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Transcatheter aortic valve replacement (TAVR) has emerged as an effective therapy for aortic stenosis in patients who are at intermediate and high surgical risk. Vascular access remains critical to the success of the TAVR procedure. This article reviews the use of imaging in planning and executing TAVR access.

Objectives The objective of this study was to evaluate clinical outcomes and patency rates using the Viabahn endoprosthesis in complex (TASC-II C and D) femoropopliteal lesions. Background Traditional treatment of symptomatic TASC-II C and D femoropopliteal lesions has mainly centered on open surgical options in patients deemed appropriate candidates. Endovascular treatment of these lesions with balloon angioplasty has been historically hampered by aggressive restenosis and relatively early clinical failure. The Viabahn endoprosthesis was developed with the intent of reducing restenosis while improving overall flexibility in the femoropopliteal segment. Methods Between March 2009 and July 2011 a total of 51 limbs in 41 patients underwent implantation of one or more Viabahn endovascular stent grafts for the treatment of symptomatic TASC-II C or D lesions. Patients were followed clinically at regular intervals and also underwent routine surveillance duplex ultrasound at 1, 3, 6, and 12 months post-procedure. The average follow-up from the index procedure was 14.6 months (range 13–35.2 months). Results A total of 22 TASC-II C and 29 TASC-II D lesions were treated (51 limbs in 41 patients). The mean lesion length was 22.4 cm. The overall 1-year primary patency rate was 74.8% (95% CI: 61.2%–88.4%), assisted primary patency rate was 87.4% (95% CI: 70.9%–95.9%), and the secondary patency rate was 94.9% (95% CI: 88.0%–100.0%). Conclusions The Viabahn endoprosthesis is a safe and effective option for the treatment of TASC-II C and D femoropopliteal lesions. Patency rates are favorable despite the complexity of these lesions, although multiple endovascular re-interventions may be necessary to achieve an acceptable long-term result.

Risk assessment models for transcatheter aortic valve replacement (TAVR) versus surgical aortic valve replacement in high-risk patients and TAVR versus palliation in inoperable patients are based on surgical data and have limited discrimination and calibration in the setting of TAVR. Several novel risk models specifically designed for TAVR have improved discrimination over existing models but require further validation. Several clinical and echocardiographic variables, such as chronic lung disease, mitral regurgitation, and stroke volume index, influence outcomes. This article reviews current and novel risk models and important predictors of TAVR outcomes and proposes a framework to integrate them into clinical decision-making for patients with severe, symptomatic aortic stenosis.

Aortic valve (AV) replacement with a pulmonary autograft (ROSS Procedure) has been used for treatment of aortic stenosis (AS), but degeneration of the aortic position pulmonary autograft and pulmonary position homograft often requires repeat surgical intervention. 63 year old male presented with

Introduction Left ventricular assist device (LVAD) outflow graft obstruction is a well-known and significant complication. The typical management involves treatment of presumed thrombosis of the graft with intensified anticoagulation or surgery. More recently, endovascular stenting has been reported as a possible treatment option. We describe the management of a LVAD outflow cannula obstruction with never reported intravascular ultrasound (IVUS)-guided covered endovascular stenting. Case report A 68 year-old female with non-ischemic cardiomyopathy status-post LVAD implantation in March 2016 presented with persistent symptomatic low flow alarms and clinical signs of heart failure. Symptoms seemed to worsen when she laid on her right side. She was compliant with her anticoagulation and lactate dehydrogenase level was found to be near her baseline. A CT scan with IV contrast revealed intraluminal obstruction of the LVAD outflow graft secondary to a kinked portion of the outflow cannula near the bend relief with a possible thrombotic component. The severe angulation of the cannula likely developed due to the patient's gradual weight gain of 28kg in the 24 months since LVAD implantation. Given the patient's risk profile, a percutaneous endovascular stenting approach was taken. IVUS was used to visualize the obstruction and kinking of the graft. A balloon-expandable covered stent was deployed at the stenotic site while the LVAD was briefly stopped to avoid stent/balloon migration. A covered stent was used to minimize the risk of thrombus migration/extrusion. IVUS was used again after post-dilation of the stent to confirm placement with no thrombus extrusion. Several hours later the patient had recurrent low-flow alarms. A repeat CT scan revealed that the kink had migrated and been transmitted within the outflow cannula towards the LVAD. The patient returned to the angiography suite where 2 balloon expandable stents were deployed more proximally within the outflow cannula and in an overlapping fashion with the original covered stent. Non-covered stents were used for the second procedure as there was no suspected thrombotic component. IVUS showed no significant residual kinking post-stenting. This was confirmed with a repeat CT scan. The patient recovered without any hemodynamic or neurologic sequelae. Conclusion Percutaneous endovascular stenting is an emerging option for treatment of outflow tract obstruction in LVAD patients that are not candidates for surgery. IVUS can be a valuable tool during intervention to confirm proper stent position, thrombus isolation, and outflow cannula geometry.

