Value of Voltage Histogram Analysis Derived Right Atrial Scar Burden in the Prediction of Left Atrial Scar Burden.

INTRODUCTION: Growing evidence suggests that fibrotic changes can be observed in atrial fibrillation (AF) in both atria. Quantification of the scar burden during electroanatomical mapping might have important therapeutic and prognostic consequences. However, as the current invasive treatment of AF is focused on the left atrium (LA), the role of the right atrium (RA) is less well understood. We aimed to characterize the clinical determinates of the RA low-voltage burden and its relation to the LA scaring. METHODS: We have included 36 patients who underwent catheter ablation for AF in a prospective observational study. In addition to LA mapping and ablation, high-density RA bipolar voltage maps (HD-EAM) were also reconstructed. The extent of the diseased RA tissue (≤0.5 mV) was quantified using the voltage histogram analysis tool (CARTO®3, Biosense Webster). RESULTS: The percentage of RA diseased tissue burden was significantly higher in patients with a CHA2DS2-VASc score ≥ 2 (p = 0.0305), higher indexed LA volume on the CTA scan and on the HD-EAM (p = 0.0223 and p = 0.0064, respectively), or higher indexed RA volume on the HD-EAM (p = 0.0026). High RA diseased tissue burden predicted the presence of high LA diseased tissue burden (OR = 7.1, CI (95%): 1.3-38.9, p = 0.0145), and there was a significant correlation of the same (r = 0.6461, p < 0.0001). CONCLUSIONS: Determining the extent of the right atrial low-voltage burden might give useful clinical information. According to our results, the diseased tissue burden correlates well between the two atria: the right atrium mirrors the left atrium.

Trans-catheter paravalvular leak closure: a single-centre experience.

INTRODUCTION: A significant paravalvular leak (PVL) is estimated in at least 1-3% of patients undergoing surgical aortic and/or mitral valve replacement. Surgical repair of a PVL is associated with a 30-day mortality of approximately 10%. Percutaneous closure of PVL has emerged as an alternative to surgical repair. AIM: We sought to examine the clinical outcomes of patients treated with percutaneous closure of PVL at an Irish tertiary referral centre. METHODS: A prospective registry was used to record patient and procedural characteristics at the time of the PVL procedure. Medical records were retrospectively reviewed to assess clinical outcomes during the index hospitalisation and at follow-up. RESULTS: A total of 26 PVL procedures were performed in 21 patients (mean age 68 ± 13 years, 76% male). Heart failure (HF), haemolysis (HL) or a combination of both was the presenting symptoms in 62%, 24% and 14% of patients, respectively. In the entire cohort, clinical success was achieved in 18 patients (86%). Clinical success was achieved more frequently when HF was the clinical indication compared to HL (100% versus 66%). Among patients presenting with isolated HF (n = 13), the mean NYHA class at baseline and follow-up was 2.5± 0.7 and 1.4± 0.7, respectively. Thirty-day mortality was 0%. There was one (3.8%) major adverse procedural complication (stroke). A total of six deaths (28%) occurred during follow-up (22 ± 13.4 months). CONCLUSIONS: Patients with PVL represent a high-risk patient cohort. Percutaneous PVL offers a safe alternative to surgical PVL repair and appears particularly effective in those patients who present primarily with HF.

The "dual degree". Does it change the scope of practice for oral and maxillofacial surgery?

The scope of practice for OMS is not, nor should it ever be, an issue of single or dual degree but must be related to the surgeon being trained to competence in the procedures performed. Future evolution will be based on continual advancements in the specialty and related areas as well as the development of new techniques. While the medical education may improve a core fund of general knowledge, the surgical residency and/or fellowship is the determinant of surgical competence and scope of practice.

Embryonic rotational behaviour in the pond snail Lymnaea stagnalis: influences of environmental oxygen and development stage.

Responses of freshwater organisms to environmental oxygen tensions (PO(2)) have focused on adult (i.e. late developmental) stages, yet responses of embryonic stages to changes in environmental PO(2) must also have implications for organismal biology. Here we assess how the rotational behaviour of the freshwater snail Lymnaea stagnalis changes during development in response to conditions of hypoxia and hyperoxia. As rotation rate is linked to gas mixing in the fluid surrounding the embryo, we predicted that it would increase under hypoxic conditions but decrease under hyperoxia. Contrary to predictions, early, veliger stage embryos showed no change in their rotation rate under hyperoxia, and later, hippo stage embryos showed only a marginally significant increase in rotation under these conditions. Predictions for hypoxia were broadly supported, however, with both veliger and hippo stages showing a marked hypoxia-related increase in their rotation rates. There were also subtle differences between developmental stages, with hippos responding at PO(2)s (50% air saturation) greater than those required to elicit a similar response in veligers (20% air saturation). Differences between developmental stages also occurred on return to normoxic conditions following hypoxia: rotation in veligers returned to pre-exposure levels, whereas there was a virtual cessation in embryos at the hippo stage, likely the result of overstimulation of oxygen sensors driving ciliary movement in later, more developed embryos. Together, these findings suggest that the spinning activity of L. stagnalis embryos varies depending on environmental PO(2)s and developmental stage, increasing during hypoxia to mix capsular contents and maintain a diffusive gradient for oxygen entry into the capsule from the external environment ("stir-bar" theory of embryonic rotational behaviour).