The long-term outcome of CT-guided radiofrequency ablation of the peripheral branches of the trigeminal nerve in trigeminal neuralgia.

Radiofrequency thermocoagulation (RFTC) of the peripheral branches of the trigeminal nerve has been used for trigeminal neuralgia. However, the long-term outcomes of radiofrequency thermocoagulation have not been established. To evaluate the long-term efficacy of RFTC of peripheral branches in patients with refractory trigeminal neuralgia. A retrospective cohort study was conducted in a comprehensive medical center in China. Patients who underwent radiofrequency thermocoagulation of peripheral branches for refractory trigeminal neuralgia from May 2014 to March 2021 were included for analysis. A total of 84 patients with refractory trigeminal neuralgia underwent 105 procedures. BNI I-II which represents treatment success was achieved in 76/84 (90%) patients and 93/105 (89%) procedures. During follow-up, BNI I and II were maintained in 64/76 (84%), 40/73 (55%), 20/67 (30%), 17/65 (26%), 12/61 (20%), and 8/58 (14%) of patients at 1, 2, 3, 4, 5, and 6 years, after the first procedure, respectively. For all the 105 procedures, BNI I and II were maintained in 68/93 (73%), 41/89(46%), 22/82(27%), 15/79 (19%), 8/74 (11%), and 3/72 (4%) at 1, 2, 3, 4, 5, and 6 years, respectively. There is no significant difference between the first and repeat thermocoagulation in terms of immediate (90% vs. 81%, P=0.140) and long-term efficacies (24 months vs.18 months, P=0.266). Radiofrequency thermocoagulation resulted in better long-term outcomes in patients with typical purely paroxysmal pain (24 months vs. 11 months, P=0.033). Radiofrequency ablation of the peripheral branches of the trigeminal nerve might be a safe and effective method in the treatment of refractory trigeminal neuralgia.

Assessment of tissue damage from mosquito-inspired surgical needle.

INTRODUCTION: Many percutaneous procedures utilize surgical needles to extract tissue samples in biopsy or to apply specific cancer treatments. A design of mosquito-inspired surgical needles was proposed to improve the efficacy of these procedures by reducing the needle insertion force and the resulting tissue damage. The focus of this study is to assess tissue damage caused by the insertion of a mosquito-inspired needle into soft tissues. MATERIAL AND METHODS: In this work, the geometric features and the dynamic stinging (insertion) mechanism of mosquito proboscis were mimicked for the design of 3D-manufactured bioinspired needle prototypes. A specially designed test setup was developed to measure the insertion force in bovine liver tissue. The histology assessment based on hematoxylin and eosin staining and image analysis was conducted to determine the bovine liver tissue damage. RESULTS: It was observed that the insertion force can be reduced by up to 39% and the bovine liver tissue damage was decreased by 27% using the mosquito-inspired needles when compared with using the standard needles. CONCLUSION: The findings from this study suggested that the bioinspired needle design has great potential to advance surgical needles for more effective and less invasive percutaneous procedures.

Bedside percutaneous ultrasound gastrostomy tube placement by critical care physicians.

Critically ill patients often require gastrostomy tubes. Percutaneous endoscopic gastrostomy has become the most common method of placement but is not widely performed by critical care physicians, in part due to their lack of familiarity and training in upper gastrointestinal endoscopy. Percutaneous ultrasound gastrostomy (PUG) is a novel procedure for gastrostomy tube placement that utilizes ultrasound-based methods already familiar to critical care physicians. This technical note describes bedside PUG in the first five intensive care unit patients. All patients received timely gastrostomy placement, without complication, and were able to quickly achieve goal enteral nutrition.

Air-to-Air Meeting Technique in Radiofrequency Thermocoagulation of Trigeminal Neuralgia: A Case Report.

