Spatial distribution and factors influencing the accumulation of toxic metals in soils in mountain agroecosystems, Rio De Janeiro, Brazil.

The concentrations of toxic metals (TM) were analyzed in 498 samples of agricultural soils used for intensive vegetable cultivation in the watershed of Barracão dos Mendes, Brazil. The goal of this study was to characterize the distribution of these elements and the main natural and anthropogenic factors affecting their accumulation. In general, the average concentrations of TM were higher than the reference quality values for cultivated soils in the region, with the exception of Cr, Co, Ni and Mn, and the average concentration of Cd was ten times greater. Three sources of variation in the distribution of TM concentrations were identified: one related to topographic relief, another related to lithology, and one related to the massive use of agrochemicals. These factors contributed to TM accumulation in the soil; moreover, the transport of toxic metal-enriched clay by runoff resulted in higher concentrations of these elements in the lower parts of the slope. The long-term application of massive amounts of fertilizers and pesticides resulted in the accumulation of Cr, Cu, Zn, Ni, Pb and Cd in the vegetable cultivation soils and promoted the enrichment of macronutrients, mainly P and K. Moreover, the spatial distribution of TM in the agricultural soils of this mountain agroecosystem was affected by intensive vegetable cultivation, which altered the natural TM distribution dynamics determined by variations in topographic relief and lithology. In intensive cultivation areas, the TM distribution was also influenced by soil management practices such as tillage along the slope direction and massive mineral and organic fertilization.

Acceleration strategies for Tridimensional Coupled hydromechanical problems based on CPU and GPU programming in MATLAB.

Large-scale fluid flow in porous media demands intense computations and occurs in the most diverse applications, including groundwater flow and oil recovery. This article presents novel computational strategies applied to reservoir geomechanics. Advances are proposed for the efficient assembly of finite element matrices and the solution of linear systems using highly vectorized code in MATLAB. In the CPU version, element matrix assembly is performed using conventional vectorization procedures, based on two strategies: the explicit matrices, and the multidimensional products. Further assembly of the global sparse matrix is achieved using the native sparse function. For the GPU version, computation of the complete set of element matrices is performed with the same strategies as the CPU approach, using gpuArray structures and the native CUDA support provided by MATLAB Parallel Computing Toolbox. Solution of the resulting linear system in CPU and GPU versions is obtained with two strategies using a one-way approach: the native conjugate gradient solver (pcg), and the one provided by the Eigen library. A broad discussion is presented in a dedicated benchmark, where the different strategies using CPU and GPU are compared in processing time and memory requirements. These analyses present significant speedups over serial codes.

A Small World Graph Approach for an Efficient Indoor Positioning System.

The main goal of an Indoor Positioning System (IPS) is to estimate the position of mobile devices in indoor environments. For this purpose, the primary source of information is the signal strength of packets received by a set of routers. The fingerprint technique is one of the most used techniques for IPSs. By using supervised machine learning techniques, it trains a model with the received signal intensity information so it can be used to estimate the positions of the devices later in an online phase. Although the k-Nearest Neighbors (kNN) is one of the most widely used classification methods due to its accuracy, it has no scalability since a sample that needs to be classified must be compared to all other samples in the training database. In this work, we use a novel hierarchical navigable small world graph technique to build a search structure so the location of a sample can be efficiently found, allowing the IPSs to be used in large-scale scenarios or run on devices with limited resources. To carry out our performance evaluation, we proposed a synthetic IPS dataset generator as well as implemented a complete real-world, large-scale IPS testbed. We compared the performance of our graph-based solution with other known kNN variants, such as Kd-Tree and Ball-Tree. Our results clearly show the performance gains of the proposed solution at 98% when compared to the classic kNN and at least 80% when compared to tree-based approaches.

Intraprocedural high-degree atrioventricular block or complete heart block in transcatheter aortic valve replacement recipients with no prior intraventricular conduction disturbances.

