Performer Roles and Behaviors in Dyadic Sexually Explicit Media Featuring Men Who Have Sex with Men.

Heterosexual gender roles are not directly relevant to gay romantic relationships, but gay men often take on different relationship roles depending on their sexual roles. In the present paper, we argue that gay men might draw on sexually explicit media (SEM) featuring men who have sex with men (MSM) to get information about how insertive sexual partners ("tops") and receptive sexual partners ("bottoms") typically behave. For this to be the case, however, we would have to reliably observe different behavior in SEM performers acting as tops vs. bottoms. We examined 220 of the most viewed online dyadic MSM SEM videos to determine whether performed verbal and physical intimacy, victimization, and sexual behaviors depended on the sexual role taken. We found that tops and bottoms engaged in similar amounts of intimacy behaviors, but that bottoms were depicted as initiating sexual activity more than tops. Tops enacted physical and psychological victimization more than bottoms, although these behaviors were rare. Tops were shown taking the insertive role across all sexual acts and versatile performers (i.e., those taking both insertive and receptive roles) were rarely depicted. The present study adds to the literature about the complexity of sexual-self-labels, and suggests that MSM SEM depictions of intimacy and sexual decision-making depend on the sexual role taken.

Caged-in: Successful percutaneous closure of left atrial appendage with Watchman-FLX in the presence of proximal thrombus.

Percutaneous mechanical closure of the left atrial appendage (LAA) is a valuable stroke prevention strategy in patients with atrial fibrillation and contraindication to oral anticoagulation. LAA thrombus is a common finding in patients with atrial fibrillation and frequently fails to resolve despite therapeutic anticoagulation. In this scenario, LAA occlusion device implant is generally discouraged due to the high risk of thrombus dislodgement and embolization; however, alternative management options are limited. We report the first case of a successful LAA occlusion device (Watchman-FLX) implant in the presence of a proximal thrombus.

Prevalence and outcome of dual aortic stenosis and cardiac amyloid pathology in patients referred for transcatheter aortic valve implantation.

AIMS: Cardiac amyloidosis is common in elderly patients with aortic stenosis (AS) referred for transcatheter aortic valve implantation (TAVI). We hypothesized that patients with dual aortic stenosis and cardiac amyloid pathology (AS-amyloid) would have different baseline characteristics, periprocedural and mortality outcomes. METHODS AND RESULTS: Patients aged ≥75 with severe AS referred for TAVI at two sites underwent blinded bone scintigraphy prior to intervention (Perugini Grade 0 negative, 1-3 increasingly positive). Baseline assessment included echocardiography, electrocardiogram (ECG), blood tests, 6-min walk test, and health questionnaire, with periprocedural complications and mortality follow-up. Two hundred patients were recruited (aged 85 ± 5 years, 50% male). AS-amyloid was found in 26 (13%): 8 Grade 1, 18 Grade 2. AS-amyloid patients were older (88 ± 5 vs. 85 ± 5 years, P = 0.001), with reduced quality of life (EQ-5D-5L 50 vs. 65, P = 0.04). Left ventricular wall thickness was higher (14 mm vs. 13 mm, P = 0.02), ECG voltages lower (Sokolow-Lyon 1.9 ± 0.7 vs. 2.5 ± 0.9 mV, P = 0.03) with lower voltage/mass ratio (0.017 vs. 0.025 mV/g/m2, P = 0.03). High-sensitivity troponin T and N-terminal pro-brain natriuretic peptide were higher (41 vs. 21 ng/L, P < 0.001; 3702 vs. 1254 ng/L, P = 0.001). Gender, comorbidities, 6-min walk distance, AS severity, prevalence of disproportionate hypertrophy, and post-TAVI complication rates (38% vs. 35%, P = 0.82) were the same. At a median follow-up of 19 (10-27) months, there was no mortality difference (P = 0.71). Transcatheter aortic valve implantation significantly improved outcome in the overall population (P < 0.001) and in those with AS-amyloid (P = 0.03). CONCLUSIONS: AS-amyloid is common and differs from lone AS. Transcatheter aortic valve implantation significantly improved outcome in AS-amyloid, while periprocedural complications and mortality were similar to lone AS, suggesting that TAVI should not be denied to patients with AS-amyloid.

