The predictive value of epicardial fat volume for clinical severity of COVID-19.

Introduction: Epicardial adipose tissue serves as a source of inflammatory cytokines and mediators. Cytokine storm is an important cause of morbidity and mortality in coronavirus disease 2019 (COVID-19). Objectives: To investigate the association between epicardial fat volume (EFV), inflammatory biomarkers and clinical severity of COVID-19. Methods: This retrospective study included 101 patients who were infected with COVID-19. Serum inflammatory biomarkers including C-reactive protein (CRP), interleukin-6 (IL-6), procalcitonin (PCT) and ferritin levels were measured. Computed tomography images were analyzed and semi-automated measurements for EFV were obtained. The primary composite endpoint was admission to the intensive care unit (ICU) or death. Results: The primary composite endpoint occurred in 25.1% (n=26) of patients (mean age 64.8±14.8 years, 14 male). A total of 10 patients died. EFV, CRP, PCT, ferritin and IL-6 levels were significantly higher in ICU patients. Moreover, a positive correlation was determined between EFV and CRP (r: 0.494, p<0.001), PCT (r: 0.287, p=0.005), ferritin (r: 0.265, p=0.01) and IL-6 (r: 0.311, p=0.005). On receiver operating characteristic analysis, patients with EFV >102 cm3 were more likely to have severe complications. In multivariate logistic regression analysis, EFV independently predicted admission to the ICU at a significant level (OR: 1.02, 95% CI: 1.01-1.03, p=0.025). Conclusion: EFV and serum CRP, IL-6, PCT and ferritin levels can effectively assess disease severity and predict the outcome in patients with COVID-19. EFV is an independent predictor of admission to the ICU in hospitalized COVID-19 patients.

Introdução: O tecido adiposo epicárdico é fonte de citocinas inflamatórias e mediadores. A tempestade de citocinas é uma importante causa de morbilidade e mortalidade na doença coronavírus 2019 (COVID-19). Objetivos: Investigar a associação entre volume adiposo epicárdico (VAE), biomarcadores inflamatórios e gravidade clínica da COVID-19. Métodos: Este estudo retrospetivo incluiu 101 doentes infetados com COVID-19. Foram avaliados biomarcadores inflamatórios séricos, incluindo os níveis de proteína C-reativa (PCR), de interleucina-6 (IL-6), de procalcitonina (PCT) e de ferritina. Foram analisadas imagens de tomografia computorizada (TC) e foram obtidas medições semi-automáticas do VAE. O endpoint primário composto foi a admissão na unidade de cuidados intensivos (UCI) ou morte. Resultados: O endpoint primário ocorreu em 25,1% (n=26) dos doentes (idade média 64,8±14,8 anos, 14 homens). Um total de 10 doentes morreu. Os níveis de VAE, PCR, PCT, ferritina e IL-6 foram significativamente superiores nos doentes internados na UCI. Além disso, verificou-se uma correlação positiva entre o VAE e a PCR (r: 0,494, p<0,001), PCT (r: 0,287, p=0,005), ferritina (r: 0,265, p=0,01) e IL-6 (r: 0,311, p=0,005). Na análise de regressão logistica multivariada, os doentes com VAE>102 cm3 tinham maior probabilidade de ter complicações graves. Conclusão: O VAE e os níveis séricos de PCR, IL-6, PCT e ferritina podem avaliar a gravidade da doença e prever o resultado em doentes com COVID-19. O VAE constitui um fator preditivo na admissão dos doentes hospitalizados com COVID-19 numa UCI.

Assessment of s-nitrosothiol and thiol/disulfide levels in acute coronary syndrome patients.

