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The MITRAL (Mitral Implantation of Transcatheter Valves) trial is the first prospective study for valve-in-mitral annular calcification (ViMAC), mitral valve-in-ring (MViR), and mitral valve-in-valve (MViV) using balloon-expandable aortic transcatheter heart valves. Procedural outcomes beyond 1 year are not well described.This study evaluated 2-year outcomes in ViMAC, MViR, and MViV in the MITRAL trial.This multicenter prospective study enrolled patients with severe MAC, prior failed mitral annuloplasty ring repair, or prior failed bioprosthetic MV replacement who were at high surgical risk at 13 U.S. sites.Between February 1, 2015, and December 31, 2017, 91 patients were enrolled (31 with ViMAC, 30 with MViR, and 30 with MViV). In the ViMAC group, 2-year all-cause mortality was 39.3%, 66.7% were New York Heart Association (NYHA) functional class I-II, and mean MV gradient was 5.6 ± 2.0 mm Hg. In the MViR group, 2-year all-cause mortality was 50%, 65% were NYHA functional class I-II, and mean MV gradient was 6.5 ± 2.7 mm Hg. In the MViV group, 2-year all-cause mortality was 6.7%, 85% were NYHA functional class I-II, and mean MV gradient was 6.9 ± 2.4 mm Hg. At 2 years, all patients had ≤mild mitral regurgitation and survivors in all 3 arms showed sustained improvement in Kansas City Cardiomyopathy Questionnaire scores compared to baseline.Use of balloon-expandable aortic transcatheter heart valves in selected patients with severe MAC, failed annuloplasty ring, and bioprosthetic MV dysfunction is associated with improvements in symptoms, quality of life, and stable prosthesis function at 2-year follow-up. Between 1 and 2 years, the MViR group experienced higher mortality rates than the MViV and ViMAC groups.

Background The PINNACLE FLX (Protection Against Embolism for Non‐valvular AF [Atrial Fibrillation] Patients: Investigational Device Evaluation of the Watchman FLX LAA [Left Atrial Appendage] Closure Technology) trial evaluated the safety and efficacy of a next‐generation left atrial appendage closure device (WATCHMAN FLX; Boston Scientific, Marlborough, MA). At 1 year, the study met the primary end points of safety and anatomical efficacy/appendage closure. This final report of the PINNACLE FLX trial includes the prespecified secondary end point of ischemic stroke or systemic embolism at 2 years, also making it the first report of 2‐year outcomes with this next‐generation left atrial appendage closure device. Methods and Results Patients with nonvalvular atrial fibrillation with CHA 2 DS 2 ‐VASc score ≥2 (men) or ≥3 (women), with an appropriate rationale for left atrial appendage closure, were enrolled to receive the left atrial appendage closure device at 29 US centers. Adverse events were assessed by an independent clinical events committee, and imaging was assessed by independent core laboratories. Among 395 implanted patients (36% women; mean age, 74 years; CHA 2 DS 2 ‐VASc, 4.2±1.5), the secondary efficacy end point of 2‐year ischemic stroke or systemic embolism was met, with an absolute rate of 3.4% (annualized rate, 1.7%) and an upper 1‐sided 95% confidence bound of 5.3%, which was superior to the 8.7% performance goal. Two‐year rates of adverse events were as follows: 9.3% all‐cause mortality, 5.5% cardiovascular death, 3.4% all stroke, and 10.1% major bleeding (Bleeding Academic Research Consortium 3 or 5). There were no additional systemic embolisms, device embolizations, pericardial effusions, or symptomatic device‐related thrombi after 1 year. Conclusions The secondary end point of 2‐year stroke or systemic embolism was met at 3.4%. In these final results of the PINNACLE FLX trial, the next‐generation WATCHMAN FLX device demonstrated favorable safety and efficacy outcomes.