Ultrasound guided vascular access site management and left ventricular pacing are associated with improved outcomes in contemporary transcatheter aortic valve replacement: Insights from the OxTAVI registry.

OBJECTIVES: To identify clinical and procedural practice predictors of avoidable complications during transcatheter aortic valve replacement (TAVR). BACKGROUND: TAVR is evolving as a viable strategy for treatment of aortic stenosis (AS). Vascular complications, major bleeding, or pericardial tamponade may be influenced by procedural practice. METHODS: The Oxford TAVR (OxTAVI) prospective registry was retrospectively analyzed to identify predictors of avoidable procedural complications in a contemporary cohort of transfemoral TAVR between January 2015 and September 2018. The primary endpoint was defined as a hierarchic composite of in-hospital mortality, pericardial effusion/cardiac tamponade, major bleeding, and vascular access complications. Individual components of the primary endpoint have been analyzed separately. RESULTS: Five-hundred-twenty-nine patients underwent transfemoral TAVR using contemporary techniques during the study period and were enrolled in the OxTAVI registry. Female sex and high frailty were associated with a higher risk of death, major bleeding, vascular complication or pericardial tamponade. The use of ultrasound (US) guidance for vascular access management was independently associated with a reduced composite primary endpoint (OR = 0.35, CI:0.14-0.86, p = .02) after adjustment for clinical confounders, largely driven by a threefold reduction in vascular access complication (OR = 0.29, CI:0.15-0.55, p < .001). Performing rapid pacing via the left ventricle guidewire (LV-GW) was associated with a significant decrease in the risk of cardiac tamponade/pericardial effusion (OR = 0.19, CI:0.05-0.66, p = .009). CONCLUSION: US-guided vascular access management and rapid pacing via the LV-GW are important determinants of reduced procedural complications during TAVR.

Construct validation of the Narcissistic Admiration and Rivalry Questionnaire in Spanish-speaking countries: Assessment of the reliability, structural and external validity and cross-cultural equivalence.

A recent re-operationalisation of grandiose narcissism has resulted in the distinction of two narcissistic strategies based on the cognitive, affective-motivational and behavioural dynamics: admiration (assertive self-enhancement) and rivalry (antagonistic self-protection). The Narcissistic Admiration and Rivalry Questionnaire (NARQ) was developed to assess this model with two higher-order dimensions. However, cross-validations of the NARQ have not been extensively conducted across diverse population groups and languages. This study aimed to test the internal and external validity (through the relation with envy and self-esteem), reliability and cross-cultural equivalence of the Spanish version of the NARQ. The psychometric properties were evaluated in a Spanish sample (N = 310), and cross-cultural equivalence was tested in participants from Chile (N = 234) and Colombia (N = 256). The results supported the reliability and validity of the Spanish NARQ, as well as the cross-cultural equivalence across Spanish-speaking countries. In addition, we discuss obtained differences across Spanish, Chilean and Colombian sample within two narcissistic strategies.

Paravalvular leak closure under intracardiac echocardiographic guidance.

OBJECTIVES: The objective of this study was to determine the safety and efficacy of intracardiac echocardiography (ICE) to guide percutaneous paravalvular leak (PVL) closure. BACKGROUND: PVL following surgical valve replacement occurs in 2%-15% of patients. Percutaneous treatment is an accepted management strategy in patients deemed to be too high risk for redo surgery. This is most commonly performed with transesophageal (TOE) guidance requiring general anesthesia that both potentially further increase the risk of intervention. ICE can be used to guide intervention, facilitating procedures to be performed under local anesthesia without esophageal intubation potentially making procedures shorter and safer and further enabling the treatment of patients that may have been turned down for intervention. METHODS: All patients that underwent ICE-guided percutaneous transcatheter PVL closure between 2006 and 2016 at the John Radcliffe Hospital, Oxford, United Kingdom were retrospectively analyzed. RESULTS: Twenty-one procedures were performed in 18 patients during the study period. Fourteen patients (77.8%) underwent successful ICE guided PVL closure. There were no ICE-related complications. Eleven patients (78.6%) reported symptomatic improvement of at least one New York Heart Association (NYHA) Class and the remaining 3 patients had no change. No patient demonstrated objective evidence of persistent hemolysis following successful closure. There was one death within 30 days of the procedure and 1 year survival was 71.4%. CONCLUSIONS: Percutaneous paravalvular leak closure guided by ICE without the requirement of general anesthesia is feasible, safe, and associated with acceptable procedural success rates.

