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Objectives This study sought to evaluate cardiac computed tomography (CCT) findings and their clinical impact among patients being considered for transcatheter mitral valve replacement (TMVR). Background CCT is used to evaluate whether patients are candidates for TMVR, but limited data exist on the yield of such tests. Methods Patients referred for pre-procedural CCT for TMVR planning in the context of failing mitral bioprosthetic valves, annuloplasty rings, and severe native valve disease with annular calcification were included in this study. CCT findings were analyzed to evaluate for suitability for TMVR. In the subset of patients who underwent TMVR, echocardiographic and procedural characteristics were recorded. Results Among 80 patients who underwent pre-procedural CCT, the mean age was 71.8 ± 11.4 years, 60% were women, and the mean Society of Thoracic Surgeon score was 9.4 ± 6.7. Most cases were referred for valve-in-native annular calcification planning (n = 43), followed by valve-in-valve (n = 29), and valve-in-ring procedures (n = 8). A total of 51 (64%) patients did not undergo TMVR, 37 of whom had high-risk features identified on CCT. The most common reason for exclusion was related to large annular size, followed by heightened risk of left ventricular outflow tract (LVOT) obstruction. Among 29 patients (36%) who underwent TMVR, the 30-day mortality rate was 17%. Five patients experienced LVOT obstruction, 4 of whom were predicted by CCT. Following TMVR, 5 patients had at least moderate peri-valvular regurgitation. Conclusions A minority of patients referred for TMVR planning ultimately undergo the procedure. CCT identifies unsuitable anatomy and leads to exclusion in a significant number of cases.

Purpose The purpose of this project was to design, develop, implement, and manage a sustainable process for pediatric preoperative COVD-19 testing and use the test results to determine the level of personal protective equipment and infection control required for each patient for optimal surgical scheduling and preservation of resources. Design This quality improvement project used the Plan-Do-Study-Act methodology. Multiple cycles of re-evaluation refined this process which was standardized across the enterprise. Methods A process for preoperative testing for all patients undergoing procedures requiring anesthesia was developed and implemented. Findings A safe, feasible, timely process was developed and piloted to obtain COVID-19 test results to guide individualized interventions. During the pilot, 1,707 patients were screened, and five tested positive for COVID-19, eliminating the need to manage 1702 patients as COVID-19 positive. Conclusion To continue to safely re-open, knowledge of the patient's COVID-19 status is imperative to ensure a safe journey through the perioperative area.

Background With the increasing complexity of procedures being performed in the cardiac catheterisation laboratory, the multidisciplinary team has the challenge of providing safe care to patients who present with a multitude of healthcare needs. Although the use of a surgical safety checklist has become standard practice in operating theatres worldwide, the use of a pre-procedure checklist has not been routinely adopted into interventional cardiology. Objective The aim of this study was to design and evaluate a pre-procedure checklist specific to the cardiac catheterisation laboratory. Method A descriptive, exploratory design was used to develop a specifically designed pre-procedure checklist for use in the cardiac catheterisation laboratory in a private hospital in Melbourne, Australia. The pre-procedure checklist was developed by exploring the multidisciplinary team's opinion regarding the organisation's previous surgical pre-procedure checklist through a pre-implementation survey and focus groups. Following an expert review, and implementation of the proposed pre-procedure checklist, a post-implementation survey was completed. Results Thirty-five (70%) cardiac catheterisation laboratory healthcare professionals completed the pre-implementation survey, with 31 (62%) completing the post-implementation survey. Ninety-one per cent of participants agreed that important clinical information required for interventional procedures was not documented on the previous surgical checklist. A specific checklist was developed from the results of the survey and six focus groups (N = 25) and implemented in the cardiac catheterisation laboratory. In the post-implementation survey, participants identified that the cardiac catheterisation laboratory specific pre-procedure checklist included all relevant clinical information and improved documentation of patient information. Conclusion The development of a specific cardiac catheterisation laboratory pre-procedure checklist has led to an improved transfer of pertinent clinical information required prior to procedures being performed in the unit. The outcome of this study has implications for other cardiac catheterisation laboratories with the potential to standardise practice within interventional cardiology practice and improve patient safety outcomes.

