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Classic Impella exchange interrupts flow when the old device is pulled into the aorta before advancing the new device across the aortic valve, threatening circulatory collapse and loss of left ventricular access. In "double barrel," uninterrupted Impella exchange, the new device is placed into the ventricle alongside the old, where flow is first transitioned completely. Of 31 consecutive patients undergoing this procedure, none experienced intraoperative cardiac arrest, and 96.8% (30/31) had no new aortic insufficiency. One vascular complication ensued following known preoperative iliac injury. One patient suffered nonembolic stroke; another had subarachnoid hemorrhage. Fifty-five percent (17/31) of patients survived, with 22.6% (7/31) recovering, 25.8% (8/31) undergoing transplant, and 6.5% (2/31) transitioning to durable left ventricular assist device. Impella-only survival (83.3%, 10/12) was significantly higher than Impella-extracorporeal membrane oxygenation survival (36.8%, 7/19; (operating room) OR 14.46, 95% ((confidence interval) CI 1.74-119.93, p = 0.01). We conclude the "double barrel" technique is reliable in device-dependent cardiogenic shock patients, offering significant advantages and minimal risk. [ABSTRACT FROM AUTHOR]

A 17-year-old boy complaining of progressive dyspnea, fever, palpitations, a 22 mm Hg blood pressure difference between the 2 arms, and arm claudication. He had a history of psoriasis-like skin lesions and bronchiectasis. Echocardiography revealed a reduced left ventricular ejection fraction, severe eccentric aortic insufficiency, circumferential aortic wall thickening, and a dilated ascending aorta with severe atherosclerotic changes. Based on imaging findings, a TA diagnosis was suggested. During his follow-up, the patient developed strabismus, blurred vision, and right sixth cranial nerve paralysis and went into a deep coma. Unfortunately, after 6 months of treatment, he expired due to COVID-19 infection. [ABSTRACT FROM AUTHOR]

A 36-year-old male patient was hospitalized due to persistent chest tightness and dyspnea lasting over 10 days. An echocardiogram revealed significant aortic valve regurgitation, the presence of vegetation on the aortic valve, severe mitral valve regurgitation, and enlargement of both the left atrium and left ventricle. Following a comprehensive multidisciplinary consultation, the focus was directed towards the aortic valve vegetation as the primary concern, with particular attention given to the potential diagnosis of blood culture-negative infective endocarditis (IE) and non-bacterial thrombotic endocarditis, while differentiating it from rheumatic heart disease. Ultimately, the vegetation was excised during a surgical aortic valve replacement procedure, which facilitated histopathological examination, biological culture, and high-throughput metagenomic sequencing of pathogenic microorganisms. The definitive diagnosis was established as aortic valve infective endocarditis ( Q fever IE ) leading by infection of Coxiella burnetii. [ABSTRACT FROM AUTHOR]

A giant unruptured left sinus of Valsalva aneurysms is extremely rare. Even if asymptomatic, surgical repair should be performed, considering comorbidities, and patient's physical condition. In this case, patch repair with coronary artery bypass, correction of sinotubular junction, and aortic annulus for aortic regurgitation benefited the older patient. [ABSTRACT FROM AUTHOR]