BACKGROUND: Conduction disturbances are the most frequent complication of transcatheter aortic valve replacement (TAVR). However, no data exists regarding the outcomes of intraprocedural high-degree atrioventricular block (HAVB) or complete heart block (CHB) in patients without previous conduction disturbances. OBJECTIVES: The aim of this study was to evaluate the outcomes of intraprocedural-HAVB/CHB in patients without previous intraventricular conduction disturbances. METHODS: The occurrence of intraprocedural-HAVB/CHB was assessed in 676 consecutive patients undergoing TAVR, and two groups were established according to its duration: persistent-HAVB/CHB (PHAVB/CHB) and transient-HAVB/CHB (THAVB/CHB), not present at the end of the procedure. RESULTS: Intraprocedural-HAVB/CHB occurred in 50 patients (7.4%), being persistent in 32 (64.0%), and transient in 18 (36.0%). The use of Medtronic Corevalve Revalving System (MCRS) and a greater oversizing of the valve increased the risk of intraprocedural-HAVB/CHB (p < 0.001). Permanent pacemaker implantation (PPI) was more frequent in the PHAVB/CHB than in the THAVB/CHB group (96.9% vs. 33.3%; p < 0.001). At 1-month follow-up, the PHAVB/CHB group showed a 98% ventricular pacing rate (VPR) compared to 16% in the THAVB/CHB group (p < 0.001), and similar VPR were observed at 1-year follow-up (98% vs. 37%, p < 0.001). Left ventricular ejection fraction (LVEF) decreased at 1-year follow-up in patients with PHAVB/CHB (-3.9 ± 1.8%, p = 0.003). CONCLUSIONS: In TAVR recipients with no prior intraventricular conduction disturbances, intraprocedural-HAVB/CHB occurred in 7.4% of cases. HAVB/CHB was persistent in most cases and determined a high rate of PPI post-TAVR. Very high VPR at 1- and 12-month follow-up were observed, which in turn was associated with a negative effect on LVEF. These results support early PPI and close follow-up in patients developing intraprocedural-PHAVB/CHB.

Clinical and Technical Characteristics of Coronary Angiography and Percutaneous Coronary Interventions Performed before and after Transcatheter Aortic Valve Replacement with a Balloon-Expandable Valve.

OBJECTIVES: To report on the feasibility and technical differences between coronary procedures performed before and after TAVR with the balloon-expandable Edwards-SAPIEN or the SAPIEN XT valves. BACKGROUND: Coronary artery disease (CAD) and aortic stenosis often coexist. Transcatheter aortic valve replacement (TAVR) is emerging as a treatment for younger and lower surgical risk patients who might not present with clinically evident CAD before TAVR. The demand for performing post-TAVR coronary angiograms (CAs) and percutaneous coronary interventions (PCIs) will thus increase, posing new technical challenges. METHODS: Over 1000 TAVRs were performed at the Quebec Heart and Lung Institute, of which 616 with the abovementioned valves. Of these, 28 patients had an analyzable pre- and post-TAVR CAs and 13 patients had pre- and post-TAVR PCIs performed. Procedural characteristics were gathered from all coronary procedures and subsequently compared amongst the same type of procedure performed at these two distinct time periods. RESULTS: Neither CAs-nor PCIs-performed after valve implantation revealed significant differences regarding arterial access site, catheter diameter, number of diagnostic or guiding catheters used, procedural duration, fluoroscopy time, or achievement of selective coronary injection. Lesion location and classification, as well as the preference of using a drug-eluting stent, remained unchanged. During post-TAVR CA, the amount of contrast delivered and the radiation dose area product were significantly lower compared with pre-TAVR CA values. CONCLUSIONS: Performance of CA and PCI after TAVR with a balloon-expandable valve appears unaffected by its presence.

Soil heavy metal content on the hillslope region of Rio de Janeiro, Brazil: reference values.