Multiple chemotherapeutic drugs are used in the treatment of breast cancer, many of which have the potential to produce cardiotoxicity. The anthracyclines are highly efficacious against breast cancer, but pose a particularly high risk for cardiotoxicity. The incidence of anthracycline-induced cardiomyopathy increases in a dose-related fashion and with prior cardiac radiation exposure. The exact mechanism of toxicity is unknown, but the maximum tolerated cumulative dose can be increased by reducing peak drug levels and with concurrent administration of dexrazoxane. Because anthracycline-induced cardiomyopathy is largely irreversible and cumulative, prevention is the preferred strategy. Monitoring by assessment of left ventricular function by the most reproducible method available as patients approach potentially toxic doses can substantially reduce toxicity. The long-term outcome of anthracycline-induced cardiomyopathy is better than previously reported because of advances in therapy. Recommendations for cardiac monitoring depend on the baseline cardiac function. In patients with baseline left ventricular ejection fraction (LVEF) >50%, periodic assessment of LV function will depend on other cardiac risk factors present and cumulative dosing of the cardiotoxic drugs. A decrease in LVEF of more than 10% or an absolute decrease to less than 30% is an indication for doxorubin discontinuation. Doxorubin-based chemotherapy should not be initiated in patients with a baseline LVEF of less than 30%.

The management of drug and standard catheter ablation refractory scar mediated ventricular tachycardia remains a therapeutic challenge. This can be made more difficult if the presentation is complicated by unstable hemodynamics status. The patient is an 82 year old male with history of coronary

Activity-induced brain-derived neurotrophic factor (BDNF) expression is negatively modulated by circulating adrenal steroids. The rat BDNF gene gives rise to four major transcript forms that each contain a unique 5′ exon (I–IV) and a common 3′ exon (V) that codes for BDNF protein. Exon-specific in situ hybridization was used to determine if adrenalectomy has differential effects on basal and activity-induced BDNF transcript expression in hippocampus. Adrenalectomy alone had only modest effects on BDNF mRNA levels with slight increases in exon III-containing mRNA with 7–10-day survival and in exon II-containing mRNA with 30-day survival. In the dentate gyrus granule cells, adrenalectomy markedly potentiated increases in exon I and II cRNA labeling, but not increases in exon III and IV cRNA labeling, elicited by one hippocampal afterdischarge. Similarly, for the granule cells and CA1 pyramidal cells, hilus lesion (HL)-induced recurrent limbic seizures elicited greater increases in exon I and II cRNA hybridization in adrenalectomized (ADX) as compared to adrenal-intact rats. In this paradigm, adrenalectomy modestly potentiated the increase in exon III-containing mRNA in CA1 but had no effect on exon IV-containing mRNA content. These results demonstrate that the negative effects of adrenal hormones on activity-induced BDNF expression are by far the greatest for transcripts containing exons I and II. Together with evidence for region-specific transcript expression, these results suggest that the effects of stress on adaptive changes in BDNF signalling will be greatest for neurons that predominantly express transcripts I and II.

Current classification systems of coronary bifurcation lesions are confusing and difficult to memorize. As coronary revascularization techniques become increasingly complex, it is important to establish a universal classification system. This manuscript proposes a simplified classification system that uses a combination of letters and numbers to provide a clinically relevant anatomic description of a given coronary artery bifurcation lesion. This classification consists of the prefix B (for Bifurcation lesion), followed by the addition of 4 separate suffixes. The first suffix consists of one of the letters C, N, S, or L. C = Close to the bifurcation: the lesion is close to a bifurcation, but the distance from the carina is more than the width of the plaque protruding into the lumen; N = Bifurcation lesion with one branch being Nonsignificant: nonsignificant being defined as less than 2.0 mm vessel diameter; S = Small proximal segment; or L = Large proximal segment: large defined as more than two-thirds of the sum of the diameters of both branch vessels. The second suffix describes the number of diseased ostia. 1M = only the Main vessel ostium is involved; 1S = only the Side branch ostium is involved; or 2 = both ostia are involved. The third suffix classifies the angle between the bifurcation vessels and uses the letters V or T; V = the angle between the two branches is less than 70 degrees, T = angle more than 70 degrees. The fourth suffixes are optional: CA for calcified, LM for left main involvement.