One-pot Unsymmetrical Ketone Synthesis Employing a Pyrrole-Bearing Formal Carbonyl Dication Linchpin Reagent.

A one-pot procedure for the synthesis of unsymmetrical ketones utilizing a pyrrole-bearing carbonyl linchpin reagent (carbonyl linchpin N,O-dimethylhydroxylamine pyrrole; CLAmP) is reported. In contrast to other carbonyl dielectrophile equivalents, CLAmP enables the synthesis of ketones from a variety of organolithium and Grignard reagents. The electrophilic nature of CLAmP enables the addition of less reactive as well as thermally unstable nucleophiles. CLAmP was designed to form kinetically stable tetrahedral intermediates upon the addition of organometallic nucleophiles. Evidence for the existence of persistent tetrahedral intermediates was obtained through in situ IR studies.

Left Atrial Appendage Occlusion: British Cardiovascular Intervention Society and British Heart Rhythm Society Position Statement.

Percutaneous left atrial appendage occlusion aims to reduce the risk of stroke in patients with AF, particularly those who are not good candidates for systemic anticoagulation. The procedure has been studied in large international randomised trials and registries and was approved by the National Institute for Health and Care Excellence in 2014 and by NHS England in 2018. This position statement summarises the evidence for left atrial appendage occlusion and presents the current indications. The options and consensus on best practice for pre-procedure planning, undertaking a safe and effective implant and appropriate post-procedure management and follow-up are described. Standards regarding procedure volume for implant centres and physicians, the role of multidisciplinary teams and audits are highlighted.

Left Atrial Appendage Occlusion: British Cardiovascular Intervention Society and British Heart Rhythm Society Position Statement.

Percutaneous left atrial appendage occlusion aims to reduce the risk of stroke in patients with AF, particularly those who are not good candidates for systemic anticoagulation. The procedure has been studied in large international randomised trials and registries and was approved by the National Institute for Health and Care Excellence in 2014 and by NHS England in 2018. This position statement summarises the evidence for left atrial appendage occlusion and presents the current indications. The options and consensus on best practice for pre-procedure planning, undertaking a safe and effective implant and appropriate post-procedure management and follow-up are described. Standards regarding procedure volume for implant centres and physicians, the role of multidisciplinary teams and audits are highlighted.

Prioritizing echocardiography in Staphylococcus aureus bacteraemia.

OBJECTIVES: Infective endocarditis (IE) is a severe complication in Staphylococcus aureus bacteraemia (SAB) and recent guidelines from the BSAC recommend all patients undergo echocardiography. We assessed the use of echocardiography at a major tertiary referral centre and sought to identify those patients most likely to have positive findings. METHODS: We retrospectively evaluated all cases of SAB at Oxford University Hospitals NHS Trust between September 2006 and August 2011. RESULTS: Three-hundred-and-six out of 668 patients with SAB underwent cardiac imaging on average 9.8 ± 1.3 days from the first culture. Thirty-one patients (10.1%) had echocardiographic evidence of IE. Risk factors for observing evidence of IE on scanning included the presence of prosthetic heart valves (32% versus 4%, P < 0.001) or cardiac rhythm management (CRM) devices (16% versus 3%, P < 0.004). On excluding patients with prosthetic valves or CRM devices from the analysis, no patient with a line-related bacteraemia and only one patient (an intravenous drug user) with no/mild regurgitation on transthoracic echocardiography had echo evidence of IE. CONCLUSIONS: We propose that the use of scarce echocardiography resources could be prioritized. Patients with prosthetic heart valves or a CRM device should receive early cardiological input and transoesophageal echocardiography. In patients with a clearly defined line-related bacteraemia who do not have a prosthetic valve or CRM device or clinical features of IE, response to treatment could be closely monitored and imaging deferred. Patients without a line-related infection or prosthetic valve/device could receive a transthoracic echocardiogram as a screening tool.

Standalone balloon aortic valvuloplasty: indications and outcomes from the UK in the transcatheter valve era.

