Clinical Impact of Crossover Techniques for Primary Access Hemostasis in Transfemoral Transcatheter Aortic Valve Replacement Procedures.

OBJECTIVES: To determine the occurrence of vascular complications (VCs) following transfemoral transcatheter aortic valve replacement (TAVR) with new-generation devices according to the use of a crossover technique (COT). BACKGROUND: The use of a COT (with/without balloon) has been associated with a reduction of VCs in TAVR patients. However, scarce data support its use with second-generation devices. Also, its potential benefit in obese patients (at high-risk of VCs) has not been elucidated. METHODS: A multicenter study including 2214 patients who underwent full percutaneous transfemoral TAVR (COT, 1522 patients; no COT, 692 patients). Thirty-day events were evaluated according to the use of a COT using a multivariate logistic regression model. A subanalysis was performed in obese patients. RESULTS: Primary access major VCs (3.5% COT vs 3.9% no COT; P=.19), major/life-threatening bleeding (3.4% COT vs 2.0% no COT; P=.33), and mortality rates (2.4% COT vs 2.6% no COT; P=.23) were similar between groups. However, minor VCs (11.7% COT vs 5.9% no COT; P<.001) and postprocedural acute renal failure (8.9% COT vs 3.9% no COT; P<.001) were higher in patients undergoing the COT. In the overall cohort, percutaneous closure device failure was more frequent in obese patients (4.0% in the obese group vs 1.9% in the non-obese group; P<.01), but these differences were no longer significant in those undergoing a COT (3.4% in the obese group vs 2.0% in the non-obese group; P=.12). Indeed, in the subset of obese patients, the COT tended to be associated with fewer VCs (3.4% COT vs 5.9% no COT; P=.09). CONCLUSIONS: The use of a COT was not associated with a reduction of major VCs or improved outcomes. However, some patient subsets, such as those with higher body mass index, may benefit from the use of a COT. These findings would suggest the application of a tailored strategy, following a risk-benefit assessment in each TAVR candidate.

2020 guidelines for conducting plastic reconstructive short-term surgical projects in low-middle income countries.

Many low- or middle-income countries (LMICs) continue to suffer from a lack of safe and timely essential and emergency surgery despite growing attention to this problem. Short-term surgical projects (STSPs) continue to play an important role in addressing LMIC unmet surgical need and strengthening local healthcare systems. Guidelines here present recommendations for performing plastic reconstructive STSPs for pediatric patients in a safe, ethical, and effective manner. These guidelines represent consensus physician expert opinions, assembled collaboratively by members of Volunteers in Plastic Surgery and the Society for Pediatric Anesthesia's global health committee, with broad input from physicians practicing daily in LMICs. Organizations must partner with hosts to thoughtfully plan and carefully execute STSPs. We outline crucial items to STSP success, including choice of host facility, team selection, patient selection, staffing, ensuring proper equipment and supplies, disinfecting reusable equipment, creation of a safety culture, and data collection for quality assessment/improvement and research. Patient factors are discussed and recommendations given for developing exclusion criteria, as well as for determining which patients and procedures may require the team to include expertise in pediatric anesthesia or critical care. We recommend that educational opportunities for hosts are sought and advanced to optimize education/training at both the resident and post-trainee levels. Host education during STSPs has become crucial as LMICs ramp up training at a time when their surgical volumes remain grossly behind well-resourced countries. Recommendations here aim to assist organizations, hosts, and volunteers as they navigate the enormously complex and ever changing STSP environment. Patient safety and transfer of knowledge and skills should be central concerns of all who participate in this highly rewarding endeavor.

Long-Term Outcomes After Transcatheter Aortic Valve-in-Valve Replacement.

BACKGROUND: Data on long-term outcomes after valve-in-valve (ViV) transcatheter aortic valve replacement (TAVR) are scarce. The objective of this study was to determine the long-term clinical outcomes and structural valve degeneration (SVD) over time in patients undergoing ViV-TAVR. METHODS AND RESULTS: Consecutive patients undergoing ViV-TAVR in 9 centers between 2009 and 2015 were included. Patients were followed yearly, and clinical and echocardiography data were collected prospectively. SVD was defined as subclinical (increase >10 mm Hg in mean transvalvular gradient+decrease >0.3 cm2 in valve area or new-onset mild or moderate aortic regurgitation) and clinically relevant (increase >20 mm Hg in mean transvalvular gradient+decrease >0.6 cm2 in valve area or new-onset moderate-to-severe aortic regurgitation). A total of 116 patients (mean age, 76±11 years; 64.7% male; mean Society of Thoracic Surgeons score, 8.0±5.1%) were included. Balloon- and self-expandable valves were used in 47.9% and 52.1% of patients, respectively, and 30-day mortality was 6.9%. At a median follow-up of 3 years (range, 2-7 years), 30 patients (25.9%) had died, 20 of them (17.2%) from cardiovascular causes. Average mean transvalvular gradients remained stable up to 5-year follow-up ( P=0.92), but clinically relevant SVD occurred in 3/99 patients (3.0%), and 15/99 patients (15.1%) had subclinical SVD. One patient with SVD had redo ViV-TAVR. CONCLUSIONS: About one-fourth of ViV-TAVR recipients had died after a median follow-up of 3 years. Overall valve hemodynamics remained stable over time and clinically relevant SVD was infrequent, but 1 out of 10 patients exhibited some degree of SVD.

PETMiner-A Visual Analysis Tool for Petrophysical Properties of Core Sample Data.

The aim of the PETMiner software is to reduce the time and monetary cost of analysing petrophysical data that is obtained from reservoir sample cores. Analysis of these data requires tacit knowledge to fill 'gaps' so that predictions can be made for incomplete data. Through discussions with 30 industry and academic specialists, we identified three analysis use cases that exemplified the limitations of current petrophysics analysis tools. We used those use cases to develop nine core requirements for PETMiner, which is innovative because of its ability to display detailed images of the samples as data points, directly plot multiple sample properties and derived measures for comparison, and substantially reduce interaction cost. An 11-month evaluation demonstrated benefits across all three use cases by allowing a consultant to: (1) generate more accurate reservoir flow models, (2) discover a previously unknown relationship between one easy-to-measure property and another that is costly, and (3) make a 100-fold reduction in the time required to produce plots for a report.