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Background: The outcome of Low Flow-Low Gradient (LF-LG) severe aortic stenosis (AS) patients who underwent Transcatheter Aortic Valve Replacement (TAVR) procedure is not well defined. We conducted a systematic review of the literature to compare the outcomes of TAVR in LF-LG AS patients to the more traditional high gradient (HG) aortic stenosis., Methods: We comprehensively searched for controlled randomized and non-randomized studies from 4 online databases. We are presenting the data using risk ratios (95 % confidence intervals) and measuring heterogeneity using Higgins' I 2 index., Results: Our analysis included 4380 patients with 3425 HG patients and 955 LF-LG patients from 6 cohort (5 retrospective and 1 prospective) studies. When compared to LFLG; TAVR was associated with significantly lower 30 days mortality in HG patients (5.1 % vs 7.4 %; relative risk [RR]: 0.55; 95 % confidence interval [CI]: 0.35 to 0.86; p < 0.01). Similar findings were also observed in 12-month cardiovascular (CV) mortality (5.5 % vs. 10.4 %; RR: 0.47; 95 % CI: 0.38 to 0.60; p < 0.01 and 12-month all-cause mortality (15.9 % vs 20.9 %; RR: 0.70; 95 % CI: 0.49 to 1.00; p < 0.05). There was no significant difference in myocardial infarction (MI) after TAVR between HG and LF-LG at 30 days (0.16 % vs. 0.95 %; p < 0.09) or 12 months (0.43 % vs. 0.95 %; p = 0.20). Similarly, there was no difference in stroke rates at 30 days (2.9 % vs. 2.86 %) or at 12 months (3.6 % vs. 3.06 %)., Conclusions and Relevance: Patients with LF-LG severe AS who underwent TAVR had worse 1-year all-cause mortality, 30-day all-cause, and 1-year CV mortality when compared to TAVR in HG severe AS. There was no difference in MI or stroke rates. Therefore, with heart team discussion and informed patient decision regarding the risk and benefit, TAVR would still offer better outcomes in LFLG AS compared to conservative medical management., Competing Interests: Declaration of competing interest All the authors have no declarations to make., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: 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., Methods: 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' I 2 ., Results: Sixteen observational studies on Transcarotid TAVR were included in the analysis; 4 studies compared 180 TC-TAVR patients vs 524 TT-TAVR patients. The mean age and STS score for patients undergoing TC-TAVR were 80 years and 7.6 respectively. For TT-TAVR patients, the mean age and STS score were 79.7 years and 8.7 respectively. TC-TAVR patients had lower 30-day MACE [7.8 % vs 13.7 %; OR 0.54 (95 % CI 0.29-0.99, P = 0.05)] and major or life-threatening bleeding [4.0 % vs 14.2 %; OR 0.25 (95 % CI 0.09-0.67, P = 0.006)]. There was no significant difference in 30-day: mortality [5.0 % vs 8.6 %; OR 0.61 (95 % CI 0.29-1.30, P = 0.20)], stroke or transient ischemic attack [2.8 % vs 4.0 %; OR 0.65 (95 % CI 0.25-1.73, P = 0.39)] and moderate or severe aortic valve regurgitation [5.0 % vs 4.6 %; OR 1.14. (95 % CI 0.52-2.52, P = 0.75)]. There was a trend towards fewer major vascular complications in TC-TAVR [3.0 % vs 7.8 %; OR 0.42 (95 % CI 0.16-1.12, P = 0.08)]., Conclusion: Compared with transthoracic TAVR, TC-TAVR patients had lower odds of 30-day MACE and life-threatening bleeding and no differences in 30-day mortality, stroke or TIA, aortic valve regurgitation., Competing Interests: Declaration of competing interest All the authors have no declarations to make., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

On February 12th, 2020, and after a yearlong discussion, the National Board of Medical Examiners (NBME) announced that the reporting of the U.S. Medical Licensing Examination (USMLE) step one exam will transition to pass/fail reporting system and is expected to kick in as early as 2022. The decision was met with various responses, especially by the IMG community. In this paper, we discuss this change and its effect on IMG trainees and their selection process., Competing Interests: There are no conflicts of interest., (Copyright: © 2021 Avicenna Journal of Medicine.)