BACKGROUND: The level of nitric oxide (NO) is important to protect the heart from ischemic damage in acute coronary syndrome (ACS) patients. S-nitrosothiol (SNO) is a molecule that represents the main form of NO storage in the vascular structure. In addition, dynamic thiol/disulfide homeostasis (TDH) is known to play an important role in maintaining the oxidant-antioxidant balance. In this study, our aim is to evaluate the oxidative/nitrosative stress status according to SNO level and TDH in patients with ACS. METHODS: The study included 124 patients who were admitted to the emergency service and 124 consecutive individuals who applied to the cardiology outpatient clinic with cardiac complaints and underwent coronary angiography (CAG). Blood was drawn from all participants included in the study to determine SNO, nitrite, total thiol, native thiol, and disulfide levels after 12 h of fasting. RESULTS: Serum SNO levels were found to be significantly lower in ACS patients compared to the control group (0.3 ± 0.08 vs. 0.4 ± 0.10 µmol/L, successively, p < 0.001). In addition, while the total thiol, native thiol, and native thiol/total thiol levels were lower in the patient group compared to the control group, nitrite, disulfide/native thiol and disulfide/total thiol levels were higher. As a result of multivariate logistic regression analysis, it was determined that age, gender, smoking, low-density lipoprotein cholesterol, glycosylated haemoglobin, and SNO levels were independent predictors in predicting ACS patients. DISCUSSION: S-nitrosothiol and thiol levels were found to be significantly lower in ACS patients. In addition, SNO molecule was independently associated with the presence of ACS diagnosis.

Plasma thiol and disulphide levels and their relationship with left ventricular systolic functions: A propensity score matching analysis.

OBJECTIVE: Left ventricular (LV) systolic function measured through LV ejection fraction (LVEF) has prognostic implications in patients with cardiac and non-cardiac conditions. The balance of thiol and disulphide levels reflects oxidative status in the body. In this study, we aimed to investigate the relationship between plasma thiol and disulphide levels, and LVEF calculated by transthoracic echocardiography (TTE). METHODS: This retrospective study included 1,048 patients referred for TTE examination and biochemical analyses, including plasma thiol and disulphide levels. After the application of exclusion criteria, the remaining 611 patients were included in the statistical analysis. Patients were classified into two groups, namely normal LVEF (n-LVEF) (n=446) and low LVEF (l-LVEF) (n=165) according to a cut-off level of LVEF 50%. To reduce sample selection bias and adjust for the influence of differences in patient characteristics on LVEF and oxidative status, 1: 1 propensity score matching analysis was applied. RESULTS: Propensity score matching analysis yielded 125 patients in both groups with comparable demographics, medications, and blood parameters. Native thiol and total thiol levels were lower in l-LVEF patients than in n-LVEF patients (p<0.001 for both), whereas disulphide levels were higher in l-LVEF group (p=0.008). Native thiol (r=0.384, p<0.001), total thiol (r=0.35, p<0.001), and disulphide levels (r=-0.129, p=0.004) significantly correlated with LVEF. CONCLUSION: Plasma thiol levels decrease and disulphide levels increase suggesting the presence of oxidative stress in patients with l-LVEF. Significant correlation between oxidative stress and LVEF sheds light about the possible pathogenetic role of thiol and disulphide in heart failure.

A novel ultrasound-based technique to establish a correlation between disease activity and local carotid stiffness parameters in rheumatoid arthritis.

AIM: Cardiovascular (CV) disease is the reason for most mortality cases in RA and cannot be explained only by the presence of traditional CV risk factors. In this study, we aimed to investigate the relationship between local carotid stiffness (CS) parameters measured by a novel ultrasound method and inflammatory disease activity in rheumatoid arthritis (RA) patients. Material and methods: The study was conducted with 70 RA patients and 35 control subjects. According to their disease activity score (DAS-28), the RA patients were classified into active RA (n = 36; DAS-28 > 3.2) and inactive RA (n = 34; DAS-28 ≤ 3.2) groups. A novel non-invasive echo-tracking system was used to measure carotid intima-media thickness (C-IMT), diameter, pulsatile strain, distensibility, and carotid pulse wave velocity (PWV) on 128 sites of the common carotid artery. Erythrocytesedimentation rate (ESR) and C-reactive protein (CRP) levels were also determined. RESULTS: Carotid PWV and IMT were significantly higher in the active RA patients (8.20±1.47 m/s and 6.88±1.50 mm, respectively) compared to the inactive group (6.06±1.21 mm and 7.32±1.19 m/s, respectively) and the control subjects (0.68±0.12 mm and 6.41±0.98, respectively). In all RA patients, a statistically significant correlation was found between carotid PWV and age (r=0.435, p<0.001), ESR (r=0.257, p=0.033), and DAS-28 (r=0.314, p=0.009). According to the multivariate logistic regression analysis, age, DAS-28, and ESR were independent predictors of CS. CONCLUSION: A strong correlation was found between disease activity and local CS parameters in patients with RA. We also demonstrated that both active and inactive RA patients showed increased PWV values compared with the control subjects. This easily applicable and previously confirmed method can be used in future to assess cardiovascular risk in broad study populations from different risk groups.