The increasing concern regarding the preservation of soil quality suggests the adoption of quality reference values as a first step in environmental monitoring actions. In this context, the objective of this study was to establish soil quality reference values for Al, Zn, Mn, Cd, Fe, Pb, Ni, Cr, and Cu and to correlate several soil properties with the occurrence of these elements in the hillslope region of Rio de Janeiro State. Sixty-two samples were collected at depths of 0-20 and 20-40 cm and analyzed using the USEPA method 3051A. After clustering analysis, the samples were separated into three groups. Classification functions were obtained based on the variables pH - Mg - Fe - Mn, i.e., the variables that were best related to heavy metal content. We determined to establish the quality reference values for the 75th percentile of the three groups. The relief forms of the area, which facilitate the transport of soil fine-particle fractions and accumulation in lowlands, were revealed to be one of most important factors in understanding the distribution of soil heavy metals.

Indoor environment dataset based on RSSI collected with bluetooth devices.

This paper describes a data collection experiment focused on researching indoor positioning systems using Bluetooth Low Energy (BLE) devices. The study was conducted in a real-world scenario with 150 test points and collected signals from 11 mobile devices. The dataset contains RSSI values from the mobile devices in relation to 15 fixed anchor nodes in the experimentation scenario. The dataset includes data on device identification, labels and coordinates of test points, and the room where the data was collected. The data is organized as CSV files and offers valuable information for researchers developing and assessing location models. By sharing this dataset, we aim to support the creation of robust and precise indoor localization models.

Application of microtomography and petrography techniques for the characterization of porosity of synthetic carbonatic rock minerals before and after acidification processes.

The objective of this work is to physically characterize and analyze synthetic carbonate rocks through microtomography and petrography techniques, focusing on a comparative analysis before and after degradation with a reactive fluid. For this study, physical characterization analysis with computerized microtomography and petrography on the samples before and after the acidification procedure was performed. The petrographic analysis verified an increase in both intergranular and intragranular porosities after dissolution. The microtomography analysis quantified the maximum increase in porosity, from 11.8 to 41.3% in the two-dimensional analysis and 31.6-52% in the three-dimensional analysis of the porous structures. Furthermore, the pores were quantified according to their area, and data was obtained on the orientation of the pores, providing insight into the preferred paths of fluid flow. It was also observed that the microtomography technique was an effective tool for characterizing fractures in the samples before and after dissolution. Such analyses are crucial for the extraction and injection of fluids at high depths due to the mechanical and physical risks arising from the dissolution of minerals as well as changes in pressure, temperature, and saturation, all of which affect the stress state of the reservoir rock.

Hemodynamic and Clinical Outcomes in Redo-Surgical Aortic Valve Replacement vs. Transcatheter Valve-in-Valve.

Background: Transcatheter valve-in-valve replacement (ViV-TAVR) has emerged as an alternative to redo-surgical aortic valve replacement (Redo-SAVR) for the treatment of failed surgical aortic bioprostheses. However, the benefit of ViV-TAVR compared with Redo-SAVR remains debated with regard to short-term hemodynamic results and short- and long-term clinical outcomes. Objective: This study aimed to compare short-term hemodynamic performance and long-term clinical outcomes of ViV-TAVR vs. Redo-SAVR in patients treated for surgical aortic bioprosthetic valve failure. Methods: We retrospectively analyzed the data prospectively collected in 184 patients who underwent Redo-SAVR or ViV-TAVR. Transthoracic echocardiography was performed before and after the procedure and analyzed in an echocardiography core laboratory using the new Valve Academic Research Consortium-3 criteria. An inverse probability of treatment weighting was used to compare the outcomes between both procedures. Results: ViV-TAVR showed lower rate of intended hemodynamic performance (39.2% vs. 67.7%, p < 0.001) at 30 days, which was essentially driven by a higher rate (56.2% vs. 28.8%, p = 0.001) of high residual gradient (mean transvalvular gradient ≥20 mm Hg). Despite a trend for higher 30-day mortality in the Redo-SAVR vs. ViV-TAVR group (8.7% vs. 2.5%, odds ratio [95% CI]: 3.70 [0.77-17.6]; p = 0.10), the long-term mortality was significantly lower (24.2% vs. 50.1% at 8 years; hazard ratio [95% CI]: 0.48 [0.26-0.91]; p = 0.03) in the Redo-SAVR group. After inverse probability of treatment weighting analysis, Redo-SAVR remained significantly associated with reduced long-term mortality compared with ViV-TAVR (hazard ratio [95% CI]: 0.32 [0.22-0.46]; p < 0.001). Conclusions: ViV-TAVR was associated with a lower rate of intended hemodynamic performance and numerically lower mortality at 30 days but higher rates of long-term mortality compared with Redo-SAVR.