Background: Experience with retrieval of a Watchman left atrial (LA) appendage (LAA) closure device (WD) is limited. An embolized or grossly malpositioned WD warrants retrieval to minimize the risk of thromboembolic complications and vascular occlusion., Objective: The purpose of this study was to report approaches for percutaneous retrieval of a WD from multicenter experience., Methods: Data on successful WD retrievals were obtained from high-volume operators. Data included clinical characteristics; structural characteristics of the LA and LAA; and procedural details of the deployment and retrieval procedure, type of retrieval (immediate: during the same procedure; delayed: during a separate procedure after the successful deployment), equipment used, complications, and postretrieval management., Results: Ten successful percutaneous and 1 surgical retrievals comprised this study. Seven patients had immediate retrieval, while 4 had delayed retrieval. The median duration before delayed retrieval was 45 days (range 1-45 days). The median LAA diameter and size of a successfully deployed WD was 16 mm (range 14-24 mm) and 21 mm (range 21-30 mm), respectively. A WD was retrieved from the LA (n = 1), LAA (n = 2), left ventricle (n = 2), and aorta (n = 6). The reason for retrieval from the LAA was inadequate deployment, resulting in a significant peri-device leak. Retrieval from the LA or LAA was successfully performed using snares (n = 2) and a Raptor grasping device (n = 1). Retrieval from the left ventricle was achieved with a snare (n = 1) and surgery (n = 1). Retrieval from the aorta required snares (n = 5) and retrieval forceps (n = 1). Five patients were successfully reimplanted with a larger size WD. The only complication during percutaneous retrieval was a pseudoaneurysm., Conclusion: Retrieval of an embolized or malpositioned WD is feasible, and familiarity with snares and grasping tools can facilitate a successful removal., (Copyright © 2020 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Background: Transaortic flow, maximum velocity (V max), mean gradient (MG), left ventricular ejection fraction (LVEF), Aortic valve area (AVA) and dimensional index (DI) are important determinants of prognosis in patients with severe aortic stenosis. The specific role of these echocardiography-derived values in predicting prognosis of severe aortic stenosis patients undergoing Transcatheter aortic valve replacement (TAVR) is less defined., Methods: We identified all severe AS patients who underwent TAVR between 01/2012 and 6/2016. Baseline characteristics, clinical, procedural and one year follow-up data were obtained. Hierarchical logistic regression was used to assess predictors of 1-year mortality after TAVR. Normal flow (NF) was defined as having stroke volume index (SVI) of ≥35 ml/m2; while low Flow (LF) was defined as SVI < 35 ml/m2. High gradient (HG) was defined as mean gradient of ≥40 mmHg; while low gradient (LG) was defined as <40 mmHg., Results: A total of 399 patients were analyzed. There were no significant differences in baseline characteristics. LVEF less than 35% was associated with higher rate of 1-year mortality (17.6% LVEF <35% vs. 8.9% LVEF≥35%; RR = 2.19; CI 1.05 to 4.54; P = 0.03). There was no difference in 1-year mortality outcomes after TAVR in relation to: Mean Gradient MG, transaortic flow/Stroke Volume Index SVI, DI, V max or AVA., Conclusion: Low LVEF <35% remains the strongest parameter associated with 1 year mortality after TAVR., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: To compare the clinical outcomes following transcatheter aortic valve replacement (TAVR) with and without the use of the Sentinel Cerebral Protection System (Sentinel CPS)., Background: Stroke occurs in 2-5% of patients at 30 days after TAVR and increases mortality >3 fold. The Sentinel CPS is the only FDA (Food and Drug Administration) approved cerebral embolic protection device., Methods: The Cochrane Library, PubMed and Web of Science were searched for relevant studies for inclusion in the meta-analysis. Two authors independently screened and included studies comparing the clinical outcomes after TAVR with and without the Sentinel CPS. Risk of bias was assessed using the Cochrane tools (RoB2.0 and ROBINS-I)., Results: Four studies comparing 606 patients undergoing TAVR with Sentinel CPS to 724 without