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Mitral valve anatomy is complex, and one size does not fit all. More recently, percutaneous mitral valve interventions have revolutionized the management of primary and secondary mitral regurgitation (MR). However, edge-to-edge leaflet repair is not suitable for a large proportion of individuals including those with a failing bioprosthetic mitral valve/annuloplasty ring, and patients with significant mitral annular calcification resulting in mixed mitral valve disease/mitral stenosis. For this high risk cohort, transcatheter mitral valve replacement seems to be an attractive alternative.

Transcatheter aortic valve replacement (TAVR) has changed the management paradigm of severe aortic stenosis. Cardiac magnetic resonance (CMR) has an emerging role in the evaluation of aortic stenos...

Robotic-assisted percutaneous coronary intervention (PCI) has become popular among operators due to substantial reduction in radiation dose. Complex coronary intervention often requires mechanical support and have long fluoroscopy time. Robotic PCI offers an elegant solution by reducing operator fatigue and offering better analysis in the robotic console. We report a hybrid robotic impella assisted single arterial access complex high-risk PCI to the left anterior descending artery via the left internal mammary artery.

Background: To explore the relationship between comorbidity burden and mortality, peri-procedural complications, and length of stay in patients treated with TAVR in the National Inpatient Sample (NIS). Patients undergoing transcatheter aortic valve replacement (TAVR) often have multiple comorbidities. Whilst the impact of individual comorbid conditions on clinical outcomes following TAVR has been previously assessed, the impact of more global measures of comorbidity remains unknown in this cohort. To explore the relationship between comorbidity burden and mortality, peri-procedural complications, and length of stay in patients treated with TAVR NIS. Methods: TAVR procedures were identified between 2011 and 2014 and comorbidities were defined by the Elixhauser classification system (ECS) consisting of 30 comorbidity measures. Endpoints included in-hospital mortality, periprocedural complications, and length of stay. Patients were classified based on their ECS in five categories (ECS I < 0, ECS II = 0, ECS III = 1–5, ECS IV = 6–13, ECS V ≥ 14). Results: A total of 40,604 TAVR patients were identified. Mean age was 81.2 ± 8.5 years. Patients with ECS category V accounted for more than 40% of the cohort and experienced almost a 2.5-fold increase in in-hospital mortality (OR 2.42, 95% CI: 1.28–4.56), acute kidney injury (OR: 6.23, 95% CI: 4.13–9.41), major bleeding (OR: 2.26, 95% CI: 1.71–2.99), post-procedural stroke or TIA (OR: 2.02, 95% CI: 1.08–3.78). It was also associated with a mean 4.14-day increased length of stay (95% CI: 3.67 to 4.65) compared to patients with lower ECS category after adjusting for confounding factors. Conclusions: Our study of over 40,000 TAVRs shows that Elixhauser comorbidity score was independently associated with higher mortality, periprocedural complications, and length of stay. Global comorbidity burden is an important consideration for risk stratification in patients undergoing TAVR.

Objectives The aim of this study was to describe the rates and causes of unplanned readmissions at different time periods following percutaneous coronary intervention (PCI). Background The rates and causes of readmission at different time periods after PCI remain incompletely elucidated. Methods Patients undergoing PCI between 2010 and 2014 in the U.S. Nationwide Readmission Database were evaluated for the rates, causes, predictors, and costs of unplanned readmission between 0 and 7 days, 8 and 30 days, 31 and 90 days, and 91 and 180 days after index discharge. Results This analysis included 2,412,000 patients; 2.5% were readmitted between 0 and 7 days, 7.6% between 8 and 30 days, 8.9% between 31 and 90 days, and 8.0% between 91 and 180 days (cumulative rates 2.5%, 9.9%, 18.0%, and 24.8%, respectively). The majority of readmissions during each time period were due to noncardiac causes (53.1% to 59.6%). Nonspecific chest pain was the most common identifiable noncardiac cause for readmission during each time period (14.2% to 22.7% of noncardiac readmissions). Coronary artery disease including angina was the most common cardiac cause for readmission during each time period (37.4% to 39.3% of cardiac readmissions). The second most common cardiac cause for readmission was acute myocardial infarction between 0 and 7 days (27.6% of cardiac readmissions) and heart failure during all subsequent time periods (22.2% to 23.7% of cardiac readmissions). Conclusions Approximately 25% of patients following PCI have unplanned readmissions within 6 months. Causes of readmission depend on the timing at which they are assessed, with noncardiovascular causes becoming more important at longer time points.

