Temporal Trends, Outcomes, and Predictors of Next-Day Discharge and Readmission Following Uncomplicated Evolut Transcatheter Aortic Valve Replacement: A Propensity Score-Matched Analysis.

BACKGROUND: Next-day discharge (NDD) outcomes following uncomplicated self-expanding transcatheter aortic valve replacement have not been studied. Here, we compare readmission rates and clinical outcomes in NDD versus non-NDD transcatheter aortic valve replacement with Evolut. METHODS AND RESULTS: Society of Thoracic Surgeons/American College of Cardiology TVT (Transcatheter Valve Therapy) Registry patients (n=29 597) undergoing elective transcatheter aortic valve replacement with self-expanding supra-annular valves (Evolut R, PRO, and PRO+) from July 2019 to June 2021 were stratified by postprocedure length of stay: ≤1 day (NDD) versus >1 day (non-NDD). Propensity score matching was used to compare risk adjusted 30-day readmission rates and 1-year outcomes in NDD versus non-NDD, and multivariable regression to determine predictors of NDD and readmission. Between the first and last calendar quarter, the rate of NDD increased from 45.4% to 62.1% and median length of stay decreased from 2 days to 1. Propensity score matching produced relatively well-matched NDD and non-NDD cohorts (n=10 549 each). After matching, NDD was associated with lower 30-day readmission rates (6.3% versus 8.4%; P<0.001) and 1-year adverse outcomes (death, 7.0% versus 9.3%; life threatening/major bleeding, 1.6% versus 3.4%; new permanent pacemaker implantation/implantable cardioverter-defibrillator, 3.6 versus 11.0%; [all P<0.001]). Predictors of NDD included non-Hispanic ethnicity, preexisting permanent pacemaker implantation/implantable cardioverter-defibrillator, and previous surgical aortic valve replacement. CONCLUSIONS: Most patients undergoing uncomplicated self-expanding Evolut transcatheter aortic valve replacement are discharged the next day. This study found that NDD can be predicted from baseline patient characteristics and was associated with favorable 30-day and 1-year outcomes, including low rates of permanent pacemaker implantation and readmission.

Clinical Impact of Standardized TAVR Technique and Care Pathway: Insights From the Optimize PRO Study.

BACKGROUND: Procedural success and clinical outcomes after transcatheter aortic valve replacement (TAVR) have improved, but residual aortic regurgitation (AR) and new permanent pacemaker implantation (PPI) rates remain variable because of a lack of uniform periprocedural management and implantation. OBJECTIVES: The Optimize PRO study evaluates valve performance and procedural outcomes using an "optimized" TAVR care pathway and the cusp overlap technique (COT) in patients receiving the Evolut PRO/PRO+ (Medtronic) self-expanding valves. METHODS: Optimize PRO, a nonrandomized, prospective, postmarket study conducted in the United States, Canada, Europe, Middle East, and Australia, is enrolling patients with severe symptomatic aortic stenosis and no pre-existing pacemaker. Sites follow a standardized TAVR care pathway, including early discharge and a conduction disturbance management algorithm, and transfemoral deployment using the COT. RESULTS: A total of 400 attempted implants from the United States and Canada comprised the main cohort of this second interim analysis. The mean age was 78.7 ± 6.6 years, and the mean Society of Thoracic Surgeons predictive risk of mortality was 3.0 ± 2.4. The median length of stay was 1 day. There were no instances of moderate or severe AR at discharge. At 30 days, all-cause mortality or stroke was 3.8%, all-cause mortality was 0.8%, disabling stroke was 0.7%, hospital readmission was 10.1%, and cardiovascular rehospitalization was 6.1%. The new PPI rate was 9.8%, 5.8% with 4-step COT compliance. In the multivariable model, right bundle branch block and the depth of the implant increased the risk of PPI, whereas using the 4-step COT lowered 30-day PPI. CONCLUSIONS: The use of the TAVR care pathway and COT resulted in favorable clinical outcomes with no moderate or severe AR and low PPI rates at 30 days while facilitating early discharge and reproducible outcomes across various sites and operators. (Optimize PRO; NCT04091048).

Methods for a composite ecological suitability measure to inform cumulative restoration assessments in Gulf of Mexico estuaries.