any embolic protection device were included. Sentinel CPS use was associated with lower rates of 30-day mortality [0.8% vs 2.7%; RR 0.34 (95% CI 0.12, 0.92) I 2  = 0%], 30-day symptomatic stroke [3.5% vs 6.1%; RR 0.51 (95% CI 0.29, 0.90) I 2  = 0] and major or life-threatening bleeding [3.3% vs 6.6%; RR 0.50 (0.26, 0.98) I 2  = 16%]. There was no significant difference between the two arms in the incidence of acute kidney injury [0.8% vs 1%; RR 0.85 (95% CI 0.22, 3.24) I 2  = 0%] and major vascular complications [5.1% vs 6%; RR 0.74 (0.33, 1.67) I 2  = 45%]., Conclusion: The results suggest that Sentinel CPS use in TAVR is associated with a lower risk of stroke, mortality and major or life-threatening bleeding at 30 days., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Coronary stent neoatherosclerosis, thrombosis, and restenosis remain significant concerns with new-generation drug-eluting stents (DES). The Dual-Therapy CD34 antibody-covered sirolimus-eluting stent [dual therapy stent (DTS)] is a sirolimus-eluting stent with CD34 antibodies immobilized on its luminal surface to capture circulating endothelial progenitor cells and promote early endothelialization. We conducted a meta-analysis to determine whether the DTS was superior to standard DES., Methods: We conducted a comprehensive search for controlled randomized and non-randomized studies. We presented data using risk ratios (95% confidence intervals) and measured heterogeneity using Higgins' I 2 ., Results: Five studies with a low risk of bias met the inclusion criteria, with a total of 1884 patients in the DTS and 1819 in standard DES arms. There was no difference between the 2 arms in the following 1-year outcomes: cardiac death [1% vs 0.9% RR 1.13 (95% CI 0.49-2.62) I 2  = 0%], target lesion failure [6.2% vs 5.3% RR 1.12 (0.80-1.58) I 2  = 0%], target lesion revascularization (TLR) [4.9% vs 3.4% RR 1.40 (0.93-2.10) I 2  = 15%], target vessel failure [8.2% vs 6.1% RR 1.24 (0.75-2.04) I 2  = 0%], target vessel myocardial infarction [1.1% vs 1.8% RR 0.73 (0.19-2.90) I 2  = 62%] and stent thrombosis [0.4% vs 0.6% HR 0.85 (0.27-2.62) I 2  = 0%]. However, compared with second-generation DES (EES and ZES), the DTS had significantly higher one-year TLR [5% vs. 3.1% RR 1.58 (1.02-2.46) P = 0.04 I 2  = 0%]., Conclusion: One-year TLR was significantly higher in the DTS arm compared with second-generation DES. There was no difference in the other 1-year clinical outcomes compared with standard DES., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Bicuspid aortic valve (BAV) disease is considered the most common congenital heart disease and the main etiology of aortic valve stenosis (AS) in young adults. Although transcatheter aortic valve replacement (TAVR) is routinely used in high- and intermediate-risk patients with AS, BAV patients with AS were excluded from all pivotal trials that led to TAVR approval. We sought, therefore, to examine in-hospital outcomes of patients with BAV who underwent TAVR in comparison with surgical aortic valve replacement (SAVR)., Methods: Using the National Inpatient Sample from 2011 to 2014, we identified patients with BAV with International Classification of Diseases-Ninth Revision-CM code 746.4. Patients who underwent TAVR were identified using ICD-9 codes 35.05 and 35.06 and those who underwent SAVR were identified using codes 35.21 and 35.22 during the same period., Results: A total of 37,052 patients were found to have BAV stenosis. Among them, 36,629 patients (98.8%) underwent SAVR, whereas 423 patients (1.14%) underwent TAVR. One-third of enrolled patients were female, and the majority of the patients were White with a mean age of 65.9 ± 15.1 years. TAVR use for BAV stenosis significantly increased from 0.39% in 2011 to 4.16% in 2014 ( P < 0.001), which represents a 3.77% overall growth in procedure rate. The median length of stay decreased significantly throughout the study period (mean 12.2 ± 8.2 days to 7.1 ± 5.9 days, P < 0.001). There was no statistically significant difference between SAVR and TAVR groups in the in-hospital mortality (0% vs. 5.9%; adjusted P = 0.119)., Conclusion: There is a steady increase in TAVR use for BAV stenosis patients along with a significant decrease in length of stay., Competing Interests: There are no conflicts of interest., (Copyright: © 2020 Avicenna Journal of Medicine.)