Patients presenting with acute myocardial infarction complicated by cardiogenic shock (AMI-CS) are at high risk for impaired antiplatelet activity secondary to malabsorption, systemic hypoperfusion, hypothermia, need for mechanical ventilation, and high use of analgesics. The use of antiplatelet therapy in these high-risk patients is not well studied.Using the National Cardiogenic Shock Initiative database, we analyzed patients who presented with AMI-CS at 60 hospitals from March 2018 to December 2020. All patients were treated using a standard shock protocol. Herein, the patterns of antiplatelet use are described.A total of 204 patients were included in the analysis, of which 174 (85.3%) presented with ST-segment elevation myocardial infarction (STEMI). The majority (84.3%) received antiplatelet therapy before percutaneous coronary intervention (PCI); of those who received antiplatelets, 77.9% received aspirin, 55.2% received an oral P2Y12 inhibitor, and 19.2% received intravenous (IV) antiplatelet therapy. Ticagrelor was the most common P2Y12 inhibitor administered (41.9%), followed by clopidogrel (12.2%) and prasugrel (1.2%). Only 18.6% of oral antiplatelet agents were crushed. Baseline characteristics of patients who received IV vs non-IV antiplatelet agents were similar. Thrombolysis in Myocardial Infarction (TIMI) 0 flow was present in 69.6% of patients before PCI and aspiration thrombectomy was performed in 24.5% of patients. The presence of STEMI, cardiac arrest, cardiopulmonary resuscitation, hypothermia, vasopressor use, elevated lactate levels, or number of vessels treated did not influence the use of IV antiplatelet agents.The use of crushed and IV antiplatelet agents in AMI-CS is low. Further studies are needed in this high-risk population to assess whether more potent antiplatelet inhibition will improve outcomes.

Objectives The aim of this study was to report the 2-year results of the SURTAVI (Surgical Replacement and Transcatheter Aortic Valve Implantation) trial and confirm the interim Bayesian analysis. Background Transcatheter aortic valve replacement (TAVR) with a self-expanding valve was noninferior to surgery in patients with severe aortic stenosis and intermediate operative risk using Bayesian statistical methods. Novel Bayesian designs have been used to shorten the time to primary endpoint analysis in randomized clinical trials, although the predictive value of Bayesian analysis compared with frequentist approaches remains debated. Methods The SURTAVI trial randomized 1,660 patients. An interim analysis was performed 1 year after the 1,400th patient was treated to estimate the primary 2-year endpoint of all-cause mortality or disabling strokes for all patients. Results The Kaplan-Meier rate for the complete 2-year primary endpoint was 12.7% in the TAVR group and 12.6% in the surgery group (0.0% difference; 95% confidence interval: −3.4% to 3.5%), compared with 12.6% with TAVR and 14.0% with surgery (−1.4% difference; Bayesian credible interval: −5.2% to 2.3%) in the interim Bayesian analysis. A comparison of individual clinical, hemodynamic, and quality-of-life endpoints using Bayesian and frequentist methods found no significant differences. Conclusions The complete analysis of all patients with aortic stenosis at intermediate risk for surgery in the SURTAVI trial confirmed the noninferiority, with respect to the frequency of all-cause mortality or disabling stroke, of TAVR to surgery, as determined in the interim Bayesian analysis. Follow-up will extend out to 10 years.

This paper describes the use of Supersonic Laser Deposition (SLD) to manufacture nickel/graphite composite coatings on titanium and aluminium substrates. Laser heating is critical for depositing coatings containing up to 13.3 vol% graphite. For a given feedstock composition, the resulting graphite content and average size of the graphite particles retained in the coating increases with laser power, until substrate melting occurs. The effect of the powder type, feedstock composition, and process conditions on coating structure is characterized. The friction and wear behaviour of selected coating compositions is examined. Nickel coatings containing 13.3 vol% graphite demonstrated self-lubricating behaviour with a stable coefficient of friction below 0.14 in pin-on-disc testing.

Several studies have pair-wise compared access sites for transcatheter aortic valve replacement (TAVR) but pooled estimate of overall comparative efficacy and safety outcomes are not well known. We sought to compare short- and long-term outcomes following various alternative access routes for TAVR.Thirty-four studies with a pooled sample size of 32,756 patients were selected by searching PubMed and Cochrane library databases from inception through 11th June 2021 for patients undergoing TAVR via 1 of 6 different access sites: Transfemoral (TF), Transaortic (TAO), Transapical (TA), Transcarotid (TC), Transaxillary/Subclavian (TSA), and Transcaval (TCV). Data were extracted to conduct a frequentist network meta-analysis with a random-effects model using TF access as a reference group.Compared with TF, both TAO [RR 1.91, 95% CI (1.46-2.50)] and TA access [RR 2.12, 95% CI (1.84-2.46)] were associated with an increased risk of 30-day mortality. No significant difference was observed for stroke, myocardial infarction, major bleeding, conversion to open surgery, and major adverse cardiovascular or cerebrovascular events at 30 days between different accesses. Major vascular complications were lower in TA [RR 0.43, (95% CI, 0.28-0.67)] and TC [RR 0.51, 95% CI (0.35-0.73)] access compared to TF. The 1-year mortality was higher in TAO [RR of 1.35, (95% CI, 1.01-1.81)] and TA [RR 1.44, (95% CI, 1.14-1.81)] groups.Non-thoracic alternative access site utilization for TAVR implantation (TC, TSA and TCV) is associated with outcomes similar to conventional TF access. Thoracic TAVR access (TAO and TA) translates into increased short and long-term mortality.