Evaluation of local carotid stiffness and inflammatory biomarkers in stable angina pectoris.

INTRODUCTION: Arterial stiffness (AS) is a well-accepted and reliable predictor of atherosclerotic diseases. Inflammation plays an important role in the development of AS. AIM: To evaluate local carotid stiffness (CS) together with fibrinogen and high-sensitivity C-reactive protein (hsCRP) levels in stable angina pectoris (SAP) patients. MATERIAL AND METHODS: The study consisted of 353 consecutive patients with SAP. All underwent coronary angiography (CAG) after the evaluation of local CS parameters and carotid intima-media thickness (IMT) from both common carotid arteries by a real-time echo-tracking system. Baseline inflammatory biomarkers, serum hsCRP and fibrinogen levels were measured. Based on CAG findings, the patients were classified into 4 groups: control subjects with normal coronary arteries (group 1, n = 86), single-vessel disease (group 2, n = 104), double-vessel disease (group 3, n = 95) and triple-vessel disease (group 4, n = 68). RESULTS: The mean carotid pulse wave velocity (PWV) in patients with angiographically confirmed coronary artery disease (CAD) was significantly higher than that in patients with normal coronary arteries (7.82 ±1.76 vs. 6.51 ±0.85 cm/s, p = 0.001). The mean carotid IMT was detected to be significantly higher in group 4 patients compared to those in group 1 (p < 0.001) and group 2 (p = 0.001). Significant correlations were observed between both inflammatory biomarkers and the number of diseased vessels and carotid PWV. Using multi-variate analysis, carotid stiffness, carotid IMT, hsCRP and fibrinogen were independently associated with the presence and extent of CAD. CONCLUSIONS: Local CS, carotid IMT, hsCRP and fibrinogen levels are significant predictors of atherosclerotic burden and they may facilitate the identification of high-risk patients for the early diagnosis and prompt treatment of CAD.

Assessment of local carotid stiffness in seronegative and seropositive rheumatoid arthritis.

OBJECTIVES: Rheumatoid arthritis (RA) is a chronic, inflammatory disease associated with increased risk of cardiovascular (CV) disease. Arterial stiffness (AS) is an independent predictor of CV events. This study aimed to analyse local carotid AS parameters in seronegative and seropositive RA patients. DESIGN: Of 347 consecutive RA patients, we selected specifically those who were free of established CV diseases and risk factors. As a result, 140 patients (126 women, 52.2 ± 10 years) and 140 healthy controls (122 women, 52.7 ± 8.0 years) were enrolled into this study. The common carotid AS was evaluated using radio frequency echo-tracking system to determine the local carotid pulse wave velocity (cPWV) and carotid intima-media thickness (cIMT). Based on rheumatoid factor (RF) and/or anti-citrullinated protein antibody (ACPA) positivity, RA patients were categorized into seronegative and seropositive subgroups. RESULTS: Carotid PWV was determined to be significantly higher in all patients and subgroups than controls (p < .001 for all). Although cIMT was similar between the patients, controls and seropositive subgroup, seronegative patients had significantly higher cIMT compared to controls (p = .035) and seropositive group (p = .010). Moreover, a significant positive correlation was found between cPWV and age (r: 0.603, p < .001), ESR (r: 0.297, p = .004), ACPA (r: 0.346, p = .001) and cIMT (r: 0.290, p = .005) in seropositive patients. CONCLUSIONS: RA per se is sufficient to cause arteriosclerosis in the absence of classical CV risk factors. However, arterial hypertrophy is only increased in seronegative patients but not in seropositive group.

Lichenoid type cutaneous hyperpigmentation induced by nebivolol.

Cutaneous hyperpigmentation is a common and well-defined side effect of many drugs, such as non-steroidal anti-inflammatory drugs, beta-blockers, and tetracyclines, but to the best of our knowledge there is no case of skin discoloration related to nebivolol in the literature. Presently described is lichenoid type cutaneous hyperpigmentation in a 46-year-old female patient. Hyperpigmentation emerged 3 months after initiating use of nebivolol and resolved after cessation of drug use. It was concluded that effect emerged as result of therapeutic doses of nebivolol.

The effect of transcatheter aortic valve implantation on mean platelet volume.