Background: Dialysis is associated with higher rate of aortic valve calcification and higher cardiovascular mortality. Transcatheter aortic valve replacement (TAVR) is an established alternative for surgical aortic valve replacement (SAVR) in patients with higher and intermediate co-morbidities including dialysis., Methods: Two independent investigators systematically searched Medline, Cochrane, and Web of Science. The ROBINS-I tool was used to analyze and assess the bias from the selected studies., Results: The search resulted in 4 observational studies with a total of 966 patients. TAVR in dialysis patients was associated with no significant difference in in-hospital mortality [8.1% vs 10.3%; OR (95% CI) 0.74 (0.35, 1.60), I2 = 50%, P = 0.45], risk-of-strokes at 30 days [2% vs 4.4%; OR (95% CI) 0.49 (0.22, 1.09), I2 = 0%, P = 0.08], vascular complications [12.7% vs 13.2%; OR (95% CI) 0.96 (0.55, 1.67), I2 = 0%, P = 0.89], need of blood transfusion [43.1% vs 66.4%; OR (95% CI) 0.27 (0.05, 1.39), I2 = 89%, P = 0.12], or bleeding risk [5.6% vs 6.8%; OR (95% CI) 0.91 (0.18, 4.64), I2 = 5%, P = 0.91] when compared to SAVR. TAVR was associated with significantly shorter length of stay [8.5 days vs 14.2 days; mean difference (95% CI) -5.89 (-9.13, -2.64), I2 = 76%, P < 0.0001] and higher pacemaker implantation [11.4% vs 6.8%; OR (95% CI) 1.74 (1.07, 2.81), I2 = 5%, P = 0.02]., Conclusion: TAVR outcomes were comparable to SAVR but had a significantly shorter length of stay and a higher pacemaker implantation rate in dialysis patients., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Chronic liver disease increases cardiac surgical risk, with 30-day mortality ranging from 9% to 52% in patients with Child-Pugh class A and C, respectively. Data comparing the outcomes of transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR) in patients with liver disease are limited. Methods: We searched PubMed, Cochrane Library, Web of Science, and Google Scholar for relevant studies and assessed risk of bias using the Risk of Bias in Non-Randomized Studies - of Interventions (ROBINS-I) Cochrane Collaboration tool. Results: Five observational studies with 359 TAVR and 1,872 SAVR patients were included in the analysis. Overall, patients undergoing TAVR had a statistically insignificant lower rate of in-hospital mortality (7.2% vs 18.1%; odds ratio [OR] 0.67; 95% confidence interval [CI] 0.25, 1.82; I 2 =61%) than patients receiving SAVR. In propensity score-matched cohorts, patients undergoing TAVR had lower rates of in-hospital mortality (7.3% vs 13.2%; OR 0.51; 95% CI 0.27, 0.98; I 2 =13%), blood transfusion (27.4% vs 51.1%; OR 0.36; 95% CI 0.21, 0.60; I 2 =31%), and hospital length of stay (10.9 vs 15.7 days; mean difference -6.32; 95% CI -10.28, -2.36; I 2 =83%) than patients having SAVR. No significant differences between the 2 interventions were detected in the proportion of patients discharged home (65.3% vs 53.9%; OR 1.3; 95% CI 0.56, 3.05; I 2 =67%), acute kidney injury (10.4% vs 17.1%; OR 0.55; 95% CI 0.29, 1.07; I 2 = 0%), or mean cost of hospitalization ($250,386 vs $257,464; standardized mean difference -0.07; 95% CI -0.29, 0.14; I 2 =0%). Conclusion: In patients with chronic liver disease, TAVR may be associated with lower rates of in-hospital mortality, blood transfusion, and hospital length of stay compared with SAVR.