Aim TAVR in patients with bicuspid aortic valves (BAV) is more challenging compared to individuals with trileaflet aortic valves (TAV). BAV have been excluded from the large randomized clinical trials assessing transcatheter aortic valve replacements (TAVR) and has been considered as a relative contraindication to TAVR. To report the outcomes of TAVR in BAV and compare them to TAV in the National Inpatient Sample (NIS). Methods and results TAVR procedures were identified between 2011 and 2014 in the NIS dataset. Endpoints assessed included in-hospital mortality, periprocedural complications, length of stay and cost. Of 40,604 identified TAVR procedures, 407 (1%) were BAV and the 40,197 (99%) were TAV. Patients with BAV were younger and had a lower comorbidity burden. In hospital mortality (4.89% vs 4.17%, OR: 1.71, 95%CI: 0.57–5.12, P = 0.21), AMI (3.49% vs 3.58%, OR: 1.12, 95%CI: 0.36–3.54, P = 0.85), stroke and TIA (2.49% vs 3.55%, OR: 0.75, 95%CI: 0.18–3.16, P = 0.70), vascular complications (2.39% vs 5.58%, OR:0.47, 95%CI: 0.11–1.93, P = 0.29), major bleeding (16.96% vs 23.50%, OR: 0.63, 95%CI: 0.34–1.17, P = 0.15) and rates of permanent pacemaker (PPM) (9.88% vs 10.88%, OR: 1.19, 95%CI: 0.57–2.51, P = 0.64) were similar in both cohorts. Conclusions With multimodality imaging and further improvement in technology, our study demonstrates off-label TAVR should not be considered prohibitive and can be successfully performed for BAV with similar peri-procedural outcomes compared to those with TAV. However, there is a need for robust large prospective studies.

Transcatheter aortic valve replacement (TAVR) is an accepted treatment for patients with severe symptomatic aortic stenosis, with an intermediate or high risk of surgical mortality. 1,2 Despite bei...

•Coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome (SARS) coronavirus 2 has affected 188 countries worldwide with a global death toll of over half a million•Patients with valvular heart disease are also at an increased risk of adverse outcomes from coronavirus disease-2019•Prognosis of patients with the combination of COVID 19 and severe valvular heart disease is poor•This is the first reported case of MitraClip insertion in a patient with severe COVID 19 infection. This procedure assisted in the patient's recovery relieving his cardiac burden and pulmonary edema enabling him to undergo colorectal surgery.

Percutaneous coronary intervention (PCI) in the context of heavily calcified coronary arteries can be challenging. Intravascular lithotripsy (IVL) has been suggested as an alternative to rotational atherectomy (RA). We report a case of stent under expansion, despite plaque modification using rotational atherectomy that was successfully managed with intravascular lithotripsy.

Transcatheter aortic valve replacement over the last few years has revolutionized the way severe aortic stenosis patients are being managed [ [1] , [2] , [3] , [4] ]. Randomized clinical trials commonly excluded bicuspid aortic valves and pure native severe aortic regurgitation [ 2 , 4 ]. We present a case with severe acute aortic regurgitation complicated by refractory pulmonary oedema successfully managed by transfemoral transcatheter aortic valve replacement using a Sapien 3 valve.