Epiploic appendagitis in a Spiegel hernia: A case report and review of the literature.

INTRODUCTION: Spigelian hernia is a rare differential diagnosis of abdominal pain. It affects mainly women above the fifth decade of life, more on the left side than on the right side, usually with comorbidities that lead to an increase in intra-abdominal pressure, described as risk factors for the outbreak of ventral hernias. The content of a ventral hernia might be an epiploic appendix and lead to appendagitis. PRESENTATION OF CASE: This article presents the case of an 82-year-old female patient who presented epiploic appendagitis in a Spigelian hernia. DISCUSSION: Spigelian hernia is a rare type of ventral hernia, especially in association with an epiploic appendagitis. A literature search of this rare entity yielded three publications presenting epiploic appendagitis in a Spigelian hernia. The initial approach after the diagnosis should be adequate analgesia associated with surgical correction of the hernia. There is no gold standard treatment for the repair. European and American societies suggest that if there is no palpable nodule, laparoscopic repair is preferable, always using a mesh. CONCLUSION: Epiploic appendagitis in a Spigelian hernia is a rare condition whose diagnosis is a big challenge. However, the correct diagnosis can lead to a shorter hospital stay, with less cost and avoid the use of unnecessary medications.

Reclassification of prosthesis-patient mismatch after transcatheter aortic valve replacement using predicted vs. measured indexed effective orifice area.

AIMS: The objective was to compare the incidence and impact on outcomes of measured (PPMM) vs. predicted (PPMP) prosthesis-patient mismatch following transcatheter aortic valve replacement (TAVR). METHODS AND RESULTS: All consecutives patients who underwent TAVR between 2007 and 2018 were included. Effective orifice area (EOA) was measured by Doppler-echocardiography using the continuity equation and predicted according to the normal reference for each model and size of valve. PPM was defined using EOA indexed (EOAi) to body surface area as moderate if ≤0.85 cm2/m2 and severe if ≤ 0.65 cm2/m2 (respectively, ≤ 0.70 and ≤ 0.55 cm2/m2 if body mass index ≥ 30 kg/m2). The outcome endpoints were high residual gradient (≥20 mmHg) and the composite of cardiovascular mortality and hospital readmission for heart failure at 1 year. Overall, 1088 patients underwent a TAVR (55% male, age 79.1 ± 8.4 years, and STS score 6.6 ± 4.7%); balloon-expandable device was used in 83%. Incidence of moderate (10% vs. 27%) and severe (1% vs. 17%) PPM was markedly lower when defined by predicted vs. measured EOAi (P < 0.001). Balloon-expandable device implantation (OR: 1.90, P = 0.029) and valve-in-valve procedure (n = 118; OR: 3.21, P < 0.001) were the main factors associated with PPM occurrence. Compared with measured PPM, predicted PPM showed stronger association with high residual gradient. Severe measured or predicted PPM was not associated with clinical outcomes. CONCLUSION: The utilization of the predicted EOAi reclassifies the majority of patients with PPM to no PPM following TAVR. Compared with measured PPM, predicted PPM had stronger association with haemodynamic outcomes, while both methods were not associated with clinical outcomes.