Yasushi Nakai,1 Nobumichi Tanaka,1 Toshihiko Matsubara,1 Satoshi Anai,1 Makito Miyake,1 Shunta Hori,1 Tomomi Fujii,2 Chiho Ohbayashi,2 Kiyohide Fujimoto1 1Department of Urology, Nara Medical University, Nara, Japan; 2Department of Diagnostic Pathology, Nara Medical University, Nara, JapanCorrespondence: Nobumichi TanakaDepartment of Urology, Nara Medical University, 840 Shijo-cho, Nara, 634-8522, JapanTel +81-744-22-3051 (ext. 2338)Fax +81-744-22-9282Email sendo@naramed-u.ac.jpObjective: To evaluate factors correlated with pain during prostate biopsy and willingness to undergo transrectal ultrasound-guided prostate biopsy (TR-PBx) again without anesthesia in patients undergoing TR-PBx without anesthesia.Methods: This retrospective, single-center study evaluated 624 patients who underwent TR-PBx without anesthesia. Based on a nomogram using patient age and prostate volume, 6– 12 core biopsy samples were allocated. Anxiety was evaluated using the Faces Anxiety Scale before the TR-PBx. Pain was evaluated using the Faces Pain Scale at each puncture and immediately after confirmation of cessation of bleeding from the rectum after the transrectal probe was pulled out. The question “If this operation must be repeated, would you agree to undergo it again under same conditions?” was asked after the procedure was completed. The change in pain at each puncture and factors correlated with post-procedural pain were calculated using multiple regression analysis, and factors predicting an answer of “yes” to the question using binary logistic analysis were evaluated.Results: Scores on the Faces Pain Scale significantly increased from the first core sample to last as the number of samples increased. However, the number of samples did not show significant correlation with pain evaluated after the procedure was complete. Time during the biopsy and the anxiety score had a significant correlation with the pain scale score for the completed procedure. Short duration of TR-biopsy and a low anxiety score predicted a reply of “Yes” to the question.Conclusion: A long operative time during the TR-PBx procedure and strong pre-procedure anxiety can increase pain for patients undergoing the procedure without anesthesia and cause patients to be unwilling to undergo TR-PBx again without anesthesia.Keywords: anesthesia, anxiety, biopsy, pain, prostate cancer

Objectives: Iliac vein stenting is a relatively new procedure in the treatment of chronic venous insufficiency. Research has shown that it is a safe and effective form of treatment, however, one of the well-known risks is in-stent thrombosis. We hypothesize that a single 75 mg dose of Clopidogrel the night prior to the procedures along with a 3-month regimen post-op would decrease the 30-day thrombosis rate. Methods: A retrospective study was performed on 3,518 patients from September 2012 to August 2018 who received an iliofemoral stent. Patients were broken down into 2 main groups: those given Clopidogrel post-stent and those given Clopidogrel both pre- and post-stent. In our practice, we prescribe a 3-month course of Clopidogrel after iliac vein stenting. Patients were also checked for any anticoagulant medications pre- and/or post-stent. The 30-day thrombosis rates were recorded for each patient. Results: 1,205 patients received Clopidogrel pre-procedurally and post-procedurally, 1,941 patients received Clopidogrel only post-procedurally. 372 patients were excluded from the study because they were on other anti-coagulant medications. Mean follow-up for this cohort was 17 months. 112 total patients developed some degree of 30 day in-stent thrombosis (3.6%). 74 patients developed a complete thrombosis of the stent and 38 developed a partial (≤60% occlusion) thrombosis. Of the 1,205 patients who were on clopidogrel pre-stenting, 28 had a complete thrombosis and 10 had a partial in-stent thrombosis. Of the 1,941 patients on Clopidogrel only post-stenting, 46 had a complete thrombosis and 28 had a partial in-stent thrombosis. Using the Chi-squared test, there were no statistically significant differences between the group of patients receiving Clopidogrel pre- and post-stent vs. just post-stent with respect to 30-day any degree of thrombosis rates (complete and partial thrombosis) (p = .33). Using the Chi-squared test, there were no statistically significant differences between the group of patients receiving Clopidogrel pre- and post-stent vs. just post-stent with respect to 30-day complete thrombosis rates (p = .93). Conclusions: There appears to be no statistical difference in 30-day thrombosis rates between those receiving Clopidogrel the night prior vs. those who do not receive Clopidogrel the night prior. Therefore, we conclude that it is not necessary to give this single dose the night prior to iliac vein stenting procedures.

Recently, antegrade dissection re-entry (ADR) with re-entry device for chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has evolved to become one of the pillar techniques of the hybrid algorithm. Although the success rate of the device is high, it could be improved. We sought to evaluate the current trends and issues associated with ADR in Japan and evaluate the potential of cardiac computed tomography angiography (CCTA) for ADR procedure. A total 48 patients with CTO suitable for ADR evaluated by baseline conventional angiography and CCTA were enrolled. Procedural success and technical success were evaluated as the primary and secondary observations. Furthermore, all puncture points were analyzed by CCTA. CT score at each punctured site depended on the location of plaque deposition (none; + 0, at isolated myocardial site; + 1, at epicardial site; + 2) and the presence of calcification (none; + 0, presence; + 1) was analyzed and calculated (score 0–3). Overall procedure success rate was 95.8%. Thirty-two cases were attempted with the ADR procedure and 25 cases of them were successful. The technical success rate was 78.1% and myocardial infarction or other major complications were not observed in any cases. CT score at 60 puncture sites in 32 cases were analyzed and the score at technical success points was significantly smaller compared to that at technical failure points (0.68 ± 1.09 vs 1.77 ± 1.09, p