OBJECTIVES: We sought to characterize UK-wide balloon aortic valvuloplasty (BAV) experience in the TAVI era. BACKGROUND: BAV for acquired calcific aortic stenosis is in a phase of renaissance, largely due to the development of transcatheter aortic valve implantation (TAVI). METHODS: Data from 423 patients at 14 centers across the UK were analyzed. RESULTS: Patients were aged 80.9 ± 9.5 years; 52.5% were male. Mean logistic EuroScore was 27.3% ± 16.8%. Mean peak transaortic gradient fell from 62.0 ± 26.3 to 28.3 ± 16.2 mm Hg. Aortic valve area increased from 0.58 ± 0.19 to 0.80 ± 0.25 cm(2) echocardiographically. Procedural complication rate was 6.3%, comprising death (2.4%), blood transfusion ≥ 2 U (1.2%), cardiac tamponade (1.0%), stroke (1.0%), vascular surgical repair (1.0%), coronary embolism (0.5%), and permanent pacemaker (0.2%). Mortality was 13.8% at 30 days and 36.3% at 12 months. Subsequently, 18.3% of patients underwent TAVI and 7.0% sAVR, with improved survival compared to those who had no further intervention (logrank < 0.0001). Multivariate Cox proportional hazard analysis demonstrated that survival was adversely effected by the presence of coronary artery disease (HR 1.53, 95%CI 1.08-2.17, P = 0.018), poor LV function (HR 1.54, 95%CI 1.09-2.16, P = 0.014), and either urgent (HR 1.70, 95%CI 1.18-2.45; P = 0.004) or emergent presentation (HR 3.72, 95%CI 2.27-6.08; P < 0.0001). CONCLUSION: Balloon aortic valvuloplasty offers good immediate hemodynamic efficacy at an acceptable risk of major complications. Medium-term prognosis is poor in the absence of definitive therapy.

Free floating left atrial ball thrombus: a rare cause of stroke.

In the setting of mitral valve stenosis and atrial fibrillation, left atrial ball thrombus is a rare but recognized cause of stroke and can occur even in the presence of therapeutic anticoagulation. This case report highlights the need for echocardiography to rule out treatable cardioembolic substrates for stroke. We report a case of cardioembolic stroke as a result of free floating left atrial ball thrombus presenting as a complication of rheumatic mitral valve disease. This case highlights that, in all patients with a history of structural heart disease, atrial fibrillation, or rheumatic fever, prompt cardiac ultrasound to exclude free floating atrial thrombus is essential.

Utilizing procalcitonin in a clinical setting to help differentiate between aspiration pneumonia and aspiration pneumonitis.

OBJECTIVE: Aspiration can lead to complications such as aspiration pneumonia (ASPNA) or aspiration pneumonitis. Use of procalcitonin (PCT) assays has been supported to help differentiate between bacterial and nonbacterial etiologies for infection. We hypothesize PCT levels will differ significantly in patients with ASPNA versus aspiration pneumonitis. METHODS: This study retrospectively analyzed patients with an ICD-10 diagnosis of ASPNA or aspiration pneumonitis from September 2017 to September 2019. 228 patients met criteria and were divided into two cohorts: aspiration pneumonitis (45 patients) or ASPNA (183 patients). Initial and 48-hour PCTs were assessed. RESULTS: The aspiration pneumonitis cohort had a higher percentage of patients with normal initial PCT levels than the ASPNA cohort (86.7% vs 38.8%; P < 0.0001). CONCLUSION: This study suggests PCT could be a useful tool to help differentiate between ASPNA and aspiration pneumonitis. We postulate utilizing PCT levels alongside current diagnostic criteria would allow for more appropriate treatment and improved antibiotic stewardship.

Passengers' self-protective intentions while using ride-hailing services during the COVID-19 pandemic.

In the transport context, there has been limited research examining passengers' health-protective behaviour while travelling during a health-related crisis such as COVID-19. This study develops a conceptual model aiming to explore determinants associated with passengers' self-protective intentions using the context of ride-hailing services in Vietnam. Ride-hailing services are popular in countries where public transport is underdeveloped. The conceptual model is based on perceived risk and self-efficacy as the main predictor of self-protective intentions when using ride-hailing services. In addition, the proposed conceptual model explores the direct and indirect impact of subjective knowledge and the perceived effectiveness of preventive measures on self-protective intentions. The proposed conceptual model was tested on a large sample of ride-hailing users in Vietnam (n = 527). The structural equation modelling (SEM) analysis results indicate that self-efficacy has the highest total impact on self-protective behaviour, followed by subject knowledge and perceived effectiveness of preventive measures. Self-efficacy also plays a fully mediating role in the linkage between the perceived effectiveness of preventive measures implemented by ride-hailing organisations and the intention to engage in self-protective behaviour. The results of this study expand the current understanding of ride-hailing passengers' health-protective behaviour and contribute to the transport and public health literature.