Multimodality evaluation of transcatheter structural valve degeneration at long-term follow-up.

INTRODUCTION AND OBJECTIVES: We assessed the long-term hemodynamic performance of transcatheter heart valve (THV) by paired transthoracic echocardiography (TTE), and the incidence, characteristics and factors associated with THV structural valve degeneration (SVD). METHODS: A total of 212 patients who underwent transcatheter aortic valve replacement and had a potential follow-up >5 years with at least 1 TTE ≥ 1-year postprocedure were included. All patients had a TTE at 1 to 5 years and 36 had another one at 6 to 10 years. SVD was defined as subclinical (increase >10mmHg in mean transvalvular gradient+decrease >0.3cm2 in valve area and/or new-onset mild or moderate aortic regurgitation) and clinically relevant (increase> 20mmHg in mean transvalvular gradient+decrease> 0.6cm2 in valve area and/or new-onset moderate-to-severe aortic regurgitation). Fifteen patients had a transesophageal echocardiography at the time of SVD diagnosis, and 85 an opportunistic computed tomography examination at 1 (0.5-2) years. RESULTS: Transvalvular mean gradient increased and valve area decreased over time (P<.01). At 8 years of follow-up, SVD occurred in 30.2% of patients (clinically relevant: 9.3%). Transesophageal echocardiography revealed thickened and reduced-mobility leaflets in 80% and 73% of SVD cases, respectively. No baseline or procedural factors were associated with SVD. THV underexpansion (3.5%) or eccentricity (8.2%) had no impact on valve hemodynamics/SVD at follow-up. CONCLUSIONS: A gradual THV hemodynamic deterioration occurred throughout a 10-year period, leading to SVD in ∼30% of patients (clinically relevant in < 10%). Leaflet morphology/mobility were frequently impaired in SVD cases, but THV geometry did not influence valve hemodynamics or SVD.

Radiation Exposure During Transcatheter Aortic Valve Replacement: Impact of Arterial Approach and Prosthesis Type.

BACKGROUND: The impact of novel alternative access and valve type on radiation exposure during transcatheter aortic valve replacement (TAVR) has not yet been evaluated. This study sought to determine the impact of a transarterial approach and prosthesis type on physician and patient exposure to radiation during TAVR. METHODS: This was a prospective study including 140 consecutive patients undergoing TAVR by transfemoral (n = 102) or transcarotid (TC) (n = 38) access at 2 centers. Implanted valves were the self-expanding Evolut R/PRO system (Medtronic, Minneapolis, MN; n = 38) and the balloon-expandable SAPIEN 3 valve (Edwards Lifesciences, Irvine, CA; n = 102). The primary endpoint was first operator radiation exposure. The secondary endpoint was patient radiation exposure. RESULTS: First operator radiation exposure was 4-fold greater during TC TAVR (P < .001). The use of a self-expanding valve was associated with a longer x-ray time (P = .015) and a 2-fold greater first operator radiation dose (P = .018). Patient radiation dose was not significantly affected by arterial approach (P = .055) or valve type (P = .095). After adjustment for potential confounders, the TC approach remained associated with a 174.8% (95% confidence interval, 80.6-318.3, P < .001) increase in first operator radiation dose, whereas the use of a self-expanding valve no longer influenced the first operator dose (P = .630). CONCLUSIONS: TC access and the use of a self-expanding valve were associated with a 4- and 2-fold greater first operator radiation exposure during TAVR procedures, respectively. Unlike the arterial approach, the effect of bioprosthesis type on radiation exposure was mainly related to x-ray time and was no longer significant after adjustment.

Brazilian Version of the Self-Estimated Functional Inability Because of Pain in Dancers: A Validation Study.