Background: Benzodiazepines and opioids are commonly used for conscious sedation (CS) in cardiac catheterization laboratory (CCL) patients. Both drugs are known to predispose to hypoxemia, apnea and decreased responsiveness to PCO 2 , resulting in decreased arterial pH and PO 2 , as well as increased PCO 2 . We want to determine the effects of CS on arterial blood gas (ABG) in CCL patient, and identify if pulse oximetry monitoring is adequate., Methods: We enrolled 18 subjects undergoing elective catheterization. Measurement of ABGs at one-minute intervals was done from the moment of arterial access until case end. The results of ABGs were not available to the clinician who administered sedation. Relationships of pH, PCO 2 , PaO 2 and SaO 2 were studied by plotting time series graphs. Significant changes were defined as pH <7.30, SaO 2  < 90, and PCO 2  > 50 mmHg., Results: No significant change in pH, PCO 2 , PaO 2 and SaO 2 was noted in 4/18 (22%) subjects. A significant drop in SaO 2 was noted in 4/18 (22%). A significant change in PCO 2 and/or pH was noted in 10/18 (55%) cases. Among the 16 (16/18) subjects receiving supplemental oxygen, 7 (7/18, 39%) had no drop in SaO 2 , but developed respiratory acidosis. At the end of the case, 5/18 (28%) subjects had respiratory acidosis with normal PaO 2 ., Conclusion: Significant hypercarbia and acidosis occurred frequently in this small study during CS in patients undergoing cardiac catheterization. Relying on pulse oximetry alone especially with patients on supplemental oxygen may lead to failure in detecting respiratory acidosis in a significant number of patients., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: The concomitant presence of mitral stenosis (MS) in the setting of symptomatic aortic stenosis represent a clinical challenge. Little is known regarding the outcome of mitral stenosis (MS) patients undergoing transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR). Therefore, we sought to study the outcome of MS patients undergoing aortic valve replacement (AVR)., Method: Using weighted data from the National Inpatient Sample (NIS) database between 2011 and 2014, we identified patients who were diagnosed with MS. Patients who had undergone TAVR as a primary procedure were identified and compared to patients who had SAVR. Univariate and multivariate logistic regression analysis were performed for the outcomes of in-hospital mortality, length of stay (LOS), blood transfusion, postprocedural hemorrhage, vascular, cardiac and respiratory complications, permanent pacemaker placement (PPM), postprocedural stroke, acute kidney injury (AKI), and discharge to an outside facility., Results: A total of 4524 patients were diagnosed with MS, of which 552 (12.2%) had TAVR and 3972 (87.8%) had SAVR. TAVR patients were older (79.9 vs 70.0) with more females (67.4% vs 60.0%) and African American patients (7.7% vs 7.1%) (P < 0.001). In addition, the TAVR group had more comorbidities compared to SAVR in term of coronary artery disease (CAD), congestive heart failure (CHF), chronic lung disease, hypertension (HTN), chronic kidney disease (CKD), and peripheral vascular disease (PVD) (P < 0.001 for all). Using Multivariate logistic regression, and after adjusting for potential risk factors, TAVR patients had lower in-hospital mortality (7.9% vs 8.1% adjusted Odds Ratio [aOR], 0.615; 95% confidence interval [CI], 0.392-0.964, P = 0.034), shorter LOS. Also, TAVR patients had lower rates of cardiac and respiratory complications, PPM, AKI, and discharge to an outside facility compared with the SAVR group., Conclusion: In patients with severe aortic stenosis and concomitant mitral stenosis, TAVR is a safe and attractive option for patients undergoing AVR with less complications compared with SAVR., (© 2018 Wiley Periodicals, Inc.)