Introduction: Tennis elbow is a common problem, for which current available treatments are often unsatisfactory. Biologic therapies, such as platelet rich plasma (PRP) injections, aimed at stimulating healing of degenerative tendons by releasing growth factors, have shown promise in vitro study but clinical research is limited. The objective of present study is to study the efficacy of platelet rich plasma in tennis elbow, and to evaluate the outcomes of this recent modality of treatment for tennis elbow by MRI studies.Materials and Methods: Patients who were diagnosed with tennis elbow and undergone conservative treatment for at least 3 months but not improved were included in the study after obtaining written informed consent. After preparation of PRP by centrifugation, the injection was given under ultrasonography (USG) guidance at the site of tendinopathy within 4 hours of preparation. The patients were evaluated by Magnetic Resonance Imaging (MRI) pre procedure and post procedure at 1 week, 1, 2, 3, and 6 months. Result: 30 patients fulfilling the inclusion criteria were included in the study and treated with PRP. Majority of them showed significant improvement in terms MRI studies and were able to return to work at 6 months of follow up. Conclusion: Platelet-rich plasma (PRP) may represent a therapeutic option for tennis elbow. Thus, future research should focus on identifying proper treatment time, optimal dosage and ideal PRP concentration.

Background: Balloon pulmonary valvuloplasty is the procedure of choice for pulmonary valve stenosis in any age group. The data on efficacy of the procedure in adolescent and adult population is scanty in Pakistan. Objective: To determine the early outcome of balloon pulmonary valvuloplasty in adolescents and adults. Study Design: Descriptive retrospective case series. Settings: Pediatric cardiology department of Faisalabad Institute of Cardiology, Faisalabad-Pakistan. Duration: Three years and Six months from 01-01-2016 to 30-06-2019. Methodology: All consecutive patients of age 10 years or above who underwent percutaneous balloon pulmonary valvuloplasty in the study period were enrolled. The outcome parameters including successfulness and complications of procedure recorded. The procedure was labelled successful if peak to peak pressure gradient across pulmonary valve reduced to less than 50% or more of the pre procedure value, suboptimal if gradient reduced by 25-49% and unsuccessful if gradient reduced by less than 25%. Results: A total of 41 patients underwent balloon pulmonary valvuloplasty procedure. Mean age was 22.2± 10.5 years while female to male ratio was 1.05:1. Majority of the patients (n=26, 63.4%) were symptomatic and dyspnea on exertion was the dominant symptom (n=16, 39%). Majority of the patients had doming pulmonary valve (n=37, 90.2%). Mean balloon to pulmonary valve annulus ratio was 1.24 ± 0.1 (range 1.1-1.43). The procedure was successful in all patients (n=41, 100%) as the mean peak to peak pressure gradient across pulmonary valve decreased from 121.9 ± 53.2 mmHg (pre valvuloplasty) to 30.1±11.9 mmHg (post valvuloplasty) irrespective of doming or dysplastic valve. There were no major complications. Transient self-limiting vaso-vagal syncope was noted in 7.3% of patients (n=3). On post procedure echocardiography there was not a single case of moderate or severe pulmonary valve regurgitation (PR) while mild PR was observed in 48.8% patients (n=20). Conclusion: Balloon pulmonary valvuloplasty in adolescent and adult patients is a very safe procedure with high success but very low complications rate.

BACKGROUND The brachial plexus is a network of nerves exiting the spinal cord through the fifth, sixth, seventh, and eighth cervical nerves (C5-C8) as well as the first thoracic nerve (T1) to conduct signals for motion and sensation throughout the arm. Brachial plexus birth injuries (BPBI) occur in 1.5 per 1,000 live births. The purpose of this study was to determine the perceived change in musculoskeletal health-related quality of life of brachial plexus patients utilizing the Pediatric Outcomes Data Collection Instrument (PODCI). PODCI scores were examined along with the patient's procedure history (surgical or Botulinum Toxin), extent of involvement and demographics. PATIENTS A total of 81 patients from two to eighteen years of age from nine different states met the inclusion criteria of having a pre-procedure and post-procedure PODCI score along with a Narakas score from 2002-2017. These patients were seen at the Brachial Plexus Center, which is an interdisciplinary clinic at a large academic medical centerMETHODS: This retrospective study utilized PODCI data collected annually during their regular brachial plexus clinic visits. Upper extremity (UE) and global functioning (GFx) scores pre- and post-procedure were stratified by Narakas Classification. Data were analyzed using paired t-test and ANOVA testing. RESULTS Patients with a Brachial Plexus Birth Injury (BPBI) had lower PODCI scores for UE and GFx when compared with the pediatric normative scores for age-matched healthy children. Scores in both UE and GFx domains were higher after procedure in the groups of Narakas I and IV. There was significant correlation between UE and GFx scores and documented first PODCI score (2 years of age) and age at intervention (5 years of age). CONCLUSION Procedures increased the perceived quality of life for children with a BPBI and increased their overall PODCI scores for both UE and GFx.