Improving antimicrobial use through better diagnosis: The relationship between diagnostic stewardship and antimicrobial stewardship.

Antimicrobial stewardship programs (ASPs) exist to optimize antibiotic use, reduce selection for antimicrobial-resistant microorganisms, and improve patient outcomes. Rapid and accurate diagnosis is essential to optimal antibiotic use. Because diagnostic testing plays a significant role in diagnosing patients, it has one of the strongest influences on clinician antibiotic prescribing behaviors. Diagnostic stewardship, consequently, has emerged to improve clinician diagnostic testing and test result interpretation. Antimicrobial stewardship and diagnostic stewardship share common goals and are synergistic when used together. Although ASP requires a relationship with clinicians and focuses on person-to-person communication, diagnostic stewardship centers on a relationship with the laboratory and hardwiring testing changes into laboratory processes and the electronic health record. Here, we discuss how diagnostic stewardship can optimize the "Four Moments of Antibiotic Decision Making" created by the Agency for Healthcare Research and Quality and work synergistically with ASPs.

Understanding sexual activity while driving as a form of distracted driving.

Sexual activity while driving has been reported in emerging research. Sexual activity while driving is a form of distracted driving because it includes an individual (the driver) who deviates resources from the primary task (driving) towards a secondary task (sexual activity). However, most of our current knowledge about the range of sexual activities while driving is based on self-reported data or media reports. Thus, an in-depth understanding of sexual activities while driving and their interactions with non-sexual driving behaviours and vehicle control is missing. Additionally, there is limited information on the context of where sexual activities while driving occurs and the influence of factors such as the environment, the vehicle, interactions with other road users, and other in-vehicle distractions. To cover this gap, a content analysis of sexually explicit media (SEM) was conducted on a sample of 270 videos depicting real driving. We conducted descriptive analyses and used decision tree analysis to explore the association between sexual activities while driving and their interactions with non-sexual driving behaviours and vehicle control. The videos portrayed a naturalistic driving situation of a driver of a moving vehicle engaging in sexual activity. The results show that when engaging in sexual activity, drivers do not present safe vehicle control. Sexual activity imposes additional cognitive, physical, and visual demands on the driver, thereby decreasing safety. Similar to other distractions, drivers engaging in sexual activity while driving appear to mitigate risks. Concerning the potential for legal sanctions, it appears that drivers may attempt to conceal sexual activity by reducing their visible nudity and minimising interactions with other road users. Finally, mobile phones and cameras appear to interact with sexual activities while driving, by imposing potential restrictions on the range of sexual activities. Implications for policymakers and practitioners are discussed.

Noninferiority of Subcutaneous Versus Intravenous Casirivimab/Imdevimab for Outpatient Treatment of SARS-CoV-2 in a Real-World Setting.

Monoclonal antibody (mAb) therapy has emerged as one of the mainstay treatment options for SARS-CoV-2. To improve speed of delivery and decrease bedside nursing needs, subcutaneous (SC) delivery of mAbs has been explored as an alternative to standard intravenous (IV) administration. To date, data regarding the effectiveness of SC compared with IV mAb are lacking. This retrospective cohort analysis conducted between April 2021 and August 2021 compared hospitalization rates among patients receiving IV versus SC administration of casirivimab/imdevimab (Regen-COV) at a single institution in Arkansas. Casirivimab/imdevimab was a promising mAb therapy utilized during the height of the Delta variant surge of the SARS-CoV-2 pandemic. Before resistance developed by the Omicron variant, casirivimab/imdevimab was utilized for outpatient treatment of SARS-CoV-2 patients at risk of deterioration. Primary outcomes of this investigation were the 30-day post-treatment rate of hospitalization and intensive care unit (ICU) care during hospitalization. There was no increased risk of hospitalization or ICU care with SC administration compared with IV administration. As SARS-CoV-2 continues to mutate into variants such as Omicron and develop resistance to existing mAbs, these preliminary findings of noninferiority of SC versus IV warrant ongoing investigation into SC administration of other mAbs.