In the 2021 Transcatheter Valve Therapy (TVT) registry, 8.9 % of patients underwent TAVR via access sites other than the femoral artery. Transthoracic approaches may be contraindicated in some patients and may be associated with poorer outcomes. Therefore other alternative access routes are increasingly being performed. We conducted a systematic review of the literature on transcarotid transcatheter aortic valve replacement (TC-TAVR) and meta-analysis comparing outcomes of TC-TAVR and other access routes. We comprehensively searched for controlled randomized and non-randomized studies from 4 online databases. We presented data using risk ratios (95 % confidence intervals) and measured heterogeneity using Higgins' I2. Sixteen observational studies on transcarotid TAVR were included in the analysis; 4 studies compared TC-TAVR vs TF-TAVR. The mean age and STS score for patients undergoing TC-TAVR were 80 years and 7.6 respectively. For TF-TAVR patients, mean age and STS score were 81.2 years and 6.5 respectively. There was no difference between patients undergoing TC-TAVR and TF-TAVR in the following 30-day outcomes: MACE [8.4 % vs 6.7 %; OR 1.32 (95 % CI 0.71–2.46 p = 0.38) I2 = 0 %], mortality [5.6 % vs 4.0 %; OR 0.42 (95 % CI 0.60–3.37, P = 0.42) I2 = 0 %] and stroke [0.7 % vs 2.3 %; OR 0.49 (95 % CI 0.09–2.56, P = 0.40) I2 = 0 %]. There was no difference in 30-day major vascular complications [0.7 % vs 3 %; OR 0.55 (95 % CI 0.06–5.29, P = 0.61) I2 = 39 %], major bleeding [0.7 % vs 3.8 %; OR 0.39 (95 % CI 0.09–1.67, P = 0.21) I2 = 0 %], and moderate or severe aortic valve regurgitation [8.6 % vs 9.9 %; OR 0.89 (95 % CI 0.48–1.65, P = 0.72) I2 = 0 %]. There are no significant differences in mortality, stroke MACE and major or life-threatening bleeding or vascular complications when TC-TAVR is compared to TF-TAVR approaches. • Transcarotid TAVR was associated with similar 30-day MACE, mortality, stroke and major vascular complications, when compared to Transfemoral TAVR. • Transcarotid TAVR was associated with a trend towards less bleeding when compared to Transfemoral TAVR. • TC-TAVR patients had a history of PAD, myocardial infarction, and a higher mean STS PROM score compared to TF-TAVR patients. [ABSTRACT FROM AUTHOR]

Laparoscopic robot-assisted colorectal surgery can pose significant haemodynamic challenges for patients with severe aortic regurgitation. The increased afterload caused by pneumoperitoneum and aortic compression, along with concurrent factors like hypercarbia, Trendelenburg positioning and ventilatory impairment, can worsen aortic regurgitation, leading to myocardial ischaemia and heart failure. Transoesophageal echocardiography (TOE) assists haemodynamic management intraoperatively but requires subspecialist skills and enables limited inferences to be drawn regarding the impact of afterload on myocardial performance. Minimally invasive haemodynamic monitoring enabling real-time visualisation of a patient's 'pressure field' has been suggested as a potential adjunct or alternative to TOE, with the added advantage of providing continuous quantitative information about both stroke volume and the afterload to ventricular ejection in a single visualisation. We describe an example of successful concurrent use of pressure field haemodynamic monitoring and TOE in a patient with severe aortic regurgitation having a prolonged laparoscopic robot-assisted pelvic exenteration. [ABSTRACT FROM AUTHOR]

The article discusses the consensus opinion from the Fetal Heart Society on the acute maternal hyperoxygenation (MH) protocol. Acute MH testing can help understand fetal pulmonary vascular reactivity and simulate postnatal circulatory shifts. The document provides a standardized approach to conducting acute MH testing, including indications, timing, oxygen administration, fetal echocardiography assessments, and interpretation of findings. The consensus opinion aims to guide fetal cardiac centers interested in implementing acute MH testing for clinical and research purposes. [Extracted from the article]