Ecosystem management requires a systematic, holistic approach that considers ecological and social outcomes. Effective restoration practices promote a balance of ecological and social goals by addressing ecological integrity, efficiently maximizing benefits while minimizing investment, and encompassing collaborative stakeholder engagement. Socio-ecological assessments can inform adaptive management and be utilized to prioritize restoration activities and monitor restoration effectiveness. In estuarine systems, socio-ecological assessments should evaluate the ability of habitats to support both ecologically and locally important species. The composite measure presented utilizes a combination of ecological and social measures to characterize ecological suitability for individual and multiple Gulf of Mexico estuarine species. The ecological suitability value (ES) for a given spatial unit is based on a suite of biophysical measures of the quality and extent of suitable habitat for each species, the species' trophic importance in a food web context, and the importance of each species in relation to stakeholder values and benefits. ES values for individual spatial units can be aggregated to estimate the distribution of ecological suitability at the estuarine scale. The ES values are calculated using examples for each step in the process. The information provided by ecological suitability characterizations can support restoration prioritization decisions for Gulf of Mexico estuaries and can provide a baseline measure to gauge restoration effectiveness over time to inform cumulative restoration assessments.

A conceptual approach to characterizing ecological suitability: Informing socio-ecological measures for restoration effectiveness.

A combination of ecological and socio-economic outcome indicators is essential for understanding and assessing the effectiveness of the remediation and restoration of degraded ecosystems and revitalizing communities that could benefit from these ecosystem management activities. In this paper, we propose and develop a conceptual approach to characterize ecological suitability that incorporates ecological attributes that support ecosystem structural diversity and functionality, stakeholder values and perceptions, and the benefits derived from ecosystem goods and services. A structured literature review was used to identify existing restoration frameworks and indicators to inform the conceptual foundation for characterizing ecological suitability. The structure of the conceptual approach primarily builds from ecological and social attributes in the International Principles and Standards for the Practice of Ecological Restoration (Gann et al., 2019). We provide a conceptual example of the ecological suitability approach in estuaries. This example is based on habitat suitability and food web characterizations in combination with the provisioning of ecosystem services and desired social benefits to prioritize and evaluate restoration effectiveness. This foundational work sets the stage for developing a composite measure of ecological suitability. The holistic conceptual approach presented complements existing information regarding restoration effectiveness evaluations. Characterizing ecological suitability is a novel way to incorporate ecological and social information and communicate potential restoration outcomes to ecosystem managers and stakeholders.

Retrospective of Roland Shack's global view of diffraction [Invited].

In April of 1972, Professor Roland Shack presented a series of four colloquium talks at the Optical Sciences Center at the University of Arizona in which he reformulated scalar diffraction theory in terms of the direction cosines of the propagation vectors of the angular spectrum of plane waves described by the Fourier integral transform of the diffracting aperture. The fourth lecture, entitled Radiometry and Lambert's Law, described diffuse reflectance and surface scatter phenomena as merely a diffraction phenomenon caused by random phase variations in the system pupil function. In 1974, he elegantly condensed these four lectures into a single colloquium talk entitled A Global View of Diffraction. This paper is intended to provide a compilation showing the further development of that work over the last 46 years.

Rapid peat development beneath created, maturing mangrove forests: ecosystem changes across a 25-yr chronosequence.

Mangrove forests are among the world's most productive and carbon-rich ecosystems. Despite growing understanding of factors controlling mangrove forest soil carbon stocks, there is a need to advance understanding of the speed of peat development beneath maturing mangrove forests, especially in created and restored mangrove forests that are intended to compensate for ecosystem functions lost during mangrove forest conversion to other land uses. To better quantify the rate of soil organic matter development beneath created, maturing mangrove forests, we measured ecosystem changes across a 25-yr chronosequence. We compared ecosystem properties in created, maturing mangrove forests to adjacent natural mangrove forests. We also quantified site-specific changes that occurred between 2010 and 2016. Soil organic matter accumulated rapidly beneath maturing mangrove forests as sandy soils transitioned to organic-rich soils (peat). Within 25 yr, a 20-cm deep peat layer developed. The time required for created mangrove forests to reach equivalency with natural mangrove forests was estimated as (1) <15 yr for herbaceous and juvenile vegetation, (2) ~55 yr for adult trees, (3) ~25 yr for the upper soil layer (0-10 cm), and (4) ~45-80 yr for the lower soil layer (10-30 cm). For soil elevation change, the created mangrove forests were equivalent to or surpassed natural mangrove forests within the first 5 yr. A comparison to chronosequence studies from other ecosystems indicates that the rate of soil organic matter accumulation beneath maturing mangrove forests may be among the fastest globally. In most peatland ecosystems, soil organic matter formation occurs slowly (over centuries, millennia); however, these results show that mangrove peat formation can occur within decades. Peat development, primarily due to subsurface root accumulation, enables mangrove forests to sequester carbon, adjust their elevation relative to sea level, and adapt to changing conditions at the dynamic land-ocean interface. In the face of climate change and rising sea levels, coastal managers are increasingly concerned with the longevity and functionality of coastal restoration efforts. Our results advance understanding of the pace of ecosystem development in created, maturing mangrove forests, which can improve predictions of mangrove forest responses to global change and ecosystem restoration.