Introduction Colchicine has been used in diverse clinical settings. Primary idiopathic pericarditis is complicated by recurrence in 15 to 30% of cases. Aspirin, non-steroidal anti-inflammatory drugs, colchicine and steroids are the commonly prescribed medications. We synthesised the available evidence from the randomised trials to assess the efficacy and safety of colchicine in primary and recurrent pericarditis. Methods A systematic search was conducted using MEDLINE, PubMed, EMBASE, Current Contents Connect, Cochrane library, Google Scholar, Science Direct, and Web of Science. Original data was abstracted from each study and used to calculate an odds ratio (OR) and 95% confidence interval (95% CI). Results Seven randomised trials comprising 1275 patients met full criteria for analysis. Two open label randomised controlled trials and five double-blind randomised controlled trials were included. Colchicine was useful in reducing the incidence of primary pericarditis (OR: 0.38, 95% CI: 0.22- 0.65) as well as recurrent pericarditis (OR: 0.31, 95% CI: 0.22-0.44). The most common side-effects were related to the gastrointestinal system and no severe adverse events were observed. Colchicine cessation either by patient or physician was similar in both groups (OR: 1.53, 95% CI: 0.86-2.71). Conclusion Colchicine is effective in preventing both primary and recurrent episodes of pericarditis. The number needed to treat for preventing recurrent pericarditis was five. Gastrointestinal side-effects were the most common adverse events.

Introduction Transcatheter aortic valve implantation (TAVI) has become an alternative to open surgery in those deemed high risk. The purpose of this study was to evaluate the effectiveness and outcomes of this emerging procedure. We have examined available literature to provide an overview of valve-in-valve implantation using transcatheter heart valves (THVs) in aortic, mitral, pulmonary, tricuspid positions. Methods A systematic search was conducted using MEDLINE, PubMed, EMBASE, Current Contents Connect, Cochrane library, Google Scholar, Science Direct, and Web of Science. Results Only 61 studies met full criteria and were included the review. This included 31 studies reporting transcatheter aortic valve-in-valve implantation, mitral valve-in-valve implantation (13 studies), tricuspid valve-in-valve implantation (12 studies), and pure native aortic valve regurgitation (nine studies). One of the limitations of this review is that most of the studies included were case reports, together with some case series. Conclusion Valve-in-valve implantation can be considered as an acceptable alternative to conventional open heart surgery for elderly high-risk surgical patients with bioprosthetic degeneration. Long-term follow-up of treated patients will be necessary to establish the true role of valve-in-valve implantation for bioprosthetic degeneration. Patients should be evaluated on an individual basis until outcomes are proven in large cohort studies or randomised trials.

Introduction The prevalence of patent foramen ovale among patients with cryptogenic stroke is higher than that in the general population. Closure with a percutaneous device is often recommended in such patients, but it is not known whether this intervention reduces the risk of recurrent stroke. Methods A systematic search was conducted using MEDLINE, PubMed, EMBASE, Current Contents Connect, Cochrane library, Google Scholar, Science Direct, and Web of Science. Original data were abstracted from each study and used to calculate a pooled event rate (ER), odd ratio (OR) and 95% confidence interval (95% CI). Results Only three randomised trials comprising 2303 patients met full criteria for analysis. Procedural success (ER: 94.20%, 95% CI: 87.6–97.4%) and effective closure (ER: 92.70%, 95% CI: 85.9–96.4%) of closure therapy were good. The odds ratio for stroke (OR: 0.654, 95% CI: 0.358–1.193) and transient ischaemic attack (OR: 0.768, 95% CI: 0.413–1.429) did not confer a benefit of PFO closure over medical therapy. Age { 45 years (OR: 0.707, 95% CI: 0.27–1.856)}, gender {males (OR: 0.498, 95% CI: 0.247–1.004), females (OR: 1.16, 95% CI: 0.597–2.255)}, substantial shunt size (OR: 0.354, 95% CI: 0.089–1.406) and the presence of atrial septal aneurysm (OR: 0.7, 95% CI: 0.21–2.33) did not influence the treatment effect of PFO closure. However, the adverse events like major vascular complication (OR: 10.905, 95% CI: 1.997–59.562) and atrial fibrillation (OR: 3.297, 95% CI: 0.874–12.432) were significantly higher in the closure group. Conclusions In patients with cryptogenic stroke or TIA who had a patent foramen ovale, closure with a device does not confer an advantage over medical therapy and is associated with adverse events like major vascular complication and atrial fibrillation.