The World Health Organization (WHO) introduced surgical safety checklist (SSC) as a part of Second Global Patient Safety Challenge: Safe Surgery Saves Lives to address the safety of surgical care. Althoughfound to be benefi cial for general surgical patient, we introduced certain modification to suit neurosurgical patients and hereby present our experience with the modified checklist.We introduced the modified SSC in July 2012 for neurosurgical purpose after we identified minor but common errors in carefully audited 100 patients in our operating theatre. Modification included checklists in pre procedure room, during sign in enquiring for pulse oximeter (for local anesthetic procedures) and lastly during sign out an elaborated list of items to guarantee safe transfer of the patients. Nurses and doctors were trained and SSC was methodically administered.Outcome as number of complications was evaluated and graded according to no harm, low harm, moderated harm, severe harm and death. During last 5 years (July 2012 to June 2017), 1310 patients undergoing surgical procedures in neurosurgical theatre at KMCTH were studied. Modified SSC was used in both routine (50.5%) and emergency cases (49.5%), of which compliance was 80% and 55% respectively. Poor compliance was due to ignorance of its use, emergency nature of procedure, change of staff. Completeness of mSSC was found in 70% cases with most left out part of mSSC was during signing out (i.e during transfer of patients). Use of mSSC identified many common but minor negligent acts on part of doctors, nurses and OR technicians which could be rectified in time and hence avoided any major mishaps. Age of the patients ranged from newborn to 98 year old. There were no major mishaps including death on table events. Despite confirming during mSSC checklist, machine failure occurred in 10 cases (0.8%) which were of low harm category. The total time taken for performing and filling the checklist took roughly 7 minutes.We modified WHO surgical safety checklist to include post operative transfer out to recovery room and used it in both routine and emergency procedures. This has helped us to avoid major mishaps during and after the neurosurgical procedures. We recommend stringent use of SSC in all neurosurgical centre and advise suitable local modifications according to prevailing conditions for special procedures or locations.Nepal Journal of Neuroscience, Volume 14, Number 3, 2017, page: 7-12

Background and aims: With the onset of the Coronavirus Disease 2019 (COVID-19) pandemic, healthcare providers abruptly changed their delivery of care to protect patients and staff from infection. One such change was to convert in-person advanced gastrointestinal endoscopy pre-procedure consultations to telemedicine visits. The use of telemedicine has been successfully used in the field of gastroenterology in managing symptoms and chronic conditions among established patients. However, to our knowledge, there is little literature on the utility of this modality for pre-procedure consultation visits, where patients often meet their proceduralists for the first time. The aim of this study was to compare overall patient satisfaction among those who had pre-procedure consultation visits by telemedicine, in –person, or a direct access procedure (instructions and procedure explained by a nurse practitioner or physicians assistant). Methods: Patients who had undergone an advanced endoscopic procedure at Long Island Jewish Hospital from the months of May 2020 to August 2020 were called by telephone and asked to complete a modified version of the validated patient satisfaction survey mGHAA-9. The survey was designed to assess patient satisfaction in their pre-procedure, intra-procedure, and post procedure experiences. Patients were grouped based on whether they had received an in-clinic consultation visit by the endoscopist, telemedicine consultation visit by the endoscopist, or direct access. Geographic location to the office, prior endoscopic experience, type of endoscopic procedure (diagnostic vs. therapeutic), and new gastrointestinal cancer diagnosis data were recorded. Results: Of the total 322 patients that were called, 123 agreed to participate (38%) and provided responses to the survey. There were 26 who had in person consultation visits, 32 who had telemedicine consultation visits, and 65 direct access visits. Overall mean satisfaction among the three groups did not reveal a statistically significant difference (p value= 0.983). Furthermore, sub-analysis of the preprocedure, intra procedure, and post procedure satisfaction scores did not reveal statistically significant differences (p=0.996, p=0.244, and p=0.998, respectively). However, patients with a new gastrointestinal cancer diagnosis had a statistically significant higher mean satisfaction score in those who had telemedicine visits with proceduralists compared to those who had direct access procedures (P=0.0116). Conclusion: Our study suggests that pre-procedure consultation visits by telemedicine, in-person, or direct access all have similar satisfaction scores among patients. However, telemedicine consultation visits with the endoscopist may be preferred over direct access in patients who have a clinically high suspicion for a new gastrointestinal cancer diagnosis. [Formula presented]

Introduction: Tendinopathy is a repetitive strain injury caused by repetitive overuse of the muscles of the body. It causes pain and functional impairment in daily activities. The treatment of this condition includes conservative therapy and surgical interventions. The effectiveness of oral nonsteroidal anti-inflammatory agents, topical and injectable medications including corticosteroids and botulinum toxins, splinting, physical therapy, and iontophoresis has been evaluated in many studies. Platelet-rich plasma (PRP) therapy has been utilized for nearly two decades to treat degenerative joint disease and speed recovery from soft tissue injuries to tendons, muscles and ligaments. Aim: The present study aims at evaluating the results of PRP treatment in chronic tendinopathy and assessment of joint function and functional abilities of patients in follow up studies. Materials and Methods: This study was a prospective, comparative, single blind study, carried out in 30 patient. The patients were assessed pre procedure and post procedure in form of range of movements, pain, tenderness, joint stiffness and early mobilization. Quantity of PRP given was 2 ml in 6 month chronicity. The functional outcome of PRP treatment was evaluated with visual analogue score. Results and Discussion: The functional outcome i.e. pain improvement in our study was evaluated using VAS (Visual analogue Score). About 64% patients in our study attained excellent VAS scores. Our results were comparable to the results obtained by Mishra and his colleagues8, in 2006, where patients who had received PRP treatment showed 60% improvement in their VAAS pain score. Conclusion: Our study had shown good to excellent symptom improvement in 90% of patient. Almost all patient treated with PRP had good range of motion and pain relief at the end of the study and most of patients were able to do their routine or previous work and activities without any difficulty. Being newer techniques, PRP treatment requires further evaluation and there is a steep learning curve