BACKGROUND/AIM: Transcatheter aortic valve implantation (TAVI) is an innovative approach to the treatment of aortic stenosis (AS) as an alternative to surgery in high-risk patients. Mean platelet volume (MPV) is considered an indicator of endothelial dysfunction, platelet function, and activation. In this study, we aimed to investigate MPV changes in patients undergoing TAVI. MATERIALS AND METHODS: This study included 100 patients diagnosed with symptomatic severe AS and treated with TAVI between July 2011 and August 2013. Hematological parameters of the patients were examined prior to the procedure and 24 h, 1 month, and 6 months after TAVI. RESULTS: A statistically significant change in patients' MPV was detected after TAVI compared to the baseline situation (P: 0.001). While no statistically significant change was observed on the first day after TAVI, at discharge, compared to the baseline situation, a statistically significant decrease was seen 1 month and 6 months after discharge. CONCLUSION: We have demonstrated a decrease in MPV after surgery compared to the value before surgery. We have sought to propound the change in MPV as an indication of endothelial function after TAVI.

Successful simultaneous ipsilateral stenting of common iliac artery stenosis and transfemoral aortic valve replacement.

Transcatheter aortic valve replacement (TAVR) was designed to treat elderly patients with severe aortic stenosis at high risk for surgery, and is most commonly performed with retrograde approach through femoral arteries. However, in up to 30% of cases, it is either not possible to use this access route or it is considered to have high risk of vascular injury. Alternative approaches have been described for patients with no suitable femoral access: trans-subclavian, transaortic, or direct aortic access; however, since the introduction of new valves deployed with low-profile delivery systems, another alternative transcatheter approach has been discovered. Presently described is experience in 2 cases in which patients were treated with transfemoral TAVR using Edwards SAPIEN 3 transcatheter heart valves immediately following ipsilateral common iliac artery stenting.

Trans-subclavian aortic valve replacement with various bioprosthetic valves: Single-center experience.

OBJECTIVE: Transcatheter aortic valve replacement (TAVR) has been accepted as an alternative to surgery in high risk or inoperable patients with severe aortic stenosis (AS). Although transfemoral approach is the most often preferred means of access, in patients with severe ilio-femoral arteriopathy, other vascular access sites may be required. The aim of the present study was to report our experience with trans-subclavian approach for TAVR using different valve systems. METHODS: Among 273 patients undergoing TAVR between June 2011 and May 2016, 10 patients (mean age: 68.3±7.6 years; 6 males) with high surgical risk were excluded from transfemoral TAVR because of ilio-femoral arteriopathy. Under general anesthesia, 9 of these patients underwent TAVR via left subclavian artery (SCA) and 1 patient via right SCA. Surgical cut-down and closure techniques were utilized in all patients. Eight balloon-expandable Edwards Sapien XT valves (size: one 23 mm, six 26 mm, and one 29 mm) were used, 1 patient received 26 mm balloon-expandable Sapien 3 valve, and 1 patient had 27 mm self-expandable Lotus valve implanted. RESULTS: Procedural success rate was 90%. Mean aortic gradient decreased to 10.6 mmHg from 47.4 mmHg. Emergent surgery was required in 1 patient due to complication of ventricular valve embolization. Thrombus formation at right SCA was detected in 1 patient and resolved with medical therapy. In-hospital mortality was not observed in any patients. CONCLUSION: Trans-subclavian approach for TAVR is safe and feasible. Proper patient and valve selection concurrent with utilization of multimodal imaging techniques are crucial for successful and uncomplicated procedure.

Low-dose oral contraceptive-induced acute myocardial infarction.

OBJECTIVES: Since their introduction, oral contraceptives (OCs) have been associated with risk to both the venous and the arterial systems. Studies have shown that OC use is associated with a risk of venous thromboembolism, ischaemic stroke and acute myocardial infarction (MI). MI is rarely seen in patients using OCs, particularly in the absence of clinical risk factors or smoking. CASE: We report a case of acute inferior MI in a 20-year-old non-smoker who had used a low-dose OC (3 mg drospirenone and 30 µg ethinyl estradiol) for 1 month. As far as we know, this is the youngest case of acute MI associated with a low-dose OC. CONCLUSION: Low-dose OCs may also be responsible for acute MI even in a very young female without any cardiovascular risk factors. Therefore, the clinicians should be aware of this mortal events during follow-up of the patient using OCs.