Impact of afterload and infiltration on coexisting aortic stenosis and transthyretin amyloidosis.

OBJECTIVE: The coexistence of wild-type transthyretin cardiac amyloidosis (ATTR) is common in patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI). However, the impact of ATTR and AS on the resultant AS-ATTR is unclear and poses diagnostic and management challenges. We therefore used a multicohort approach to evaluate myocardial structure, function, stress and damage by assessing age-related, afterload-related and amyloid-related remodelling on the resultant AS-ATTR phenotype. METHODS: We compared four samples (n=583): 359 patients with AS, 107 with ATTR (97% Perugini grade 2), 36 with AS-ATTR (92% Perugini grade 2) and 81 age-matched and ethnicity-matched controls. 99mTc-3,3-diphosphono-1,2-propanodicarboxylic acid (DPD) scintigraphy was used to diagnose amyloidosis (Perugini grade 1 was excluded). The primary end-point was NT-pro Brain Natriuretic Peptide (BNP) and secondary end-points related to myocardial structure, function and damage. RESULTS: Compared with older age controls, the three disease cohorts had greater cardiac remodelling, worse function and elevated NT-proBNP/high-sensitivity Troponin-T (hsTnT). NT-proBNP was higher in AS-ATTR (2844 (1745, 4635) ng/dL) compared with AS (1294 (1077, 1554)ng/dL; p=0.002) and not significantly different to ATTR (3272 (2552, 4197) ng/dL; p=0.63). Diastology, hsTnT and prevalence of carpal tunnel syndrome were statistically similar between AS-ATTR and ATTR and higher than AS. The left ventricular mass indexed in AS-ATTR was lower than ATTR (139 (112, 167) vs 180 (167, 194) g; p=0.013) and non-significantly different to AS (120 (109, 130) g; p=0.179). CONCLUSIONS: The AS-ATTR phenotype likely reflects an early stage of amyloid infiltration, but the combined insult resembles ATTR. Even after treatment of AS, ATTR-specific therapy is therefore likely to be beneficial.

Intracardiac echocardiography off piste? Closure of the left atrial appendage using ICE and local anesthesia.

Left atrial appendage (LAA) occlusion is increasingly accepted to reduce the risk of stroke in patients with atrial arrhythmia who are unsuitable for routine anticoagulation. It is generally performed under general anesthesia, guided by transoesophageal echocardiography with accurate imaging being essential for correct deployment of the device. We present a case where LAA occlusion was done under local anesthesia in a high-anesthetic risk patient, using novel placement of an intracardiac echo probe via a Mullins sheath in the right ventricular outflow tract and pulmonary artery. This allowed accurate visualization of device deployment in the LAA. This technique may increase the spectrum of patients who may benefit from the procedure and decrease procedure time, fluoroscopy, and procedure-related morbidity.

Prominence of the Eustachian valve in paradoxical embolism.

AIMS: to investigate the relationship between Eustachian valve (EV) length and degree of atrial septal movement in patients with patent foramen ovale (PFO) and presumed paradoxical cerebral embolism. PFO is a well-established risk factor for cryptogenic stroke. However, due to the high prevalence of PFO, many of these are bystanders rather than true pathological entities. Other studies have sought to define which patients with PFO are particularly at risk of cryptogenic stroke by measuring various parameters of right atrial anatomy. We investigated the relationship between EV length and atrial septal movement. METHODS AND RESULTS: measurements of EV length and atrial septal movement were made prospectively from 72 consecutive patients referred to our centre for PFO closure following presumed cryptogenic stroke, by intracardiac phased array echocardiography. The most significant finding from this study was that patients with fewer than 10 mm atrial septal movement had significantly longer EVs than those in whom there was >10 mm septal movement (P = 0.003). The mean EV length with >10 mm septal movement is 6.35 mm, and 13.33 mm with fewer than 10 mm movement. The prevalence of septal movement beyond 10 mm was significantly less in our series than in previously published papers. CONCLUSION: we propose that while a large degree of atrial septal movement significantly increases propensity to cerebral embolism in patients with PFO, its absence does not negate this risk. We have shown that long EV may function independently from atrial septal movement to potentiate paradoxical embolism.