Background: The current guidelines recommend empirical therapy with DAPT of aspirin and clopidogrel for six months after TAVR. This recommendation is based on expert consensus only. Giving the lack of clear consensus on treatment strategy following TAVR. Goal of this meta-analysis is to assess the efficacy and safety of mono-antiplatelet therapy (MAPT) versus dual antiplatelet therapy (DAPT) following transcatheter aortic valve replacement (TAVR)., Methods and Materials: We performed a meta-analysis from randomized clinical trials (RCTs) and prospective studies that tested DAPT vs. MAPT for all-cause mortality and major bleeding of 603 patients. The primary efficacy outcomes were 30 days mortality and stroke. The primary safety outcomes were major bleeding and major vascular complications., Results: We included 603 patients from 4 studies. The use of MAPT was associated with similar mortality rate (5.9% vs. 6.6%; RR = 0.92; 95% CI 0.49-1.71; P = 0.68) and stroke rate compared with DAPT (1.3% vs. 1.3%; RR 1.04; 95% CI 0.27 to 4.04; P = 0.81). There was no difference in major vascular complication (4.2% vs. 8.9%; RR 0.52; 95% CI 0.23 to 1.18; P = 0.17) or minor vascular complication (4.2% vs. 7.3%; RR 0.58; 95% CI 0.25 to 1.34; P = 0.14). However, MAPT was associated with significantly less risk of major bleeding (4.9% vs. 14.5%; RR 0.37; 95% CI 0.20 to 0.70; P < 0.01) but no difference in minor bleeding (4.2% vs. 3.6%; RR 1.16; 95% CI 0.43 to 3.10; P = 0.85)., Conclusion: MAPT use after TAVR is associated with lower rates of major bleeding compared with DAPT with no significant difference in mortality, stroke or vascular complications., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Chimney EVAR (CHEVAR) and Fenestrated EVAR (FEVAR) are two options for management of very complex abdominal aortic aneurysm (AAA). While some anatomical factors may favor one strategy over the other, there are some cases where the anatomical challenges may require using a hybrid approach. We are reporting the case of an 84-year-old male with a 6.8×5.7cm infrarenal abdominal aortic aneurysm that arises immediately below the level of the renal arteries and extends down to just above the iliac bifurcation with occluded celiac and inferior mesenteric arteries and severe bilateral renal artery stenosis with caudally oriented right renal and cranially oriented left renal artery. This case shows that a combined strategy with fenestrated graft and Chimney stenting is feasible for aortic aneurysm repair and may offer a reasonable option for patients with very complex aortic anatomy., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: The ACC/AHA guidelines recommend low-dose dobutamine challenge for hemodynamic assessment of the severity of AS in patients with low flow, low gradient aortic stenosis with reduced ejection fraction (EF) (LFLG-AS; stage D2). Inherent pitfalls of echocardiography could result in inaccurate aortic valve areas (AVA), which have downstream prognostic implications. Data on the safety and efficacy of coronary pressure wire and fluid-filled catheter use for low dose dobutamine infusion is sparse., Methods: We retrospectively analyzed 39 consecutive patients with EF<50%, AVA<1cm 2 and SVI<35ml/m 2 on echocardiography who underwent simultaneous right and left heart catheterization. Hemodynamic assessments were performed at baseline and at every increment in the dobutamine infusion rate (The infusion was continued until maximal dose of dobutamine or a mean AV gradient>40mmHg was attained. The occurrence of sustained ventricular arrhythmias, symptomatic hypotension or intolerable symptoms leading to cessation of infusion was recorded. Transient ischemic attacks (TIAs) or clinically apparent strokes periprocedurally or up to 30days after the procedure were recorded., Results: Dobutamine challenge confirmed true AS in 26 patients (67%) and pseudosevere AS in 34%. No sustained arrhythmias, hypotension or cessation of infusion from intolerable symptoms were observed. No clinical strokes or TIAs were observed up to 30days after procedure in any of these patients., Conclusions: Hemodynamic assessment of AS using a pressure wire with dobutamine challenge is a safe and effective tool in