To evaluate the value of pre-radiofrequency ablation (RFA) MR and post-RFA CT registration for the assessment of the therapeutic response of hepatocellular carcinoma (HCC).A total of 178 patients with single HCC who received RFA as an initial treatment and had available pre-RFA MR and post-RFA CT images were included in this retrospective study. Two independent readers (one experienced radiologist, one inexperienced radiologist) scored the ablative margin (AM) of treated tumors on a four-point scale (1, residual tumor; 2, incomplete AM; 3, borderline AM; 4, sufficient AM), in two separate sessions: (1) visual comparison between pre-and post-RFA images; (2) with addition of nonrigid registration for pre- and post-RFA images. Local tumor progression (LTP) rates between low-risk (response score, 3-4) and high-risk groups (1-2) were analyzed using the Kaplan-Meier method at each interpretation session.The patients' reassignments after using the registered images were statistically significant for inexperienced reader (p 0.001). In the inexperienced reader, LTP rates of low- and high-risk groups were significantly different with addition of registered images (session 2) (p 0.001), but not significantly different in session 1 (p = 0.101). However, in the experienced reader, LTP rates of low- and high-risk groups were significantly different in both interpretation sessions (p 0.001). Using the registered images, the cumulative incidence of LTP at 2 years was 3.0-6.6%, for the low-risk group, and 18.6-27.8% for the high-risk group.Registration between pre-RFA MR and post-RFA CT images may allow better assessment of the therapeutic response of HCC after RFA, especially for inexperienced radiologists, helping in the risk stratification for LTP.

Pediatric endoscopy has evolved into an indispensable tool in the diagnosis and management of gastrointestinal diseases in children. However, there is limited literature focusing on quality improvement initiatives in pediatric endoscopy. The primary goal of this project was to reduce the no-show rate in the pediatric endoscopy unit. Also, we aimed to improve patient and family satisfaction with the procedure by identifying opportunities for improvement. A checklist was designed based on the potential causes of no-show. The endoscopy nurse coordinator reviewed the checklist when scheduling the procedure to identify patients at high risk for non-compliance. Once a risk factor was identified, appropriate actions were taken. She also made a pre-procedure phone call as a reminder and to address any of these risks for non-compliance if present. A patient satisfaction survey was used to identify potential areas for improvement. The no-show rate decreased from an average of 7% in the pre-intervention phase to 2% in the post-intervention phase (p = 0.009). 91% of the patients/family recorded an overall satisfaction of 4 or 5 on a scale of 1–5 (5 being best). Quality improvement strategies decreased the no-show rate in the pediatric endoscopy unit. A patient satisfaction survey helped in identifying areas for improvement.

Accurate assessment of the left atrial appendage (LAA) is important for pre-procedure planning when utilizing device closure for stroke reduction. Sizing is traditionally done with transesophageal echocardiography (TEE) but this is not always precise. Three-dimensional (3D) printing of the LAA may be more accurate. 24 patients underwent Watchman device (WD) implantation (71 ± 11 years, 42% female). All had complete 2-dimensional TEE. Fourteen also had cardiac computed tomography (CCT) with 3D printing to produce a latex model of the LAA for pre-procedure planning. Device implantation was unsuccessful in 2 cases (one with and one without a 3D model). The model correlated perfectly with implanted device size (R2 = 1; p

Preoperative autologous blood donation in healthy bone marrow donors contributes to pre-procedure anemia

Background Electrocardiographic (ECG) Selvester QRS score criteria with false indication of anteroseptal scarring consistent with myocardial infarction have been found in patients with ostium secundum atrial septal defect (OS-ASD). The objective of this study was to evaluate ECGs pre and post percutaneous transcatheter OS-ASD closure to test the hypothesis that the falsely positive criteria for anteroseptal scar decline 1 day post procedure. Methods Patients (n = 34, mean age 48 ± 17 years, 79% female) that underwent OS-ASD closure and had undergone pre procedure cardiac magnetic resonance imaging showing no left ventricular (LV) scarring were included in this study. ECGs pre and 1 day post procedure were assessed according to the QRS Selvester scoring system and compared. Results Mean Selvester score in anteroseptal regions pre procedure was 6.6 (0.0–6.8) % LV scar and decreased to 4.3 (0.0–6.0) % LV scar one day after the procedure (p = 0.01). Mean Selvester score in lateral regions pre procedure was 3.7 (0.0–3.0) %LV scar and decreased to 2.8 (0.0–0.0) % LV scar one day post procedure (p = 0.25). Discussion OS-ASD patients with falsely positive anteroseptal scar criteria by the Selvester QRS score pre procedure have a significant decrease in anteroseptal Selvester score 1 day post procedure. The falsely positive anteroseptal scar criteria did not completely resolve 1 day post procedure. Further studies are needed to investigate the relationship between ECG criteria for anteroseptal scar and right ventricular volume overload in late follow up.