BACKGROUND: In a minority of cases, foramen ovales (FOs) are difficult to access due to single confounding anatomical variations. However, there is no method reported where the FO has been successfully targeted via a single puncture in the presence of two or more anatomical variations. OBJECTIVES: To observe the effect of a new stereotactic bidirectional approach guiding technique utilized in a patient who harbored a particularly difficult-to-access FO due to multiple anatomical variations. METHODS: During operation of a unique facial entry point's trigeminal neuralgia patient, make one plane which identified by a three-dimensional (3D) coordinates of the FO target and arc angle value on stereotactic frame, make this plane intersected with another plane which determined by the 3D CT-reconstruction's facial entry point data on a ruler, so as to elucidate the appropriate trajectory. The authors coined the approach "Air-to-air meeting" method. RESULTS: We completed the radiofrequency thermocoagulation (RFT) with a single puncture to successfully target the FO according to the preoperative plan confirmed by C-arm radiography. Postoperative pain scores using a visual analog scale decreased from 10 to 3 by the first day after the procedure. There were no permanent complications or morbidity from the surgery. CONCLUSIONS: To the authors' knowledge, this is the first report describing a unique facial entry point determined by this technique for the treatment of a patient with trigeminal neuralgia.

Why should cardiac surgeons occlude the left atrial appendage percutaneously?

OBJECTIVES: Percutaneous left atrial appendage (LAA) occlusion (LAAO) is a procedure dominated by cardiologists. The aim of our study was to present the results of percutaneous LAAO performed solely by cardiac surgeons. METHODS: Two hundred twenty-three consecutive patients with nonvalvular atrial fibrillation underwent percutaneous LAAO in two cardiac surgery sites. In the first center, all 84 LAAO procedures were performed with the endocardial LAA occluders: 60 cases with the Amulet and 24 cases with the LAmbre. In the second center, all 139 LAAO procedures were performed with the LARIAT epicardial device. RESULTS: The mean CHA2 DS2 -VASc-score was 3.7 ± 1.8 points, and mean HAS-BLED score was 3.6 ± 1.2 points. The procedure was successful in 97.3% of cases. Procedural or device-related adverse events were noted in 4.4% (n = 10) of cases: one periprocedural cardiac arrest, one aortic injury, one gastrointestinal bleeding, three cases of vascular access complications, and four cardiac tamponades. After a follow-up of 40.3 ± 17.3 months, 78.4% of patients were alive, with the annual mortality rate of 5.3%. Compared to the predicted risk, the observed incidence of thromboembolism was lower by 71%, and the bleeding incidence was lower by 69%. CONCLUSIONS: Percutaneous LAAO procedures can be safely performed by cardiac surgeons, with no cardiological assistance. LAAO done by surgeons is safe and effective, and periprocedural and long-term outcomes are excellent. Cardiac surgeons should be trained in both types of LAAO: endocardial and epicardial.

Quality of Life in Adults Undergoing Percutaneous Device Closure of Atrial Septal Defect.

To assess changes in the quality of life in adult patients undergoing percutaneous device closure of atrial septal defect (ASD).We used a standard Medical Outcome Study Short Form 36 (SF-36) that includes psychological and physiological aspects to assess and analyze the quality of life of 73 adult patients who underwent percutaneous device closure of ASD.Of the 73 patients who were investigated in this study, 67 completed questionnaires successfully. The following findings were revealed after analyzing the preoperative results and postoperative results. In some dimensions ( "physical functioning," "vitality," "general health" ), the postoperative perception was better than the preoperative status. Some differences were found in the quality of life feedback between the case group and the control group. Among the different subgroups, older patients scored lower than younger patients on most dimensions, and men seemed to perform better on "role-physical" factors than women. Unmarried people performed worse on "role-physical" and "bodily pain" than married people. Among people with different academic degrees, those with higher degrees demonstrated better scores on multiple dimensions ( "role-physical," "mental health," "social functioning," and "general health" ) than those with lower degrees.After percutaneous device closure of ASD, most adult patients feel that the quality of life is improved compared with that during the preoperative status. With the change of patients' own conditions, their quality of life seems to change differently. In order to better help patients integrate into life, psychological and physical support is still needed.

Treatment of venous stenosis in oncologic patients.

Symptomatic obstruction related to malignant involvement of large veins may occur in central veins both in the thoracic and pelvic regions, and in the abdominal region of the body. Both cases represent a therapeutic challenge, and endovascular revascularization, consisting of angioplasty and stent placement, is safe and effective. Superior vena cava stenting has become widespread in the management of occlusive venous disease. The percutaneous placement of large expandable metal stents allows rapid restoration of normal blood flow in the majority of patients, thus improving symptoms. Published data on the diagnosis and treatment of symptomatic cancer-related iliocaval obstructions are limited and mainly consist of case reports and small case series. The present review reports the current state of endovascular treatment for both superior vena cava occlusion and iliac compression syndrome in cancer patients.