Introduction: Chronic obstructive pulmonary disease (COPD)-induced osteoporosis, myasthenia, and disequilibrium are important risk factors for hip fracture, and decreased respiratory function after hip fracture surgery can decelerate recovery of activities of daily living (ADL) in elderly patients. Case Presentation: A 90-year-old male patient underwent an open reduction and intramedullary pinning surgery for right femoral intertrochanteric fracture. After surgery, he remained confined to bed with pain and swelling in the right lower extremity. Due to his history of COPD, he had a postoperative pulmonary infection and respiratory insufficiency. Intervention: This patient received routine rehabilitation after surgery. However, severe respiratory symptoms prevented him from completing the rehabilitation procedure. Therefore, comprehensive pulmonary rehabilitation including airway clearance techniques, inspiratory resistance training, aerobic training, respiratory muscle training, and intermittent low-flow oxygen inhalation was carried out to enhance the recovery process. Outcomes: After 4 weeks of treatment, the patient improved from continuous oxygen inhalation to being able to complete bed resistance training without supplemental oxygen. After 8 weeks, ADL reached independence, while lower limb muscle strength, pulmonary function parameters, fatigue index, and cough efficiency were improved as compared to test values obtained before treatment. Conclusion: Compared with the 6-month recovery time reported in the literature for patients with hip fractures to achieve independence with basic ADLs, the recovery time of this patient was shortened to 2 months with the application of comprehensive pulmonary rehabilitation. It is feasible to carry out pulmonary rehabilitation for elderly patients after fracture surgery, but prospective clinical trials are needed to verify its efficacy. [ABSTRACT FROM AUTHOR]

The development of aortic insufficiency (AI) during HeartMate 3 durable left ventricular assist device (dLVAD) support can lead to ineffective pump output and recurrent heart failure symptoms. Progression of AI often comingles with the occurrence of other hemodynamic-related events encountered during LVAD support, including right heart failure, arrhythmias, and cardiorenal syndrome. While data on AI burdens and clinical impact are still insufficient in patients on HeartMate 3 support, moderate or worse AI occurs in approximately 8% of patients by 1 year and studies suggest AI continues to progress over time and is associated with increased frequency of right heart failure. The first line intervention for AI management is prevention, undertaking surgical intervention on the insufficient valve at the time of dLVAD implant and avoiding excessive device flows and hypertension during long-term support. Device speed augmentation may then be undertaken to try and overcome the insufficient lesion, but the progression of AI should be anticipated over the long term. Surgical or transcatheter aortic valve interventions may be considered in dLVAD patients with significant persistent AI despite medical management, but neither intervention is without risk. It is imperative that future studies of dLVAD support capture AI in clinical end-points using uniform assessment and grading of AI severity by individuals trained in AI assessment during dLVAD support. [Display omitted] [ABSTRACT FROM AUTHOR]

Performing cardiac surgery on patients with bleeding diatheses poses significant challenges since these patients are at an increased risk for complications secondary to excessive bleeding. Despite its rarity, patients with factor VII (FVII) deficiency may require invasive procedures such as cardiac surgery. However, we lack guidelines on their pre-, peri-, and post-operative management. As FVII deficiency is rare, it seems unlikely to design and learn from large clinical studies. Instead, we need to base our clinical decision-making on single reported cases and registry data. Herein, we present the rare case of a patient with FVII deficiency who underwent double valve surgery. Pre-operatively, activated recombinant FVII (rFVIIa) was administered to reduce the risk of bleeding. Nevertheless, the patient experienced major bleeding. This case highlights the significance of FVII deficiency in patients undergoing cardiac surgery and emphasizes the importance of adequate and appropriate transfusion of blood products for these patients. [ABSTRACT FROM AUTHOR]

This article reviews and discusses non-myocardial disorders that represent diagnostic challenges when evaluating patients for suspected heart failure with preserved left ventricular ejection fraction. This includes pre-capillary pulmonary hypertension, which is important to differentiate from post-capillary hypertension caused by left-sided heart disease. The impact of electrical disorders on LV diastolic function is also reviewed, and includes a discussion of left bundle branch, which has both a direct effect on LV diastolic function, as well as a long-term effect due to remodelling. Furthermore, evaluation of diastolic function in patients with atrial fibrillation is discussed. Pericardial diseases are reviewed as well as effects of a normal pericardium on diastolic function in failing hearts. Finally, the article reviews how valvular diseases impact LV diastolic function. [ABSTRACT FROM AUTHOR]