Recent data have shown that in severe aortic stenosis (sAS), LVEF >60% predicts further deterioration of LVEF (EF) and is a risk factor for poor outcome. We hypothesized that in sAS, systolic function is better understood by investigating midwall stress-shortening (FSmw) rather than EF in patients

Biopsy of the liver is considered the ‘gold standard’ and is often necessary for histopathological characterization of hepatic disease processes. The techniques to obtain liver specimen are percutaneous liver biopsy, transjugular liver biopsy and mini-laparoscopic liver biopsy. Percutaneous route is the preferred method for its simplicity, ease and safety. Transjugular biopsy of the liver has become an accepted alternative method of obtaining hepatic tissue in patients with an established contraindication to percutaneous liver biopsy viz. coagulopathy, ascites, extreme obesity, small shrunken liver etc. A total of 67 transjugular liver biopsies were performed between January 2004 and February 2012 in a tertiary care hospital. The procedure was performed on in patient basis after thorough pre procedure work up with jugular puncture under ultrasonography guidance and fluoroscopy guided liver biopsy using LABS 100 liver access and biopsy set. The commonest indication for liver biopsy was work up for indeterminate chronic liver disease and the most common contraindications for percutaneous biopsy that led to biopsy by transjugular route were coagulopathy and ascites. Technical success of the procedure was achieved in 96% cases and no major complications were encountered in this group. Transjugular liver biopsy is a valuable tool for clinical decision making in a specific sub set of patients in whom percutaneous biopsy is contraindicated. Transjugular approach with jugular access under real time USG guidance and liver biopsy using automated core biopsy needle is safe, well tolerated, effective and provides adequate tissue for histological assessment.

BACKGROUND: Primary percutaneous coronary intervention (pPCI) is recommended in patients with ST Elevation Myocardial Infarction (STEMI) and symptom duration 12hours (late-presenters). The Anderson-Wilkin's score (AW-score) estimates the acuteness of myocardial ischemia from the electrocardiogram (ECG) in STEMI patients. We hypothesized that the AW-score is superior to symptom duration in identifying substantial salvage potential in late-presenters.METHODS: The AW-score (range 1-4) was obtained from the pre-pPCI ECG in 55 late-presenters and symptoms 12-72 hours. Myocardial perfusion imaging was performed to assess area at risk before pPCI and after 30days to assess myocardial salvage index (MSI). We correlated both the AW-score and pain-to-balloon with MSI and determined the salvage potential (MSI) according to AW-score ≥3 (acute ischemia) and AW-score RESULTS: Late-presenters had median MSI 53% (inter quartile range (IQR) 27-89). The AW-score strongly correlated with MSI (β=0.60, R(2)=0.36, pmedian was observed in 79% in patients with AW-score ≥3 vs 32% in patients with AW-score CONCLUSION: AW-score was strongly associated with myocardial salvage while pain-to-balloon time was not. STEMI patients with symptom duration between 12 -72hours and AW-score ≥3 achieved substantial salvage after pPCI.

Many procedures that were once performed only in the hospital operating room are now able to be performed safely, efficiently, and comfortably in the office-based setting. While procedure choice is important, the selection of the appropriate patient to undergo a surgical procedure in the office environment is critical. Thorough advanced evaluation for medical and surgical risks, as well as for the patient’s ability to comply with the state of awareness necessary during the office-based procedure will maximize success and patient satisfaction, while avoiding unanticipated mishaps. Selecting the right patient for office-based surgery is of paramount importance as not all patients are candidates for office-based surgery.

Contrast-induced nephropathy (CIN) is a common complication in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI), and may cause increased morbidity and mortality. We aimed to evaluate the predictive value of Canada Acute