Fetal surgery: a critical review.

Therapeutic fetal surgical procedures are predicated upon the ability to make an accurate fetal diagnosis. The earliest open fetal surgical procedures were introduced in the 1960s to treat Rh isoimmunisation. They were introduced when it became possible to predict impending fetal demise. Open procedures were abandoned when percutaneous approaches proved superior. The introduction of fetal ultrasound allowed the diagnosis of other congenital anomalies, some being amenable to fetal interventions. Open fetal surgical procedures were initially utilised, with significant maternal morbidity. For some anomalies, percutaneous approaches became favoured. In general, all of these procedures involved significant risks to the mother, to save a baby that was likely to die before or shortly after birth without fetal intervention. Fetal repair for myelomeningocele was a "sea change" in approach. The same maternal risks were taken to improve the quality of life of the affected fetus, not save its life. The completion of the "MOMs Trial" has occasioned a "tsunami" of centres in North America applying this approach. Others are attempting percutaneous repairs, with mixed results. This paper reviews the history of fetal surgery, focusing on the themes of the tension between accurate diagnosis and prognosis and open versus "minimally invasive" approaches.

Percutaneous extrapedicular vertebroplasty with expandable intravertebral implant in compression vertebral body fracture in pediatric patient-technical note.

PURPOSE: The aim of the article is to present the new extrapedicular percutaneous technique for posttraumatic vertebral column fracture. METHODS: A 15-year-old boy needed a surgical Th8 posttraumatic vertebral body (VB) compressive fracture reduction due to insufficient conservative treatment and consistent severe clinical symptoms. After 6 months of external Jevett long-roll brace stabilization, progressive sagittal balance disturbance of thoracic kyphosis was measured and persistent clinical symptoms were observed. It was decided to present a surgical technique method allowing to attempt to reduce VB fracture, rebalance the vertebral column (VC) without any motion limitation, and decrease clinical symptoms. The procedure was performed percutaneously from extrapedicular approach with intravertebral implant (Spine Jack®-Vexim™) and cement (Interface®-Vexim™) under fluoroscopic imaging (Ziehm™ 8000®). RESULTS: The whole procedure was uneventful. Now, the child is free from clinical symptoms and the partial reduction of VB fracture was achieved. The patient has been followed for 3 months. In the control CT scans, the VB fracture reduction is stable and no progression of thoracic kyphosis angle is observed. Furthermore since the surgical procedure, the patient is clinical symptom free. CONCLUSION: The extrapedicular percutaneus technique of VB fracture reduction with intravertebral fixation allowed to partially reduce the VB compressive fracture, rebalance the VC without any motion limitation, avoid external long-roll brace, and eliminate clinical symptoms. The procedure is minimally invasive, fast, and clinically effective. However, the technique should be restricted only to carefully selected clinical cases.

Performance Comparison of Augmented Reality Versus Ultrasound Guidance for Puncture: A Phantom Study.

PURPOSE: Augmented reality (AR) is an innovative approach that could assist percutaneous procedures; by directly seeing "through" a phantom, targeting a lesion might be more intuitive than using ultrasound (US). The objective of this study was to compare the performance of experienced interventional radiologists and operators untrained in soft tissue lesion puncture using AR guidance and standard US guidance. MATERIAL AND METHODS: Three trained interventional radiologists with 5-10 years of experience and three untrained operators performed punctures of five targets in an abdominal phantom, with US guidance and AR guidance. Correct targeting, accuracy (defined as the Euclidean distance between the tip and the center of the target), planning time, and puncture time were documented. RESULTS: Accuracy was higher for the trained group than the untrained group using US guidance (1 mm versus 4 mm, p = 0.001), but not when using AR guidance (4 mm vs. 4 mm, p = 0.76). All operators combined, no significant difference was found concerning accuracy between US and AR guidance (2 mm vs. 4 mm, p = 0.09), but planning time and puncture time were significantly shorter using AR (respectively, 15.1 s vs. 74 s, p < 0.001; 16.1 s vs. 59 s; p < 0.001). CONCLUSION: Untrained and trained operators obtained comparable accuracy in percutaneous punctures when using AR guidance whereas US performance was better in the experienced group. All operators together, accuracy was similar between US and AR guidance, but shorter planning time, puncture time were found for AR guidance.