Background: Aortic root rupture is a rare but potentially fatal complication of transcatheter aortic valve implantation (TAVI). Herein, we report a case of aortic root rupture during TAVI that was successfully managed with partial aortic root repair and aortic valve replacement. Case presentation: An 83-year-old woman with severe bicuspid aortic stenosis underwent transfemoral TAVI using a 26 mm SAPIEN 3 Ultra RESILIA valve. Soon after valve implantation, transesophageal echocardiography detected pericardial effusion, which was accompanied by immediate hemodynamic instability. Subxiphoid pericardial drainage was performed, and extracorporeal membrane oxygenation was promptly initiated. Owing to the eruptive hemorrhage, we converted to open-heart surgery. Direct visualization enabled the detection of the aortic root rupture and the performance of partial aortic root repair using bovine pericardium and aortic valve replacement using a 19 mm INSPIRIS RESILIA valve. The patient was transferred to a different hospital 60 days after surgery without complications and is currently doing well as an outpatient. Conclusions: In the present case, prompt treatment decisions and smooth cooperation among the institutional heart team led to the successful repair of aortic root rupture during TAVI and good clinical outcomes. [ABSTRACT FROM AUTHOR]

Background Methods and Results Conclusion Aortic regurgitation (AR) is a well‐known cause of impaired outcome in patients with centrifugal left ventricular assist devices (cfLVADs). The failure of the aortic valve (AV) to open at least intermittently is associated with cusp remodeling, commissural fusion, and ultimately developing AR.Our aim was to characterize patients in whom AV opening (AVO) was preserved 6 months after implantation and identify determinants related to it.We conducted standardized echocardiography and collected clinical and laboratory tests at the outpatient clinic 6 months after implantation. We classified patients into those showing intermittently opening of the AV, every 2–3 beats, or in every cycle (AVO) and those whose AV was continuously closed (NAVO). From the 219 cfLVAD implanted in our center between March 2018 and January 2020, 156 subjects were alive and on the device after 6 months. In 2 of the reviewed echocardiograms, we could not evaluate the AV. 99 patients (64%) showed AVO compared to 55 (36%) with NAVO. The first presented higher mean arterial pressure (84 ± 10 vs. 77 ± 13 mm Hg, p = 0.002), larger LV end‐diastolic diameter (LVEDD 57.5 ± 12 vs. 52.7 ± 13 mm, p = 0.022), a better TAPSE (15 ± 4 vs. 13 ± 4 mm, p = 0.028), and less frequently significant AR than patients with NAVO (moderate/severe AR in 6% vs. in 20%, p = 0.042). In a multiple logistic regression, a lower NYHA Class, a larger LVEDD, and a better LV ejection fraction appeared as significant predictors of AVO. After a median follow‐up of 3.2 years, we found no significant impact on survival stratifying patients by AVO (log‐rank p = 0.53).AVO was associated with better RV function, lower NYHA Class, and a lower rate of significant AR. This could indicate that AVO should be pursued in LVAD patients. [ABSTRACT FROM AUTHOR]

Background: The management of acute type A aortic dissection (ATAAD) using the Ascyrus Medical Dissection Stent (AMDS) can lead to complications due to the persistence of the false lumen (FL). This case report presents two instances of failed AMDS treatment for ATAAD, highlighting the novel use of a trifurcated hybrid prosthesis for redo aortic arch repair using a minimally invasive frozen elephant trunk (FET) technique. Case Presentation: Case 1: A 57-year-old male, previously treated with AMDS for ATAAD, presented with an enlarging aortic arch and persistent FL two years post-surgery caused by re-entry in the distal aortic arch. Redo surgery using the FET technique with an E-vita OPEN NEO Trifurcated hybrid prosthesis resulted in successful repair and partial FL thrombosis. Case 2: A 51-year-old male with prior AMDS treatment for ATAAD presented with severe aortic valve regurgitation and a maintained FL perfusion due to a residual re-entry in the proximal region of the descending aorta. Redo surgery using the FET technique with the same hybrid prosthesis led to successful repair and good recovery, confirmed by follow-up imaging. Conclusions: The use of the E-vita OPEN NEO Trifurcated hybrid prosthesis in the FET technique offers a promising solution for redo aortic arch repair in cases of failed AMDS treatment for ATAAD. This approach can improve patient outcomes by addressing complications associated with persistent FL and enhancing long-term survival. [ABSTRACT FROM AUTHOR]