This study sought to evaluate the differences in cardiogenic shock patient characteristics in trial patients and real-life patients.Cardiogenic shock (CS) is a leading cause of mortality in patients presenting with acute myocardial infarction (AMI). However, the enrollment of patients into clinical trials is challenging and may not be representative of real-world patients.We performed a systematic review of studies in patients presenting with AMI-related CS and compared patient characteristics of those enrolled into randomized controlled trials (RCTs) with those in registries.We included 14 RCTs (n = 2,154) and 12 registries (n = 133,617). RCTs included more men (73% vs 67.7%, P 0.001) compared with registries. Patients enrolled in RCTs had fewer comorbidities, including less hypertension (61.6% vs 65.9%, P 0.001), dyslipidemia (36.4% vs 53.6%, P 0.001), a history of stroke or transient ischemic attack (7.1% vs 10.7%, P 0.001), and prior coronary artery bypass graft surgery (5.4% vs 7.5%, P 0.001). Patients enrolled in RCTs also had lower lactate levels (4.7 ± 2.3 mmol/L vs 5.9 ± 1.9 mmol/L, P 0.001) and higher mean arterial pressure (73.0 ± 8.8 mm Hg vs 62.5 ± 12.2 mm Hg, P 0.001). Percutaneous coronary intervention (97.5% vs 58.4%, P 0.001) and extracorporeal membrane oxygenation (11.6% vs 3.4%, P 0.001) were used more often in RCTs. The in-hospital mortality (23.9% vs 38.4%, P 0.001) and 30-day mortality (39.9% vs 45.9%, P 0.001) were lower in RCT patients.RCTs in AMI-related CS tend to enroll fewer women and lower-risk patients compared with registries. Patients enrolled in RCTs are more likely to receive aggressive treatment with percutaneous coronary intervention and extracorporeal membrane oxygenation and have lower in-hospital and 30-day mortality.

Supersonic Laser Deposition (SLD) is a coating and fabrication process combining cold spray (CS) with laser heating of the deposition zone. Laser heating increases deformation on impact, improving bonding for a given particle velocity, eliminating the need to use helium while retaining the advantages of CS; solid-state deposition, low oxidation and high build rate (≤ 10 kg/hr). Although solid lubricants offer advantages over liquid lubrication, remaining effective over a wide range of operating temperatures and loads, while simplifying sealing, their use is limited by current application methods. SLD enables the deposition of metallic coatings which incorporate solid lubricants into metallic coatings, onto a range of substrates. This paper details the powders and conditions used to deposit nickel/graphite using SLD, and the structure and tribological properties of the coatings produced. Co-efficients of friction below 0.14 were demonstrated for nickel/graphite coatings on aluminium substrates.

We report herein Rhodococcus equi infection in an 11-y-old, male llama with a history of diarrhea and endoparasitism. Postmortem examination revealed granulomatous and ulcerative enteritis, pyogranulomatous mesenteric lymphadenitis, fibrinosuppurative peritonitis, and granulomatous hepatitis. Intralesional macrophages were laden with gram-positive cocci. Bacteriology identified R. equi, and cultures tested positive for R. equi choE and vapA genes by PCR. This case expands the reported spectrum of lesions associated with R. equi infections in llamas from pyogranulomatous bronchopneumonia and peripheral lymphadenitis to pyogranulomatous mesenteric lymphadenitis and enteritis. We also link a R. equi that is carrying the virulent-associated protein gene VapA to clinical disease in New World camelids.

Case summary An 8-year-old domestic longhair cat was evaluated for a right ventral subcutaneous cervical mass. Serial bloodwork and contrast-enhanced cranial and thoracic CT initially lacked ethmoturbinate lysis and showed a progressive, vascularized, right ventral cervical mass involving local lymph nodes. The mass was removed surgically on two occasions. Histopathology and fungal culture were diagnostic for a recurring sclerosing fungal granuloma and pyogranulomatous and eosinophilic lymphadenitis, consistent with Aspergillus species. The cat was treated with oral itraconazole; however, owing to the owner’s non-compliance in administering the medication and disease progression, the cat was humanely euthanized 3 years after diagnosis. Relevance and novel information The development of a cervical subcutaneous fungal granuloma of Aspergillus species in a domestic longhair cat before obvious maxillary, orbital or ethmoturbinate lysis on initial diagnostics is rare and suggests an early onset of lymphatic or hematogenous spread from a suspected nidus of infection within the sinonasal cavity.