OBJECTIVE: The purpose of this study was to measure the reliability, internal consistency, construct validity, and floor and ceiling effects of the Brazilian version of the Self-Estimated Functional Inability because of Pain (SEFIP-dance) instrument. METHODS: This was a questionnaire validation study. Both professional dancers and those who use dance as a recreational activity were included in the study. For test-retest reliability, SEFIP-dance was administered to the same dancer at 2 different times, with an interval of 7 days between the moments. For construct validity, Spearman's correlation coefficient (r s) was used to determine the magnitude of the correlations between SEFIP-dance and the Numerical Rating Scale, the 36-Item Short-Form Health Survey, the Roland-Morris Disability Questionnaire for general pain, and the Örebro Musculoskeletal Pain Questionnaire. RESULTS: A total of 111 dancers were recruited and included in the study. From this total sample, a subsample of 31 was used for the calculations of test-retest reliability: when considering each item of SEFIP-dance, we observed adequate κ values (κ ≥ 0.52); considering the total score, we observed excellent reliability (intraclass correlation coefficient = 0.94). In addition, we identified adequate values for internal consistency (Cronbach's α ≥ 0.80). We observed significant correlations of the SEFIP-dance total score with the Numerical Rating Scale, 36-Item Short-Form Health Survey, the Roland-Morris questionnaire, and the Örebro Musculoskeletal Pain Questionnaire (r s varying between 0.248 and 0.489). Ceiling and floor effects were not observed. CONCLUSION: This study found that the Brazilian Portuguese version of SEFIP-dance has psychometric properties suitable for its use in dancers.

Impact of Morbid Obesity and Obesity Phenotype on Outcomes After Transcatheter Aortic Valve Replacement.

Background There is a paucity of outcome data on patients who are morbidly obese (MO) undergoing transcatheter aortic valve replacement. We aimed to determine their periprocedural and midterm outcomes and investigate the impact of obesity phenotype. Methods and Results Consecutive patients who are MO (body mass index, ≥40 kg/m2, or ≥35 kg/m2 with obesity-related comorbidities; n=910) with severe aortic stenosis who underwent transcatheter aortic valve replacement in 18 tertiary hospitals were compared with a nonobese cohort (body mass index, 18.5-29.9 kg/m2, n=2264). Propensity-score matching resulted in 770 pairs. Pre-transcatheter aortic valve replacement computed tomography scans were centrally analyzed to assess adipose tissue distribution; epicardial, abdominal visceral and subcutaneous fat. Major vascular complications were more common (6.6% versus 4.3%; P=0.043) and device success was less frequent (84.4% versus 88.1%; P=0.038) in the MO group. Freedom from all-cause and cardiovascular mortality were similar at 2 years (79.4 versus 80.6%, P=0.731; and 88.7 versus 87.4%, P=0.699; MO and nonobese, respectively). Multivariable analysis identified baseline glomerular filtration rate and nontransfemoral access as independent predictors of 2-year mortality in the MO group. An adverse MO phenotype with an abdominal visceral adipose tissue:subcutaneous adipose tissue ratio ≥1 (VAT:SAT) was associated with increased 2-year all-cause (hazard ratio [HR], 3.06; 95% CI, 1.20-7.77; P=0.019) and cardiovascular (hazard ratio, 4.11; 95% CI, 1.06-15.90; P=0.041) mortality, and readmissions (HR, 1.81; 95% CI, 1.07-3.07; P=0.027). After multivariable analysis, a (VAT:SAT) ratio ≥1 remained a strong predictor of 2-year mortality (hazard ratio, 2.78; P=0.035). Conclusions Transcatheter aortic valve replacement in patients who are MO has similar short- and midterm outcomes to nonobese patients, despite higher major vascular complications and lower device success. An abdominal VAT:SAT ratio ≥1 identifies an obesity phenotype at higher risk of adverse clinical outcomes.

Transcatheter Replacement of Transcatheter Versus Surgically Implanted Aortic Valve Bioprostheses.