Acute articular rheumatism (AAR) primarily affects children aged 5 to 15, causing fever and non-suppurative arthritis, and can lead to severe heart problems such as mitral stenosis and aortic insufficiency. Descriptions of early years by Hippocrates and Galen were expanded in a in the 19th century by Jean-Baptiste Bouillaud, who linked AAR to heart complications. An exploration of the historical development of AAR can be beneficial to further medical understanding. Time period between Renaissance and mid-20th century unveiled a series of hallmarks in diagnosis, symptomatology, feverous attacks and treatment. As research method, a documentary research related to the subject. Of great importance concerning AAR’s understanding are Hippocrates’ early descriptions, Jerome Cardan’s Renaissance distinction between “morbus articularis” and podagral (gout), and Jean-Baptiste Bouillaud’s 19th-century linkage of AAR to heart disease. Furthermore, contributions from Théodore-Hermann Meynet, Louis Bard, and Edmond Weill were pivotal in clarifying the clinical and cardiac aspects of the disease. During 19th century new diagnostic factors like visceral lesions and clearer understanding of chemical and mineral drugs supplied novel approaches. In the 20th century, research in the United States confirmed the streptococcal cause of AAR, marking an advancement of great significance in the understanding the cause of AAR, as well as its progression. Even since the ancient times AAR has been recognized. Various nominations described the disease, while gradually physicians understood the causes and the nature of the disease, as philosophical physiology gave space to clinical anatomy and medical science of the mechanized era. Advancements made during the last centuries aided in AAR further understanding. The comprehension of the evolution of AAR is crucial in order to appreciate its current medical perspective and treatment. [ABSTRACT FROM AUTHOR]

Background and Aim: There is a scarcity of Indian studies on infective endocarditis. Additionally, the majority of research has focused on the paediatric age group. The purpose of this study was to investigate the microorganisms responsible for infective endocarditis in patients with rheumatic heart disease in patients attending Medicine OPD of Smt NHL Municipal Medical College, Ahmedabad. Additionally, the study aimed to assess the effectiveness of medical treatment and evaluate the prognosis of the cases. Material and Methods: Our study took place at the Department of General Medicine, a Smt. NHL Municipal Medical College, Ahmedabad, over the course of one year. We thoroughly investigated patients who were clinically suspected of having infective endocarditis. A study was conducted on 40 patients with Rheumatic heart disease who met the diagnostic criteria for infective endocarditis. A comprehensive set of medical tests were performed, including a complete hemogram, urinalysis specifically to check for microscopic haematuria, chest Xray, and EGG. Prior to starting treatment, blood cultures were collected. A comprehensive M mode and 2 D echocardiographic examination was conducted for all individuals suspected of having the condition, with additional TEE performed for cases that required further clarification. Results: A significant number of patients presented with a combination of mitral and aortic valve lesions. The most frequently observed combined lesions in our patients were mitral and aortic regurgitation. The patients included in our study experienced mild to moderate grade fever. At the time of admission, nineteen patients in the study group had a leukocyte count exceeding 10,000 cells per cubic millimetre. The majority of patients in the study group exhibited elevated ESR levels. Out of the total 40 patients, 11 had a positive blood culture (27.5%). Surprisingly, in 29 patients, the blood culture remained negative even after multiple sample collections and a seven-day incubation period. Most patients initially received a standard recommended dose of injection Penicillin G and Gentamicin on an empirical basis. However, as per the sensitivity pattern, appropriate antibiotics were administered thereafter. Conclusion: Treatment of endocarditis was more successful when suitable antibiotics were started after culture and sensitivity rather than the empirical treatment. [ABSTRACT FROM AUTHOR]

The article focuses on an 11-year-old boy presenting with slurred speech and involuntary movements, later diagnosed with a neurological disorder. Topics include his clinical symptoms such as dysarthria and abnormal involuntary movements, his physical exam findings including hyperreflexia and abnormal gait, and the absence of significant prior medical or family history.