IRE made easy: introducing the robotic grid system for multiple parallel needle insertion in irreversible electroporation treatment.

PURPOSE: Accurate needle placement is crucial for successful tumor treatment using the irreversible electroporation (IRE) method. Multiple needles are inserted around the tumor, ideally in parallel, to achieve uniform electric field distribution. This paper presents a robot utilizing a grid system to enable multiple needles insertion while maintaining parallelism between them. METHODS: The robotic system has two degrees of freedom, which allow for the adjustment of the grid system to accommodate targeting lesions in various positions. The robot's performance was evaluated by testing its accuracy across various configurations and target depth locations, as well as its ability to maintain the needle parallelism. RESULTS: The robot has dimensions of ϕ 134 mm and a height of 46 mm, with a total weight of 295 g. The system accuracy test showed that the robot can precisely target points across different target depths and needle orientations, with an average error of 2.71 ± 0.68 mm. Moreover, multiple insertions at different grid locations reveal needle orientation deviations typically below 1 ∘ . CONCLUSION: This study presented the design and validation of a robotic grid system. The robot is capable of maintaining insertion accuracy and needle parallelism during multiple needle insertions at various robot configurations. The robot showed promising results with limited needle deviation, making it suitable for IRE procedures.

Inferior Pole of the Patella Fracture Fixed by Percutaneous Approach: A Case Report.

Fractures of the inferior pole of the patella are rare but challenging orthopedic injuries. This case study presents the management of such a fracture using a percutaneous approach. A 70-year-old female patient presented with significant knee pain and swelling following a fall. Radiographic examination revealed a displaced fracture of the inferior pole of the patella along with an ipsilateral tibial plateau fracture. Surgical intervention was deemed necessary due to the extent of displacement and the potential for compromised knee function. A percutaneous technique was employed for fracture reduction and fixation using cannulated screws under fluoroscopic guidance. Postoperative rehabilitation focused on early mobilization and strengthening exercises. At a six-week follow-up, the patient demonstrated satisfactory clinical outcomes with restoration of knee function and minimal residual symptoms. This case highlights the efficacy of percutaneous fixation in managing inferior pole patellar fractures, offering a minimally invasive approach with favorable functional outcomes.

Percutaneous atrial septostomy with modified butterfly stent and intracardiac echocardiographic guidance in a patient with syncope and refractory pulmonary arterial hypertension.

PURPOSE: Syncope is associated with poor prognosis in patients with pulmonary hypertension. Atrial septostomy improves cardiac index and functional class in appropriately selected patients with pulmonary hypertension, and has been shown to improve syncope. One of the major challenges to its effectiveness is maintaining septostomy patency. We report the case of percutaneous deployment of a modified peripheral stent to create an atrial septostomy in a man with severe pulmonary hypertension and syncope, initially intolerant of medical therapy. PROCEDURES: Percutaneous butterfly stent deployment across the interatrial septum using intracardiac echocardiography and fluoroscopy. FINDINGS: The patient improved in all clinical parameters (BNP, six-minute walk test, dyspnoea score), and was subsequently able to tolerate targeted pulmonary hypertension therapies. PRINCIPAL CONCLUSIONS: Atrial septostomy using butterfly stents to maintain patency may play a role in the treatment of patients with advanced pulmonary hypertension who do not respond to targeted therapy.

HoloLens augmented reality system for transperineal free-hand prostate procedures.

Purpose: An augmented reality (AR) system was developed to facilitate free-hand real-time needle guidance for transperineal prostate (TP) procedures and to overcome the limitations of a traditional guidance grid. Approach: The HoloLens AR system enables the superimposition of annotated anatomy derived from preprocedural volumetric images onto a patient and addresses the most challenging part of free-hand TP procedures by providing real-time needle tip localization and needle depth visualization during insertion. The AR system accuracy, or the image overlay accuracy ( n = 56 ), and needle targeting accuracy ( n = 24 ) were evaluated within a 3D-printed phantom. Three operators each used a planned-path guidance method ( n = 4 ) and free-hand guidance ( n = 4 ) to guide needles into targets in a gel phantom. Placement error was recorded. The feasibility of the system was further evaluated by delivering soft tissue markers into tumors of an anthropomorphic pelvic phantom via the perineum. Results: The image overlay error was 1.29 ± 0.57 mm , and needle targeting error was 2.13 ± 0.52 mm . The planned-path guidance placements showed similar error compared to the free-hand guidance ( 4.14 ± 1.08 mm versus 4.20 ± 1.08 mm , p = 0.90 ). The markers were successfully implanted either into or in close proximity to the target lesion. Conclusions: The HoloLens AR system can provide accurate needle guidance for TP interventions. AR support for free-hand lesion targeting is feasible and may provide more flexibility than grid-based methods, due to the real-time 3D and immersive experience during free-hand TP procedures.