First trans-subclavian transcatheter aortic valve replacement using Lotus valve system.

Transcatheter aortic valve implantation (TAVI), most commonly performed via retrograde femoral artery access, is a promising alternative to surgical aortic valve replacement in elderly, high-risk patients with severe aortic stenosis (AS). Approximately one-third of these patients suffer from severe iliofemoral arteriopathy, ruling out transfemoral approach. The case of a 74-year-old man with severe AS and bilateral iliofemoral arteriopathy treated with left trans-subclavian (TS) TAVI using the Lotus valve system is described in the present report.

Higher neutrophil to lymphocyte ratio is related to a lower ejectionfraction in bicuspid aortic valve patients.

BACKGROUND/AIM: Inflammation plays an important role in the pathophysiology of vascular disease. In this study, we aimed to evaluate the associations of neutrophil to lymphocyte ratio (NLR; an indicator of inflammation) with left ventricular ejection fraction and ascending aorta diameter in patients with a bicuspid aortic valve (BAV). MATERIALS AND METHODS: One hundred and thirty-nine consecutive patients with the diagnosis of BAV were enrolled in the study. Complete blood counts were analyzed for neutrophil and lymphocyte levels and NLR. The subjects were separated into two groups based on their ascending aorta diameter. The patients with ascending aorta diameter equal to or above 3.9 cm were included in group 1 whereas those with ascending aorta diameter below 3.9 cm were included in group 2. RESULTS: When the results were compared, it was demonstrated that there was a positive correlation between NLR and ascending aorta diameter (r: 0.485, P = 0.026), whereas there was a negative correlation between NLR and left ventricular end-diastolic diameter (r: 0.475, P = 0.030), left ventricular end-systolic diameter (r: 0.482, P = 0.027), and left ventricular ejection fraction (r: -0.467, P = 0.033) in BAV patients with ascending aorta dilatation (group 1). CONCLUSION: NLR is associated with ascending aorta diameter and left ventricular ejection fraction in BAV patients with ascending aorta dilatation.

Crucial role of safety guidewire in transcatheter aortic valve implantation: Two cases with vascular complication.

Vascular complications increasing the rates of morbidity and mortality are among the most common complications observed during transcatheter aortic valve implantation (TAVI). Endovascular management is often life-saving. However, due to limitations of time in cases of iliac rupture and dissection, precautions taken prior to the procedure and the placement of safety guidewire in the contralateral femoral artery are crucial. Here, an 85-year-old woman and and 84-year-old man who had severe symptomatic aortic stenosis and underwent TAVI were presented. Although the valves were successfully implanted, the procedures were complicated by rupture and dissection of the right iliofemoral artery. With the use of safety guidewire, 2 self-expandable graft stents were inserted at the site of rupture and in the place of dissection in the iliofemoral artery, and the patients could be managed successfully.

Immediate recovery of the left atrial and left ventricular diastolic function after transcatheter aortic valve implantation: A transesophageal echocardiography study.

BACKGROUND: Chronic increased afterload due to severe aortic stenosis (AS) results in com-pensatory concentric left ventricular (LV) hypertrophy and LV dysfunction. These in turn cause remodeling of the left heart. The aim of this study was to investigate the acute effect of transcatheter aortic valve implantation (TAVI) on left atrial (LA) mechanics and LV diastolic function. METHODS: The study consisted of a total of 35 consecutive patients (mean age was 77.7 ± 5.0 years, 25 female) undergoing TAVI. All TAVI procedures have been performed under the transesophageal echocardiography (TEE) guidance. Before and 24 h after TAVI, all patients underwent transthoracic echocardiography (TTE) and mitral inflow velocities with pulsed-wave (PW) Doppler including early filling wave (E), late diastolic filling wave (A), and E/A ratio were obtained. LV diastolic function was also explored by pulsed tissue Doppler imaging (TDI). Early (E') and late (A') diastolic annular velocities, E'/A' ratio and E/E' ratio were obtained. In addition, during the procedure before and minutes after the valve implantation, the left atrial appendage-peak antegrade flow velocity (LAA-PAFV) was measured and recorded with TEE. RESULTS: Compared with baseline, the mean mitral E, septal E' and E'/A' ratio increased significantly after TAVI. In addition, the LAA-PAFV increased significantly within minutes of TAVI (32.45 ± 10.7 cm/s vs. 47.6 ± 12.6 cm/s, p < 0.001). CONCLUSIONS: TAVI improves LV diastolic function and LA performance immediately.