Fetal critical aortic stenosis with evolving hypoplastic left heart syndrome (CAS-eHLHS) can progress to a univentricular (UV) birth malformation. Catheter-based fetal aortic valvuloplasty (FAV) can resolve stenosis and reduce the likelihood of malformation progression. However, we have limited understanding of the biomechanical impact of FAV and subsequent LV responses. Therefore, we performed image-based finite element (FE) modeling of 4 CAS-eHLHS fetal hearts, by performing iterative simulations to match image-based characteristics and then back-computing physiological parameters. We used pre-FAV simulations to conduct virtual FAV (vFAV) and compared pre-FAV and post-FAV simulations. vFAV simulations generally enabled partial restoration of several physiological features toward healthy levels, including increased stroke volume and myocardial strains, reduced aortic valve (AV) and mitral valve regurgitation (MVr) velocities, reduced LV and LA pressures, and reduced peak myofiber stress. FAV often leads to aortic valve regurgitation (AVr). Our simulations showed that AVr could compromise LV and LA depressurization but it could also significantly increase stroke volume and myocardial deformational stimuli. Post-FAV scans and simulations showed FAV enabled only partial reduction of the AV dissipative coefficient. Furthermore, LV contractility and peripheral vascular resistance could change in response to FAV, preventing decreases in AV velocity and LV pressure, compared with what would be anticipated from stenosis relief. This suggested that case-specific post-FAV modeling is required to fully capture cardiac functionality. Overall, image-based FE modeling could provide mechanistic details of the effects of FAV, but computational prediction of acute outcomes was difficult due to a patient-dependent physiological response to FAV. [ABSTRACT FROM AUTHOR]

Patients with bicuspid aortic valves (BAV) are at increased risk of infective endocarditis (IE). Information of the clinical presentation and the microbiology of BAV-associated IE, however, is limited. Therefore, our study aimed to characterise the clinical features native valve endocarditis (NVE) in the setting of BAV and compared them to patients with prosthetic valve endocarditis (PVE) following BAV replacement. Adult patients with BAV or history of BAV with aortic valve replacement (AVR) and a definite or possible IE diagnosis within the Mayo Clinic Enterprise (USA) from January 2008 to December 2021, were included. BAV was confirmed by trans-oesophageal echocardiography. IE was defined according to the modified Duke criteria and only an initial episode was included. Statistical analyses were performed to compare clinical characteristics, microbiology, and IE complications. Overall, 161 patients with BAV and IE (NVE [n=60], 37.3%) and PVE [n=101, 62.7%) were included. Mean age±SD was 56.5±16.1 years, and 139 (86.3%) patients were males. PVE patients were older (p<0.01) and had a higher rate of hypertension (p<0.01), chronic heart failure (p<0.01), chronic kidney disease (p<0.01), and perivalvular abscess (p<0.01). BAV patients with NVE had a higher prevalence of isolated mitral valve IE (p<0.01), moderate to severe aortic valve regurgitation (p<0.01) and combined aortic with mitral valve IE (p<0.01). Streptococcus mitis was the most common pathogen in NVE (30.0%) while Staphylococcus aureus was the most common in PVE (15.8%). Patients with BAV are at risk of both NVE and PVE. Each syndrome has unique clinical features, including microbiologic findings, that should be appreciated in IE diagnosis and management. [ABSTRACT FROM AUTHOR]