Needle path planning in semiautonomous and teleoperated robot-assisted epidural anaesthesia procedure: A proof of concept.

BACKGROUND: Epidural anaesthesia is a Percutaneous Procedure (PP) which plays a crucial role in surgical procedures, where accurate needle insertion is still challenging. The objective of this work is to present a Tuohy needle path planning, which allows an anaesthesiologist to drive semiautonomously, with the assistance of a teleoperated robot, the tip of the needle during this PP. METHODS: We capture, analysed and modelled the anaesthetist hands' motion during the execution of this procedure, by synthetising, programing and simulating a parametrised and normalised kinematic constrains dependent on an insertion variable in a virtual robot. RESULTS: Two preoperative path planning models were obtained, which provide a teleoperated robot with kinematic constraints to semiautonomously drive a Tuohy needle in the epidural anaesthesia procedure. CONCLUSIONS: A semiautonomous robot can assist in the execution of this PP using the kinematic constraints obtained from the study of the movement of a specialist's hands.

Successful treatment of a patient with type-A acute aortic dissection with emergent percutaneous coronary intervention and thoracic endovascular aortic repair under percutaneous cardiopulmonary support: a case report.

Background: Type-A acute aortic dissection (AAD) with acute coronary involvement can be instantly fatal. The patient's haemodynamics can easily collapse, so rapid decisions regarding treatment strategy are essential. Case summary: A 76-year-old man requested an ambulance because of sudden back pain and paraplegia. He was admitted to the emergency room with cardiogenic shock due to acute myocardial infarction with ST-segment elevation. Computed tomography angiography revealed a thrombosed AAD from the ascending to the distal aorta after the renal artery bifurcation, suggesting a retrograde DeBakey type IIIb (DeBakey IIIb + r, Stanford type-A) dissection. He suddenly developed ventricular fibrillation with cardiac arrest and haemodynamic collapse. We thus performed percutaneous coronary intervention (PCI) and thoracic endovascular aortic repair under percutaneous cardiopulmonary support (PCPS). Percutaneous cardiopulmonary support and respiratory support were withdrawn 5 and 12 days after admission, respectively. The patient was transferred to the general ward on Day 28; he was eventually discharged to a rehabilitation hospital on Day 60, having recovered completely. Conclusion: Immediate decisions regarding treatment strategy are essential. Non-invasive emergent treatment strategies (such as PCI and TEVAR under PCPS) may be options for critically ill patients with type-A AAD.

Heart Team for Left Atrial Appendage Occlusion: A Patient-Tailored Approach.

BACKGROUND AND PURPOSE: Left atrial appendage occlusion (LAAO) is an accepted therapeutic option for stroke prevention; however, the ideal technique and device have not yet been identified. In this study we evaluate the potential role of a heart team approach for patients contraindicated for oral anticoagulants and indicated for left atrial appendage closure, to minimize risk and optimize benefit in a patient-centered decision-making process. METHODS: Forty patients were evaluated by the heart team for appendage occlusion. Variables considered were CHA2DS2VASc, HASBLED, documented blood transfusions, comorbidities, event forcing anticoagulant interruption, past medical history, anatomy of the left atrial appendage, and patient quality of life. Twenty patients had their appendage occluded percutaneously (65% male, mean age 72.3 ± 7.5, mean CHA2DS2VASc 4.2 ± 1.5, mean HASBLED 3.5 ± 1.1). The other twenty underwent thoracoscopic occlusion (65% male, mean age of 74.9 ± 8, mean CHA2DS2VASc 6.0 ± 1.5, HASBLED mean 5.4 ± 1.4). Percutaneous patients were on dual antiplatelet therapy for the first three months and aspirin thereafter, whereas the others received no anticoagulant/antiplatelet therapy from the day of surgery. Follow up included TEE, CT scan, and periodical clinical evaluation. RESULTS: Mean duration of procedures and hospital stay were comparable. All patients had complete exclusion of the appendage; at a mean follow up of 33.1 ± 14.1 months, no neurological or hemorrhagic events were reported. CONCLUSIONS: A heart team approach may improve the decision-making process for stroke and hemorrhage prevention, where LAAO is a therapeutic option. Percutaneous and thoracoscopic appendage occlusion seem to be comparably safe and effective. An epicardial LAAO could be advisable in patients for whom the risk of bleeding is estimated as being too high for post-procedural antiplatelet therapy.