BACKGROUND: Surgical aortic valve replacement and transcatheter aortic valve replacement (TAVR) are now both used to treat aortic stenosis in patients in whom life expectancy may exceed valve durability. The choice of initial bioprosthesis should therefore consider the relative safety and efficacy of potential subsequent interventions. OBJECTIVES: The aim of this study was to compare TAVR in failed transcatheter aortic valves (TAVs) versus surgical aortic valves (SAVs). METHODS: Data were collected on 434 TAV-in-TAV and 624 TAV-in-SAV consecutive procedures performed at centers participating in the Redo-TAVR international registry. Propensity score matching was applied, and 330 matched (165:165) patients were analyzed. Principal endpoints were procedural success, procedural safety, and mortality at 30 days and 1 year. RESULTS: For TAV-in-TAV versus TAV-in-SAV, procedural success was observed in 120 (72.7%) versus 103 (62.4%) patients (p = 0.045), driven by a numerically lower frequency of residual high valve gradient (p = 0.095), ectopic valve deployment (p = 0.081), coronary obstruction (p = 0.091), and conversion to open heart surgery (p = 0.082). Procedural safety was achieved in 116 (70.3%) versus 119 (72.1%) patients (p = 0.715). Mortality at 30 days was 5 (3%) after TAV-in-TAV and 7 (4.4%) after TAV-in-SAV (p = 0.570). At 1 year, mortality was 12 (11.9%) and 10 (10.2%), respectively (p = 0.633). Aortic valve area was larger (1.55 ± 0.5 cm2 vs. 1.37 ± 0.5 cm2; p = 0.040), and the mean residual gradient was lower (12.6 ± 5.2 mm Hg vs. 14.9 ± 5.2 mm Hg; p = 0.011) after TAV-in-TAV. The rate of moderate or greater residual aortic regurgitation was similar, but mild aortic regurgitation was more frequent after TAV-in-TAV (p = 0.003). CONCLUSIONS: In propensity score-matched cohorts of TAV-in-TAV versus TAV-in-SAV patients, TAV-in-TAV was associated with higher procedural success and similar procedural safety or mortality.

The polymethylmethacrylate effects on auricle conchal cartilage: report of 21 cases.

BACKGROUND: Both surgical and nonsurgical techniques, including soft tissue augmentation, are available to restore a youthful appearance to the face. Soft tissue augmentation with nonabsorbable fillers is increasingly important, as a growing number of patients are seeking aesthetic improvement without the downtime and cost of major surgical procedures. Polymethylmethacrylate (PMMA), an injectable implant composed of a suspension of microspheres in different media, is one such soft tissue filler. OBJECTIVES: Because the application of PMMA into the pericartilage of the ear is becoming a more common practice among plastic surgeons, the authors offer a systematic analysis of its effects. They believe this information to be of paramount importance to prevent injuries and deformities. METHODS: Twenty-one patients who presented to the lead author's clinic with prominent ears during a period of 16 months between 2007 and 2008 were retrospectively reviewed. The authors analyzed PMMA's effects on each patient's ear shell cartilage, which was extracted during correction without causing any kind of injury or deformity to the participants in this study. RESULTS: The histopathologic study from the excised skin and cartilage samples showed a granulomatous inflammation in all patients. There was no association between the incidence of tissue alterations and the mean length of PMMA on the conchal cartilage. CONCLUSIONS: The potential consequences of PMMA injection in close proximity to cartilage cannot be predicted and the possibility of myxomatous cartilage degeneration is a serious potential adverse event because it can cause permanent deformities of the cartilaginous skeleton.

Interatrial Shunting for Treating Acute and Chronic Left Heart Failure.

The creation of an interatrial shunt has emerged as a new therapy to decompress the left atrium in patients with acute and chronic left heart failure (HF). Current data support the safety of this therapy, and promising preliminary efficacy results have been reported in patients who are refractory to optimal medical/device therapy. This article aims to provide an updated overview and clinical perspective on interatrial shunting for treating different HF conditions, and highlights the potential challenges and future directions of this therapy.