Aortic valve lithotripsy can fragment aortic valve calcium deposits and potentially restore leaflet pliability in animal model and ex-vivo, but clinical data is limited. Transcatheter aortic valve implantation (TAVR) might not be feasible as an urgent procedure in critically ill patients. Balloon valvuloplasty has the major limitation of valve recoil and inducing aortic regurgitation. To determine the clinical feasibility of aortic valve lithotripsy-facilitated balloon valvuloplasty in patients with severe aortic stenosis unsuitable for valvular replacement. We performed lithotripsy as adjunctive therapy to balloon aortic valvuloplasty in ten consecutive patients, most of whom were deemed unfit for TAVR. Lithotripsy of the aortic valve was performed with simultaneous inflation of one to three peripheral lithotripsy balloons to deliver ultrasound pulses. Rapid pacing was not used during lithotripsy. Aortic valve velocity, gradient, and valve area were measured before and after the procedure by echocardiogram. Transvalvular pressure gradient was recorded intra-procedurally. Periprocedural and ninety-day clinical outcomes were followed. Procedure was technically successful in 9 out of 10 patients and aborted in one patient due to cardiogenic shock. One patient had femoral closure device related complication. There was a statistically significant decrease in valvular gradient and increase in aortic valve area. 9 out of 10 patients recovered from acute episode and were discharged. 6 patients had improvement in NYHA class. 4 patients were subsequently able to receive TAVR. 90-day mortality occurred in 3 patients. There was no stroke or bradyarrhythmia peri-procedurally and no heart failure hospitalization at 90 days. Aortic valve lithotripsy-facilitated balloon valvuloplasty has reasonable feasibility, safety and technical reproducibility and acute clinical result. Hemodynamic effect is similar to that of balloon valvuloplasty reported in the literature. Subsequent Prognosis is not altered in critically ill patients. • Critically ill and frail patients might not be suitable for valvular replacement by surgical or transcatheter approach. • Aortic valve lithotripsy facilitated valvuloplasty is a safe and technically feasible alternative with reasonable hemodynamic and short-term outcomes in this patient population. [ABSTRACT FROM AUTHOR]

Few studies have assessed the ability of internal medicine residents to perform a cardiovascular physical examination using real patients. First year internal medicine interns from 2 large academic medical centers in Maryland examined the same patient with aortic insufficiency as part of the Assessment of Physical Examination and Communication Skills (APECS). Interns were assessed on 5 clinical domains: physical exam technique, identifying physical signs, generating a differential diagnosis, clinical judgment, and maintaining patient welfare. Spearman's correlation test was used to describe associations between clinical domains. Preceptor comments were examined to identify common errors in physical exam technique and identifying physical signs. One hundred nine interns examined the same patient with aortic insufficiency across 14 APECS sessions. Only 58 interns (53.2%) correctly identified the presence of a diastolic murmur, and only 52 interns (47.7%) included aortic insufficiency on their differential diagnosis. There was a significant and positive correlation between physical exam technique and identification of the correct physical findings (r = 0.42, P <.001). Both technique (r = 0.34, P =.003) and identifying findings (r = 0.42, P <.001) were significantly associated with generating an appropriate differential diagnosis. Common errors in technique included auscultating over the gown, timing the cardiac cycle with the radial pulse, and failing to palpate for the apical impulse. Internal medicine interns had variable skills in performing and interpreting the cardiovascular physical exam. Improving cardiovascular exam skills would likely lead to increased identification of relevant cardiovascular findings, inform clinical decision making and improve overall patient care. [ABSTRACT FROM AUTHOR]