Background The current recommendation for patients with cutaneous melanoma and a positive sentinel lymph node (SLN) biopsy is a complete lymph node dissection (CLND). However, metastatic melanoma is not present in approximately 80% of CLND specimens. A meta-analysis was performed to identify the clinicopathological variables most predictive of non-sentinel node (NSN) metastases when the sentinel node is positive in patients with melanoma. Methods A systematic search was conducted using MEDLINE, PubMed, EMBASE, Current Contents Connect, Cochrane library, Google scholar, Science Direct, and Web of Science. The search identified 54 relevant articles reporting the frequency of NSN metastases in melanoma. Original data was abstracted from each study and used to calculate a pooled odds ratio (OR) and 95% confidence interval (95% CI). Findings The pooled estimates that were found to be significantly associated with the high likelihood of NSN metastases were: ulceration (OR: 1.88, 95% CI: 1.53–2.31), satellitosis (OR: 3.25, 95% CI: 1.86–5.66), neurotropism (OR: 2.51, 95% CI: 1.39–4.53), >1 positive SLN (OR: 1.77, 95% CI: 1.2–2.62), Starz 3 (old) (OR: 1.83, 95% CI: 0.89–3.76), Angiolymphatic invasion (OR: 2.46, 95% CI: 1.34–4.54), extensive location (OR: 2.22, 95% CI: 1.74–2.81), macrometastases >2 mm (OR: 1.95, 95% CI: 1.61–2.35), extranodal extension (OR: 3.38, 95% CI: 1.79–6.40) and capsular involvement (OR: 3.16, 95% CI: 1.37–7.27). There were 3 characteristics not associated with NSN metastases: subcapsular location (OR: 0.51, 95% CI: 0.38–0.67), Rotterdam Criteria Interpretation This meta-analysis provides evidence that patients with low SLN tumor burden could probably be spared the morbidity associated with CLND. We identified 9 factors predictive of non-SLN metastases that should be recorded and evaluated routinely in SLN databases. However, further studies are needed to confirm the standard criteria for not performing CLND.

Poland syndrome is a rare congenital abnormality with an estimated incidence of 1 in 20,000 to 1 in 30,000 live births. We report and discuss this rare combination of pulmonary hypertension and dextrocardia with Poland syndrome. This case report also highlights the underlying pathogenetic mechanisms during foetal development and the potential to misdiagnose cardiac ischaemia in a patient with an anatomic anomaly.

An 85 year old female was brought in to hospital confused, dyspnoeic and pre-syncopal and was found to be bradycardic down to 19bpm and hypothermic down to 34.5 °C. She was found to be hypothyroid which required insertion of a temporary pacing system. Thyroid function resolved and she was no long pacing dependent. This case highlights the sinister outcomes that can arise from thyroid dysfunction, which can be successfully treated if identified early enough.

We present a case of a young healthy lady with anomalous coronary arteries who presented with cardiogenic syncope. She had a common origin of the left and right main coronary arteries from the right sinus of Valsalva with resultant malignant narrowing of the proximal 2 cm of the left main coronary artery due to extrinsic compression between the aorta and pulmonary artery. She underwent surgical correction that involved the creation of a new left main origin in the left coronary sinus with a 4mm punch. A short segment of the saphenous vein was anastomosed to this opening and then to the left main coronary artery and the original left main coronary artery was oversewn at the aorta.

This case depicts rarely seen images of infective endocarditis in a patient who was managed non-surgically. We present various echocardiograms which closely follow the progression the infective endocarditis in a patient with previous cardiac surgery and prosthetic material in situ. A 51 year old gentleman presented presented with complaints of fevers and gastrointestinal infective symptoms in the context of previously having undergone an aortic root replacement and metallic aortic valve implantation several years prior for a previous episode of aortic dissection whilst utilising illicit intravenous drug use. Echocardiography noted an aortic valve vegetation and blood cultures grew non typhoidal Salmonella Typhimurium. A surgical opinion deemed he was not an appropriate candidate for surgical intervention due to tissue friability and continuous intravenous drug use. Serial echocardiograms show the formation of an aortic root abscess, which fistulised between the left ventricle, right ventricle and right atrium. His clinical condition stabilised and was discharged from hospital with close community monitoring and life-long antibiotic therapy. This case depicts the remarkable images surrounding the natural progression of infective endocarditis managed without surgical intervention, together with the difficulties and limitations in managing prosthetic valve endocarditis.