Background Stroke is significant cause of morbidity, disability and mortality in the United States today. There is growing support for the need for process improvement, specifically, reducing time to reperfusion in endovascular stroke therapy (EVT) to improve functional outcomes. It is suggested that every 30 minutes delay in revascularization of acute ischemic stroke leads to a 10.6% decrease in the potential for a good functional outcome (Khatri et al., 2009). Purpose To identify the impact on specific hospital based process improvement strategies in the acute ischemic stroke patient population undergoing endovascular therapy with specific intent to decrease median arrival to revascularization time, thus increasing the potential for good functional outcome. We seek to evaluate the efficacy of three hospital-based methods to improve time to revascularization in EVT for stroke: early notification, streamlined transport process and utilization of feedback tool. Methods The project includes a pre and post intervention retrospective review of patient 18 years or older, admitted through the emergency department, with hospital admission between January 1, 2014 and December 31, 2015, who undergo EVT for treatment acute ischemic stroke. Primary outcome variable: time from arrival to revascularization (first pass) and secondary outcome variables: functional outcome analysis utilizing pre procedure, post procedure and discharge modified Rankin score (MRS) 30 and 90 day MRS. The data points will be collected using the Stroke Time PI project tool based on the America Heart Association’s Get with the Guidelines-Stroke (GWTG). Results A total of 17 consecutive ED arrival endovascular ischemic stroke patients were reviewed, pre PI (Group 1, n = 9) and post PI (Group 2, n = 8). The timeline breakdown from patient arrival to revascularization is shown in Table 1. Preliminary analysis of the primary outcome demonstrates significant improvement in door to revascularization between the pre and post PI groups, 2:56 and 2:14 (p Conclusions Despite the relatively small sample size for the study, this evaluation provides evidence based practice strategies which could be implemented at stroke centers to reduce door to revascularization time in EVT. These strategies are also theorized to positively impact stroke outcomes due to the improvement in treatment times and will be reported with the final study analysis. Disclosures A. Doerr: None. S. Jenkins: None. J. Davis: None.

Background Anatomic characteristics of the cavotricuspid isthmus (CTI) have been reported to be related to the outcome of atrial flutter ablation therapy. However, preprocedural evaluation of CTI anatomy using modified transthoracic echocardiography to guide atrial flutter ablation has not been well described. Methods Transthoracic echocardiography was prospectively performed before atrial flutter ablation in 42 patients with typical CTI-dependent atrial flutter. A modified apical long-axis view was designed to visualize and evaluate anatomic characteristics of the CTI and Eustachian ridge (ER). A prominent ER, extending from the inferior vena cava to the interatrial septum, is defined as an extensive ER. Results Twenty-eight patients had straightforward ablation procedures, and 14 patients had difficult ablation procedures. Two patients with difficult procedures had unsuccessful ablation. Multivariate analysis (using CTI length, the presence of a pouch or recess, ER morphology, and significant tricuspid regurgitation as variables) showed that the presence of extensive ER was the only independent predictor of a difficult ablation procedure. The ablation time in patients with extensive ER ( n = 13) was significantly longer than in those patients with nonextensive ER ( n = 29) (1,638.4 ± 1,548.3 vs 413.8 ± 195.5 sec, P = .015). The incidence of difficulty in achieving bidirectional isthmus block was also higher in patients with extensive ER (10 of 13 vs four of 29, P Conclusion Preprocedural transthoracic echocardiography using a modified apical long-axis view is useful to characterize the morphology of the CTI and the ER. An extensive ER is a strong predictor for difficult ablation of CTI-dependent atrial flutter.

Background The use of ultrasound (US) is common in some settings before an abortion procedure. However, its positive effect on the safety or efficacy (ability to complete abortion) of the procedure has not been established. Our aim was to determine whether the use of pre-procedure US improves safety and/or efficacy of the abortion procedure. Methods We searched the following databases: Pubmed, Embase, Lilacs and Popline; reference lists of retrieved papers; and Google. We considered any controlled trial comparing women seeking abortion who received pre-procedure US to those who did not. Our outcome measures were efficacy of the abortion, complication rates and side effects. Results We did not identify any controlled trials or systematic reviews comparing the use of pre-procedure US to no US prior to abortion. Conclusions Ultrasound is widely used in pregnancy to estimate gestational age and to detect any abnormalities of the pregnancy or uterus. The effect of its use among women undergoing abortion is unclear, and only indirect evidence is available.

Heightened thrombogenicity and biomarker evidence of inflammation have been independently associated with ischemic risk in patients with coronary artery disease. However, a study examining their relation has not been reported. We analysed the relation between measurements of thrombogenicity and biomarkers in patients undergoing stenting and followed for 24 months recurrent ischemic events. In 84 consecutive patients undergoing stenting, pre-procedure thrombogenicity was measured by thrombelastography (TEG) and conventional aggregometry whereas biomarkers were measured by fluorokine multi-analyte profiling. Patients were stratified into quartiles based on platelet-fibrin clot strength (MA) by TEG and correlated with ischemic event occurrence. Patients in the highest MA quartile (high MA) had greater ADP-induced platelet aggregation (57.5 +/- 15.0% vs. 47.9 +/- 17.6%, p = 0.05), C-reactive protein (25.0 +/- 5.6 vs. 4.2 +/- 1.0 microg/mL, p = 0.006) and interleukin-8 (23.8 +/- 2.8 vs. 14.1 +/- 1.6 pg/mL, p0.001) than patients within the lowest MA quartile (low MA). Epidermal growth factor (7.7 +/- 2.2 vs. 1.2 +/- 0.3 pg/mL, p = 0.006) and vascular endothelial growth factor (296 +/- 35 vs. 190 +/- 10 pg/mL, p = 0.05) were also higher. Patients with high-MA had an ischemic event more often than patients with low-MA (48% vs. 13%, p = 0.02). Our study suggests that a link is present between inflammation and heightened thrombogenicity measured pre-procedurally in the patient at high risk for recurrent ischemic events after stenting. Larger studies are required to solidify these observations and their clinical relevance.