Balloon aortic valvuloplasty (BAV) is performed in children with significant aortic stenosis (AS). Traditionally, contrast angiography measures the annulus and assesses aortic regurgitation (AR) after each dilation. Echocardiographic guidance is hypothesized to reduce contrast and radiation exposure, without compromising efficacy or safety. Patients < 10 kg undergoing BAV from 2013 to 2022 were retrospectively investigated. Agreement between echocardiographic and angiographic annulus measurements was assessed. Echocardiogram-guided (eBAV) and traditional angiogram-guided (tBAV) outcomes were compared controlling for weight, critical AS, and other congenital heart disease (CHD). Twelve eBAV and 19 tBAV procedures were performed. The median age was 33 days, median weight was 4.3 kg, 7 patients (23%) had critical AS, and 9 patients (29%) had other CHD. Annulus measurements by intraprocedural echocardiography and angiography displayed excellent correlation (ICC 0.95, p < 0.001). eBAV patients received less contrast (0.5 vs 3.5 ml/kg, p < 0.01). Five recent eBAV procedures were performed contrast free. Radiation exposure was not statistically different between the eBAV and tBAV groups (155 vs 313 µGy·M2, p = 0.12). One eBAV patient (8%) and 3 tBAV patients (16%, p = 0.62) experienced serious adverse events. Technical success (gradient < 35 mmHg and increase in AR by ≤ 1 grade) occurred in 11 eBAV patients (92%) and 16 tBAV patients (84%, p = 0.22). AR increased in 2 eBAV patients (17%) and 8 tBAV patients (44%, p = 0.02). eBAV was associated with similar efficacy and significantly lower contrast exposure and risk of aortic regurgitation. There was strong agreement between aortic valve annulus measurements by intraprocedural echocardiography and angiography, ultimately permitting contrast free BAV. [ABSTRACT FROM AUTHOR]

Background One of the most important and relatively frequent complications of aortic valve replacement is atrioventricular block. It typically occurs by direct injury of the infranodal conduction system due to intra-operative manipulation and persists post-operatively, necessitating permanent pacemaker implantation in many cases. Case summary A 66-year-old man presented to our hospital after experiencing syncope while walking after drinking. He had experienced two episodes of alcohol-induced syncope several years earlier. His electrocardiogram (ECG) and transthoracic echocardiogram revealed complete atrioventricular block and severe aortic stenosis, respectively. He received a temporary pacemaker on the day of admission and underwent surgical aortic valve replacement on hospital Day 9. The native aortic valve was bicuspid. Unexpectedly, the ECG immediately after aortic valve replacement showed complete restoration of atrioventricular conduction during temporary atrial pacing. The atrioventricular block did not recur, and he was discharged to home on post-operative Day 13. Discussion This remarkably rare clinical course, complete restoration from complete and persistent atrioventricular block after surgical aortic valve replacement, can be explained by multifactorial mechanisms: (i) surgical removal of the aortic annulus calcification directly hindering the infranodal conduction system; (ii) relief from the ventricular pressure overload stressing the conduction system within the septum; and (iii) improvement of substantial autonomic dysregulation as manifested by alcohol-sensitive syncope in the present patient, which was a result of unloading of the intraventricular pressure affecting the left ventricular mechanoreceptor. [ABSTRACT FROM AUTHOR]

Background Transcatheter aortic valve replacement (TAVR)-in-TAVR within index supra-annular transcatheter heart valves (THVs) and high-risk anatomy can compromise coronary perfusion and re-access. Case summary An 80-year-old male presented with acute heart failure caused by degeneration of an Evolut R THV, leading to severe aortic regurgitation. Aortic computed tomography imaging revealed a high-risk anatomy characterized by the index THV's commissural plane being placed above the coronary ostia and a valve-to-aorta distance of less than 2 mm, resulting not eligible for redo-TAVR according to recent literature. The current case represents the first-in-human application of redo-TAVR with low SAPIEN 3 THV implantation within an Evolut R THV obtaining index leaflet overhang, preserving coronary perfusion and potential coronary re-engagement. Discussion Following in vitro study, this case demonstrates in vivo feasibility of redo-TAVR with low SAPIEN 3 THV implantation within an Evolut R THV obtaining index leaflet overhang. [ABSTRACT FROM AUTHOR]