Background Renal lymphoma in dogs is rare and has a poor prognosis. Granular lymphocyte morphology is rarely reported in canine renal lymphoma. Mild to moderate polycythemia is reported in a number of canine renal lymphoma cases. Case presentation A 10-year-old Labrador retriever presented to a university veterinary teaching hospital after a 1-month history of polyuria, polydipsia, and pollakiuria and a 2-week history of abdominal distention, lethargy, and increased respiratory effort. Abdominal ultrasound showed a wedge-shaped to rounded, heterogeneously hypoechoic mass lesion in the left kidney. Cytologic analysis of a percutaneous aspirate of the mass was consistent with lymphoma of granular lymphocytes. Severe polycythemia (hematocrit 0.871) was noted on a complete blood cell count. Clonality analysis identified a clonally rearranged T-cell receptor (TCR) gene and immunohistochemical staining was CD3+, CD79a- and CD11d+, supporting cytotoxic T-cell lymphoma. Conclusions To our knowledge, this is the first report of renal cytotoxic T-cell lymphoma with severe polycythemia in a dog. Severe polycythemia and renal cytotoxic T-cell lymphoma are both rare in dogs; this report adds to the body of knowledge on these conditions.

Cutaneous round cell tumors in goats present a diagnostic challenge. In this article, we provide a description of caprine cutaneous mast cell tumors (MCT) and histiocytomas, and report on the validation of anti-human antibodies to CD117/KIT and Iba1 by immunohistochemistry on a range of caprine tissues. Cells immunolabeled for CD117/KIT included resident mast cells in normal lung and skin, interstitial cells of Cajal (intestine), and neuronal cell bodies (brain). Cells immunolabeled for Iba1 included resident macrophages in many tissues including normal lung, dendritic cells (hemolymphatic tissues), Kupffer cells, and microglia. Of 5 cutaneous MCT, only one had metachromasia of cytoplasmic granules; however, neoplastic cells of all 5 MCT had positive immunolabeling for CD117/KIT. The CD117/KIT immunolabeling pattern was predominately focal paranuclear in 3 cases, and cytoplasmic or membranous in 1 case each. Two histiocytomas were identified and had strong positive immunolabeling for Iba1 but not CD117/KIT. All 7 cutaneous round cell tumors described herein occurred in goats less than 4 years of age; the 2 cutaneous histiocytomas were in goats less than 14 months of age. Neither of the cutaneous histiocytomas recurred within 24 months of surgical removal.

Supplemental Material, sj-pdf-1-vet-10.1177_0300985820988145 for Mast Cell Tumors and Histiocytomas in Domestic Goats and Diagnostic Utility of CD117/c-Kit and Iba1 Immunohistochemistry by T. William O’Neill and Christiane V. Löhr in Veterinary Pathology

The area of single point diamond turning of brittle materials like semiconductors and ceramics is significantly benefitted by incorporation of laser assistance. In a new developmental technology that is now recognized as micro-laser-assisted machining (μ-LAM), a laser is shone through a diamond tool to soften the high-pressure phase transformed ductile machining phases that in turn allows thermal softening and thereby enables a higher material removal rate during ductile mode machining. One of the lasers currently used in μ-LAM is the neodymium-doped yttrium aluminum garnet (Nd:YAG) laser operating at 100 W (continuous wave) at the wavelength of 1064 nm. Although this configuration has worked to the benefit of the technology, here we report futuristic developments that will significantly enhance temperature control by selecting a laser wavelength according to the material being machined, allowing tunable machining properties. The concept is illustrated with sample calculations for μ-LAM of silicon, and it appears to offer better target temperatures, thus enhancing the performance of the μ-LAM process.