Hemodynamic performance of the balloon-expandable SAPIEN 3 valve as assessed by cardiac magnetic resonance.

BACKGROUND: Scarce data exist on transcatheter heart valve (THV) performance evaluated by cardiac magnetic resonance (CMR) in newer generation THV patients. Furthermore, it has been suggested that echocardiographic evaluation after TAVR may inaccurately assess residual AR in some patients. This study aimed to determine the incidence and severity of aortic regurgitation (AR) assessed by CMR in patients undergoing TAVR with the SAPIEN 3 valve, and evaluate the agreement between CMR and transthoracic echocardiography (TTE) on the assessment of AR severity in such patients. METHODS: This multicentric observational study included 146 SAPIEN 3 patients with TTE and CMR within the month following their procedure. According to the CMR regurgitation fraction (RF), AR was considered mild and moderate-severe if the RF was 15-<30% and ≥ 30%, respectively. TTE exams followed VARC-2 recommendations. RESULTS: By CMR, SAPIEN 3 recipients displayed a mean RF of 5.0 ± 6.1%, and mild and moderate-severe AR rates of 3.4% and 0.7%, respectively. The agreement between CMR-TTE was modest (weighted κ = 0.2640, p<0.001), due to an overestimation of AR severity by TTE. A historical cohort of 139 SAPIEN XT patients with a post-procedure CMR, displayed a mean RF of 9.6 ± 10.7% and mild and moderate-severe AR rates of 18.7% and 3.6%, respectively (p < .001 vs. SAPIEN 3 group). CONCLUSIONS: SAPIEN 3 recipients exhibited very low rates of residual AR by CMR, suggesting a surgical-like performance regarding AR with this newer generation THV. TTE tended to overestimate the severity of AR, particularly among mild AR patients.

Transcatheter aortic valve replacement with the balloon-expandable SAPIEN 3 valve: Impact of calcium score on valve performance and clinical outcomes.

BACKGROUND: Aortic valve calcification severity has been associated with higher rates of aortic regurgitation (AR) following TAVR, but scarce data exist on its impact with the use of newer generation transcatheter heart valves. METHODS: This was a multicenter study including 626 patients with severe aortic stenosis who underwent TAVR with the SAPIEN 3 valve. Patients were divided in 2 groups according to the median index calcium score (iCS) for each sex: high CS (HCS, iCS ≥ median), and low iCS (LCS, iCS < median). Another analysis was performed in those patients with extreme iCS (ECS, iCS >75th percentile for each sex). Clinical and echocardiographic data were collected prospectively in a dedicated database. RESULTS: The mean CS was 3758 ±â€¯1417 AU and 1616 ±â€¯691 AU in the HCS and LCS groups, respectively (p < 0.001). There were no differences between groups in 30-day mortality (HCS:2.6%, LCS:1.0%, p = 0.13) and stroke (HCS:2.6%,LCS:2.6%, p = 1.0) rates, but all cases (n = 5) of annulus rupture occurred in the HCS group (1.6% vs. 0%, p = 0.061). The incidence of moderate-severe AR post-TAVR was low in both groups (HCS:1.6%,LCS:1.6%, p = 1.0), and valve gradient and area were similar between groups. The results remained similar in the ECS group (mean CS:4607 ±â€¯1424 AU), but a mildly increased mean transvalvular gradient post-TAVR was observed in ECS patients (12.1 ±â€¯5.6 vs 11.0 ±â€¯4.3 mmHg; p = 0.015). CONCLUSION: Aortic valve calcification severity failed to impact mortality/stroke rates following TAVR with the SAPIEN 3 valve. Low rates of significant AR were observed irrespective of CS, and a mild increase in transvalvular gradient was observed in ECS patients.