It is a research project that is being developed at Santa Maria University Hospital (HUSM), aiming to identify the prevalent stressors to patients which suffer of heart disease. To collect data it will be used a questionnaire to identify the patients on pre procedure, to characterize the population; and the Intensive Care Unit Environmental Stressor Scale (ICUESS) on post procedure. After indentifying the stressor on these patients’ perspective, it will be possible to organize nursing protocols that will allow an assistance adequation to the real patients’ necessities, making the environment more appropriated, pleasant, minimizing the stressors effects.

Introduction Percutaneous transhepatic cholangiography and biliary drainage (PTC) is an effective therapeutic intervention in the management of benign and malignant biliary tract disease. As predictors of outcome following PTC are not well established, we sought to investigate outcomes after PTC and identify patients most at risk of complications. Method We performed a retrospective analysis of patients undergoing PTC between January 2012 and January 2014. Results 78 patients underwent 128 procedures. 85% of procedures were undertaken for malignant disease, of those, 50% were for palliative management only. Overall 30 day mortality was 21.8%. Multivariate analysis showed pre procedure serum albumin and development of acute kidney injury (AKI) post procedure to be significant independent predictors of mortality (p Conclusion AKI following PTC is associated with increased mortality and patients at risk can be predicted by age and pre PTC creatinine. Identification of patients at risk, optimisation of renal function pre procedure and careful peri procedural management of fluid balance may help improve outcomes following PTC. Disclosure of interest None Declared.

Introduction Cancer gall bladder is twice more common in women and is the leading cancer among digestive cancers in women in the northern Indian cities. It is one of the most common cause of surgical obstructive jaundice in cases presenting to our Outpatients. Most of the time cancer gallbladder causes malignant jaundice due to high proximal duct obstruction. Majority of these patients are poor, illiterate and with daily income of less than $1-2. The overall resection rates at presentation range from 10%-30% only. Therefore, a large number of patients are inoperable with overall survival of only 5-6 months. In inoperable cancer gallbladder palliation of jaundice, pruritus, nausea and vomiting is an important quality of life issue. In these patients keeping the cost and visit to the hospital to minimum is also a challenge. In the present study an attempt has been made to see effect of external biliary drainage on quality of life of patients with inoperable cancer gallbladder. Methods Patients (n=24) who reported in Surgical OPD from Jan 2011 to Jan 2012 with unresectable carcinoma gallbladder with jaundice were enrolled. The median age of the patients was 65 years (range of 42 - 85 years). All of the patients were jaundiced, 96 % had pruritus and nausea and vomiting in 60%. Average duration of symptoms was 2.4 months (range of 1-5 months). In n=24 patients (19 females and 5 males) USG guided percutaneous external catheter drainage was performed by interventional radiologist. These patients were assessed for pre- and post-drainage total serum bilirubin levels, pruritus, nausea and vomiting and procedure related complications. Follow up information was obtained through telephonic interview or in person on OPD visit. Results Patients undergoing external drainage spent a median time of 21 days for their entire hospitalization till discharge with catheter in situ. The average pre-drainage bilirubin level was 16.8 mg/dl and post drainage was 7.5 mg/dl after one week. In patients n=18 pre procedure bilirubin level >10 mg/dL took 90 days (longer) to return to normal compared to patients n=6 whose pre procedure bilirubin levels was Conclusion Nearly 100% patients reported reduction in bilirubin levels however the duration was 90 days in patients with pre procedure bilirubin levels >10 mg/dL compared to 57 days in patients with pre procedure bilirubin levels

PCI has been done traditionally through transfemoral route. But now transradial and transbrachial routes are also coming up in practice. We compared transradial versus transfemoral routes for ease of operability, time for procedure, complications, and failure rates through a prospective study. Four hundred Patients admitted in department of cardiology for percutaneous interventions were enrolled in the study. 200 patients were assigned to each group randomly. A single team did all the procedures. Pre procedure, intra procedure and post procedure data of all the patients was collected, tabulated and analysed properly. Access time (6.0 ± 1vs 4.2 ± 0.7; P =0.001); Fluoroscopy time and overall procedure time (29 ± 11.3 Vs. 27.3 ± 12.4 min) were more with trans radial than transfemoral route, respectively. The most common post procedure complication, ecchymosis was seen in 20.5% in transfemoral group compared to 12.5% in transradial group (P 0.031). Thrombophelibites (17.5 VS 8%, P0.004); Hematoma (14.5 Vs 0%, P 0.005); post procedure access bleed (7 VS 3%, P 0.039) were seen in transfemoral than transradial group, respectively. Failure rates were almost similar. None of our patients had post procedure myocardial infarction, stroke, acute renal failure and infections. Transradial approach of PCI is better than transfemoral route with respect to complications like bleeding, haematoma formation, thrombophelebites and ecchymosis is concerned. However access and fluoroscopic time is more with the former. We recommend the transradial route for PCI. Trial is retrospectively registered in ClinicalTrials.gov with the Identifier: NCT02983721 , Date of registration is December 2, 2016.