Dynamic path planning for percutaneous procedures in the abdomen during free breathing.

PURPOSE: Percutaneous procedures are increasingly used for the treatment of tumors in abdominal structures. Most of the time, these procedures are planned based on static preoperative images and do not take into account any motions, while breathing control is not always applicable. In this paper, we present a method to automatically adjust the planned path in real time according to the breathing. METHODS: First, an estimation of the organs motions during breathing is performed during an observation phase. Then we propose an approach named Real Time Intelligent Trajectory (RTIT) that consists in finding the most appropriate moments to push the needle along the initially planned path, based on the motions and the distance to surrounding organs. We also propose a second approach called Real Time Straight Trajectory (RTST) that examines sixteen scenarios of needle insertion at constant speed, starting at eight different moments of the breathing cycle with two different speeds. RESULTS: We evaluated our methods on six 3D models of abdominal structures built using image datasets and a real-time simulation of breathing movements. We measured the deviation from the initial path, the target positioning error, and the distance of the actual path to risky structures. The path proposed by RTIT approach is compared to the best path proposed by RTST. CONCLUSIONS: We show that the RTIT approach is relevant and adapted to breathing movements. The modification of the path remains minimal while collisions with obstacles are avoided. This study on simulations constitutes a first step towards intelligent robotic insertion under real-time image guidance.

Multidisciplinary Management of Subclavian Artery Perforation and Complications.

The radial approach to cardiac catheterization and percutaneous coronary interventions has increased in popularity due to the favorable side effect profile relative to the femoral approach. Mediastinal hematoma after radial access cardiac catheterization has scarcely been reported in the literature and, if present, the exact location of the bleed was rarely identified. In this case presentation, we describe an elective transradial coronary angiography resulting in subclavian artery perforation in close proximity to the vertebral artery, with subsequent mediastinal and cervical hematoma formation. This scenario was managed by immediate imaging of the chest after sudden deterioration raised suspicion of an adverse event during wire navigation. Formation of a mediastinal hematoma is the equivalent of retroperitoneal bleed from the femoral approach and requires rapid recognition, interdisciplinary collaboration, and endovascular management.

Temporal Trends on Percutaneous Mitral Commissurotomy: 30 Years of Experience.

Background Percutaneous mitral commissurotomy ( PMC ) was the first available transcatheter technique for treatment of mitral valve diseases. Experience has led to extending the indications to patients with less favorable characteristics. We aimed to analyze (1) the temporal trends in characteristic and outcomes of patients undergoing PMC in a single center over 30 years and (2) the predictive factors of poor immediate results of PMC . Methods and Results From 1987 to 2016, 1 full year for each decade was analyzed: 1987, 1996, 2006, and 2016. Poor immediate results of PMC were defined as a mitral valve area <1.5 cm2 or MR (mitral regurgitation) grade >2. Mitral anatomy was assessed using the Cormier classification and the fluoroscopic extent of calcification. Six hundred three patients were included: 111, 202, 205, and 85, respectively. Mean age increased >10 years over time ( P<0.0001). Mitral anatomy was less favorable over the years: the presence of calcification increased from 25% of patients at the beginning of PMC to >40% during the past decade ( P<0.0001) with a 3-fold increase in severe mitral calcification. Consistently, the proportion of good immediate results decreased over time ( P<0.05) but remained at 76% in 2016. Multivariate analysis showed 3 predictive factors of poor immediate results: smaller baseline mitral valve area ( P<0.0001), pre- PMC MR grade 2 ( P<0.01), and the presence or amount of calcification ( P<0.001). Conclusions This clinic's patients became significantly older with more frequent and severe calcification in the past decade. Predictive factors of poor immediate results were related to valve anatomy, including calcification. Despite challenges raised by severe calcification, PMC was still successful in >3 out of 4 patients in recent years.