Using Re-scaled Resilience Screening Index Results and Location Quotients for Socio-Ecological Characterizations in U.S. Coastal Regions.

In terms of natural hazard events, resilience characterizations provide a means of identifying risk profiles, degrees of preparedness, and the ability of communities to respond and recover. While nationally consistent measures of community resilience to natural hazards are needed to address widespread socio-ecological impacts from a broad policy perspective, geographically specific resilience characterizations are needed to target local resources to increase community resilience. The Climate Resilience index (CRSI) was developed to characterize the resilience of socio-ecological systems in the context of governance and risk to natural hazard events for all U.S. counties for the years 2000-2015. Those resilience characterizations were based on the full range of nationwide county domain scores. This paper presents a re-scaled application of CRSI, where county domain scores are limited to the range of scores within a specific set of U.S. coastal and shoreline counties within each of eight coastal regions. The re-scaled CRSI values for selected counties/parishes in the Gulf of Mexico (GOM) region are also presented in conjunction with calculated Location Quotients (LQ) values >1.0, which represent a high employment dependence on ocean economy sectors. Using a combination of re-scaled CRSI and LQ values provides a more holistic picture of vulnerability and resilience in these U.S. coastal shoreline counties. The relative resilience assessments presented for coastal regions are useful in identifying potential strengths and weaknesses in resilience aspects given similar hazard profiles, a signature otherwise diluted in nation-wide county-level assessments. The unique approach of combining CRSI and LQ for characterizing natural hazard resilience described could be transferred to other specific geographies as defined by population groups, hazard profiles and economic dependence.

Randomized Comparison of a CrossBoss First Versus Standard Wire Escalation Strategy for Crossing Coronary Chronic Total Occlusions: The CrossBoss First Trial.

OBJECTIVES: The authors performed a multicenter, randomized-controlled, clinical trial comparing upfront use of the CrossBoss catheter versus antegrade wire escalation for antegrade crossing of coronary chronic total occlusions. BACKGROUND: There is equipoise about the optimal initial strategy for crossing coronary chronic total occlusions. METHODS: The primary endpoints were the time required to cross the chronic total occlusion or abort the procedure and the frequency of procedural major adverse cardiovascular events. The secondary endpoints were technical and procedural success, total procedure time, fluoroscopy time required to cross and total fluoroscopy time, total air kerma radiation dose, total contrast volume, and equipment use. RESULTS: Between 2015 and 2017, 246 patients were randomized to the CrossBoss catheter (n = 122) or wire escalation (n = 124) at 11 U.S. centers. The baseline clinical and angiographic characteristics of the study groups were similar. Technical and procedural success were 87.8% and 84.1%, respectively, and were similar in the 2 groups. Crossing time was similar: 56 min (interquartile range: 33 to 93 min) in the CrossBoss group and 66 min (interquartile range: 36 to 105 min) in the wire escalation group (p = 0.323), as was as the incidence of procedural major adverse cardiovascular events (3.28% vs. 4.03%; p = 1.000). There were no significant differences in the secondary study endpoints. CONCLUSIONS: As compared with wire escalation, upfront use of the CrossBoss catheter for antegrade crossing of coronary chronic total occlusions was associated with similar crossing time, similar success and complication rates, and similar equipment use and cost.

Created mangrove wetlands store belowground carbon and surface elevation change enables them to adjust to sea-level rise.

Mangrove wetlands provide ecosystem services for millions of people, most prominently by providing storm protection, food and fodder. Mangrove wetlands are also valuable ecosystems for promoting carbon (C) sequestration and storage. However, loss of mangrove wetlands and these ecosystem services are a global concern, prompting the restoration and creation of mangrove wetlands as a potential solution. Here, we investigate soil surface elevation change, and its components, in created mangrove wetlands over a 25 year developmental gradient. All created mangrove wetlands were exceeding current relative sea-level rise rates (2.6 mm yr-1), with surface elevation change of 4.2-11.0 mm yr-1 compared with 1.5-7.2 mm yr-1 for nearby reference mangroves. While mangrove wetlands store C persistently in roots/soils, storage capacity is most valuable if maintained with future sea-level rise. Through empirical modeling, we discovered that properly designed creation projects may not only yield enhanced C storage, but also can facilitate wetland persistence perennially under current rates of sea-level rise and, for most sites, for over a century with projected medium accelerations in sea-level rise (IPCC RCP 6.0). Only the fastest projected accelerations in sea-level rise (IPCC RCP 8.5) led to widespread submergence and potential loss of stored C for created mangrove wetlands before 2100.