Congenital absence of left pulmonary artery with collateralization from all major coronary arteries.

Unilateral pulmonary artery agenesis (UPA) is a rarely-observed congenital anomaly with diverse clinical signs and symptoms. It is most often diagnosed in childhood due to the high mortality rate prior to adulthood. This report describes the case of a 71-year-old woman who presented with exertional chest pain, dyspnea and palpitations and who was diagnosed as having left pulmonary artery (LPA) agenesis, hypoplastic left lung supplied by collateralization from each of the three normal major coronary arteries, and atrial fibrillation.

Bulging sign: A precursor of annular rupture observed before aortic balloon rupture during valvuloplasty in transcatheter aortic valve implantation.

Transcatheter aortic-valve implantation (TAVI) is a reliable alternative to surgical aortic-valve replacement in inoperable or high-risk patients. However, this evolving therapy is associated with a wide range of potential complications- some specific to TAVI, some often fatal. Prevention, early recognition, and taking essential precautions will significantly improve results. The case of an 85-year-old woman with balloon rupture during valvuloplasty in TAVI, a very rare and potentially fatal complication, is presented.

Association between aortic stiffness and left ventricular function in inflammatory bowel disease.

BACKGROUND: Recent studies have reported an increased incidence of both aortic stiffness and left ventricular (LV) systolic and diastolic dysfunction in patients with inflammatory bowel disease (IBD). However, the association between aortic stiffness and the LV function has not been fully defined. We aimed to investigate the relationship between aortic stiffness and the LV function in IBD patients. METHODS AND RESULTS: Seventy-two patients with IBD (56 cases of ulcerative colitis and 16 cases of Crohn's disease) and 50 healthy controls were consecutively enrolled in this study. The LV systolic and diastolic functions were assessed using conventional echocardiographic techniques, including tissue Doppler echocardiography. The degree of aortic strain and distensibility were calculated based on the aortic diameters measured on M-mode echocardiography at thelevel of 3 cm above the aortic valve and the blood pressure values obtained on sphygmomanometry. There were significant differences between the IBD and control group in the degree of aortic strain and distensibility. Significant differences were also observed between the patient and control groups in the parameters of the LV systolic and diastolic functions. Moreover, aortic stiffness was found to be associated with the LV function in the patient group. CONCLUSIONS: There is a significant relationship between aortic stiffness and LV systolic and diastolic dysfunction in patients with IBD, based on the findings of this study. The parameters of aortic elasticity measured according to 2-dimensional echocardiographic methods can be beneficial for predicting early cardiovascular risk in cases of IBD. (.

Transcatheter aortic valve implantation with the Edwards Sapien 3 valve: First experiences in Turkey.

OBJECTIVE: Transcatheter aortic valve implantation (TAVI) has shown promising results in patients with severe aortic stenosis (AS) at high risk for open heart surgery. We aimed to evaluate outcomes of patients who underwent TAVI with Edwards SAPIEN 3 Transcatheter Heart Valve (S3), a second-generation TAVI device. METHODS: Between November 2014 and June 2016, 31 high-risk patients received balloon-expandable S3 valve at Atatürk Training and Research Hospital that has the largest case series in Turkey. RESULTS: Mean age of the patients was 76.1±12.6 years. Mean Society of Thoracic Surgeons and logistic European System for Cardiac Operative Risk Evaluation scores were 7.8%±3.1 and 31.4%±17.6, respectively. S3 valve was implanted in 27 patients via transfemoral approach and via trans-subclavian approach in 4 patients under local (n=29) or general (n=2) anesthesia. Procedural success rate was 100% (23 mm, n=7; 26 mm, n=16; 29 mm, n=8). Paravalvular aortic regurgitation (PAR) was absent or trivial in 29 (93.6%) patients and mild in 2 (6.4%) patients. Permanent pacemaker implantation (PPI) was required in 2 (6.4%) patients during the procedure, and in-hospital mortality occurred in 1 (3.2%) of those 2 patients. CONCLUSION: S3 valve is associated with higher rate of device success and lower incidence of PAR, peripheral vascular complications, and need for new PPI.