Objectives This study sought to compare outcomes of patients enrolled in the NCSI (National Cardiogenic Shock Initiative) trial who were treated using a revascularization strategy of percutaneous coronary intervention (PCI) of multivessel PCI (MV-PCI) versus culprit-vessel PCI (CV-PCI). Background In patients with multivessel disease who present with acute myocardial infarction and cardiogenic shock (AMICS), intervening on the nonculprit vessel is controversial. There are conflicting published reports and lack of evidence, particularly in patients treated with early mechanical circulatory support (MCS). Methods From July 2016 to December 2019, patients who presented with AMICS to 57 participating hospitals were included in this analysis. All patients were treated using a standard shock protocol emphasizing early MCS, revascularization, and invasive hemodynamic monitoring. Patients with multivessel coronary artery disease (MVCAD) were analyzed according to whether CV-PCI or MV-PCI was undertaken during the index procedure. Results Of 198 patients with MVCAD, 126 underwent MV-PCI (64%) and 72 underwent CV-PCI (36%). Demographics between the cohorts were similar with respect to age, sex, history of diabetes, prior PCI or coronary artery bypass grafting, and prior history of myocardial infarction. Patients who underwent MV-PCI had a trend toward more severe impairment of cardiac output and worse lactate clearance on presentation, and cardiac performance was significantly worse at 12 h. However, 24 h from PCI, the hemometabolic derangements were similar. Survival and rates of acute kidney injury were not significantly different between groups (69.8% MV-PCI vs. 65.3% CV-PCI; p = 0.51; and 29.9% vs. 34.2%; p = 0.64, respectively). Conclusions In patients with MVCAD presenting with AMICS treated with early MCS, revascularization of nonculprit lesions was associated with similar hospital survival and acute kidney injury when compared with culprit-only PCI. Selective nonculprit PCI can be safety performed in AMICS in patients supported with mechanical circulatory support.

Hemodynamic support is increasingly utilized to avoid hemodynamic collapse during high-risk chronic total occlusion (CTO) percutaneous coronary intervention (PCI). Intermediate-term outcomes of Tandem Heart (TH)-supported CTO-PCI have not been previously reported.We retrospectively evaluated procedural and clinical outcomes in consecutive patients undergoing TH-assisted CTO-PCI at our institution from April 1, 2016 to January 30, 2019.Thirteen TH-assisted CTO-PCIs (25%) were performed during the study period. TH was placed before the PCI in all procedures. The most common reason for hemodynamic support was the use of retrograde CTO-PCI technique in the setting of left ventricular dysfunction (38%). Eleven patients (92%) had decreased left ventricular function with severe congestive heart failure symptoms before the procedure. The CTO vessel treated was the right coronary artery in 38% of patients. Retrograde approach was utilized in 6 PCIs (46%). Technical success was achieved in 12 PCIs (92%) despite very complex and very difficult CTO lesions, as indicated by a median J-CTO score of 3 and Progress CTO score of 2. Procedural success was achieved in 10 patients (77%). TH was removed at the completion of PCI in 11 procedures (85%). There were no major bleeding complications; however, one patient developed arteriovenous fistula at the arterial cannula insertion site. One patient had coronary perforation with hemodynamic compromise requiring pericardiocentesis. One patient died of cardiogenic shock, secondary to right ventricular wall hematoma.TH can be used for hemodynamic support during CTO-PCI to achieve a very high technical success rate.

This paper proposes a novel and coherent analysis of mass transfer and thermal stress flow (direction) in solidification of spherical components such as acetabular shells in selective laser melting of Ti-6Al-4 V. A detailed description of different phenomena such as solidification behaviour at the solid/liquid interface, behaviour of moving interface, thermal gradient, Gibbs free energy, interfacial energy and equilibrium temperature were utilised to characterise mass and thermal stress flow. Experimental results showed that thermal stress and mass flow on outer surfaces are higher than those found on inner surfaces which are related to the geometry and shape of the printed structures. Due to the mass transfer and thermal stress flow, built-up lines including a dent in the outer surfaces and grooves in the inner surfaces were observed with heights on the order of 200 μm. Post-processing is needed to remove the built-up lines which results in increasing dimensional deviations.

Incomplete revascularization is associated with worse outcomes as the number of untreated vessels increases [(1)][1]. Impella (Abiomed, Danvers, Massachusetts) and intra-aortic balloon pumps (IABP) were compared in the PROTECT-II randomized trial (A Prospective, Multi-center, Randomized

Laser machining of glassy carbon was experimentally investigated using a 1065 nm wavelength Yb-based master oscillator power amplifier fiber laser source. Ablation characteristics were determined for SIGRADUR G glassy carbon samples using laser fluence of less than 3 J / c m 2 . The ablation threshold was found to be 0.31 J / c m 2 for incident pulse repetition rates of 250 and 500 kHz. Glassy carbon exhibited excellent machining characteristics with features of clearly defined edges and smooth surfaces. The ablation rate varied linearly with fluence over the range 0.31 − 1.3 J / c m 2 . High-quality glassy carbon microstructures were created with optimum laser parameters.