Integrating optical fabrication and metrology into the optical design process.

The recent validation of a generalized linear systems formulation of surface scatter theory and an analysis of image degradation due to surface scatter in the presence of aberrations has provided credence to the development of a systems engineering analysis of image quality as degraded not only by diffraction effects and geometrical aberrations, but to scattering effects due to residual optical fabrication errors as well. This generalized surface scatter theory provides insight and understanding by characterizing surface scatter behavior with a surface transfer function closely related to the modulation transfer function of classical image formation theory. Incorporating the inherently band-limited relevant surface roughness into the surface scatter theory provides mathematical rigor into surface scatter analysis, and implementing a fast Fourier transform algorithm with logarithmically spaced data points facilitates the practical calculation of scatter behavior from surfaces with a large dynamic range of relevant spatial frequencies. These advances, combined with the continuing increase in computer speed, leave the optical design community in a position to routinely derive the optical fabrication tolerances necessary to satisfy specific image quality requirements during the design phase of a project; i.e., to integrate optical metrology and fabrication into the optical design process.

Optimizing outcomes during left main percutaneous coronary intervention with intravascular ultrasound and fractional flow reserve: the current state of evidence.

Percutaneous coronary intervention (PCI) is an evolving indication for the treatment of unprotected left main coronary arterial (UMLCA) stenoses in selected individuals. Intravascular ultrasound (IVUS)-guided PCI within the epicardial coronary tree has been shown to improve acute procedural results and subsequent clinical outcomes. Similarly, fractional flow reserve (FFR) is rapidly gaining popularity as a means to guide the coronary interventionalist to embark upon a "physiological-based" revascularization strategy. In light of the emergence of PCI for ULMCA stenoses, the lack of randomized trials has meant that there are no systematic guidelines that advocate the routine use of these adjunctive imaging techniques to optimize procedural and clinical outcomes. Given the potential dire clinical consequences of procedural failure during ULMCA PCI, in this review we systematically address the current level of evidence for the use of FFR and IVUS during the assessment for and undertaking of PCI for ULMCA stenoses. In lieu of the current available level of evidence, we recommend the use of FFR for the assessment of (angiographic indeterminate) isolated ostial or midshaft left main coronary arterial (LMCA) stenoses in patients who are considered more appropriate candidates for coronary arterial bypass grafting. In those patients with distal/bifurcation LMCA lesions and in those with diffuse/distal coronary arterial disease, we strongly recommend the liberal use of IVUS. Furthermore, in those patients considered likely candidates for ULMCA PCI, IVUS remains crucial for assessing the degree of lumen compromise and the extent, distribution, and morphology of plaque as well as for the immediate postprocedural quantification of stent deployment.

Image degradation due to surface scatter in the presence of aberrations.

Image analysis in the presence of surface scatter due to residual optical fabrication errors is often perceived to be complicated, nonintuitive, and achieved only by computationally intensive nonsequential ray tracing with commercial optical analysis codes such as ASAP, Zemax, Code V, TracePro, or FRED. However, we show that surface scatter can be treated very similarly to conventional wavefront aberrations. For multielement imaging systems degraded by both surface scatter and aberrations, the composite point spread function is obtained in explicit analytic form in terms of convolutions of the geometrical point spread function and scaled bidirectional scattering distribution functions of the individual surfaces of the imaging system. The approximations and assumptions in this formulation are discussed, and the result is compared to the irradiance distribution obtained using commercial software for the case of a two-mirror telescope operating at an extreme ultraviolet wavelength. The two results are virtually identical.

Modeling of light scattering in different regimes of surface roughness.

The light scattering of rough metallic surfaces with roughness levels ranging from a few to several hundred nanometers is modeled and compared to experimental data. Different modeling approaches such as the classical Rayleigh-Rice vector perturbation theory and the new Generalized Harvey-Shack theory are used and critically assessed with respect to ranges of validity, accuracy, and practicability. Based on theoretical calculations and comparisons with Rigorous Coupled Wave Analysis for sinusoidal phase gratings, it is demonstrated that the approximate scatter models yield surprisingly accurate results and at the same time provide insight into light scattering phenomena. For stochastically rough metal surfaces, the predicted angles resolved scattering is compared to experimental results at 325 nm, 532 nm, and 1064 nm. In addition, the possibilities of retrieving roughness information from measured scattering data for different roughness regimes are discussed.