identifying truly severe AS in patients with LFLG-AS with reduced EF., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Dextrocardia with situs inversus presents a unique anatomy with right-sided vascular system that may be associated with a number of additional cardiac and vascular malformations. A rare association is the presence of a single coronary artery ostium. To our knowledge, this is the first reported case of transcatheter aortic valve replacement using Edwards SAPIEN S3 valve in Dextrocardia patient with single coronary artery take off., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Reducing readmissions and improving metrics of care are a national priority. Supplementing traditional care with care management may improve outcomes. The Bridges program was an initial evaluation of a care management platform (CareLinkHub), supported by information technology (IT) developed to improve the quality and transition of care from hospital to home after Coronary Artery Bypass Surgery (CABG) and reduce readmissions., Methods: CareLink is comprised of care managers, patient navigators, pharmacists and physicians. Information to guide care management is guided by a middleware layer to gather information, PLR (ColdLight Solutions, LLC) and presented to CareLink staff on a care management platform, Aerial™ (Medecision). In addition there is an analytic engine to help evaluate and guide care, Neuron™ (Coldlight Solutions, LLC)., Results: The "Bridges" program enrolled a total of 716 CABG patients with 850 admissions from April 2013 through March 2015. The data of the program was compared with those of 1111 CABG patients with 1203 admissions in the 3years prior to the program. No impact was seen with respect to readmissions, Blood Pressure or LDL control. There was no significant improvement in patients' reported outcomes using either the CTM-3 or any of the SAQ-7 scores. Patient follow-up with physicians within 1week of discharge improved during the Bridges years., Conclusions: The CareLink hub platform was successfully implemented. Little or no impact on outcome metrics was seen in the short follow-up time., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Patent foramen ovale (PFO) with atrial septal aneurysm is suggested as an important potential source for cryptogenic strokes. Percutaneous PFO closure to reduce the recurrence of stroke compared to medical therapy has been intensely debated. The aim of this study is to assess whether PFO closure in patients with cryptogenic stroke is safe and effective compared with medical therapy., Method: A search of PubMed, Medline, and Cochrane Central Register from January 2000 through September 2017 for randomized controlled trails (RCT), which compared PFO closure to medical therapy in patients with cryptogenic stroke was conducted. We used the items "PFO or patent foramen ovale", "paradoxical embolism", "PFO closure" and "stroke". Data were pooled for the primary outcome measure using the random-effects model as pooled rate ratio (RR). The primary outcome was reduction in recurrent strokes., Result: Among 282 studies, 5 were selected. Our analysis included 3,440 patients (mean age 45 years, 55% men, mean follow-up 2.9 years), 1,829 in the PFO closure group and 1,611 in the medical therapy group. The I2 heterogeneity test was found to be 48%. A random effects model combining the results of the included studies demonstrated a statistically significant risk reduction in risk of recurrent stroke in the PFO closure group when compared with medical therapy (RR 0.42; 95% CI 0.20-0.91, p = 0.03)., Conclusion: Pooled data from 5 large RCTs showed that PFO closure in patients with cryptogenic stroke is safe and effective intervention for prevention of stroke recurrence compared with medical therapy., (© 2018 S. Karger AG, Basel.)

Transthoracic (transapical and transaortic) access is inferior compared with femoral artery access. Percutaneous transcaval aortic access is a reasonable alternative approach that is being used in transcatheter aortic valve replacement (TAVR) in patients with poor iliofemoral anatomy. Duplicated Inferior vena cava (DIVC) is an uncommon abnormality. We report the case of 76-year-old lady with history of severe peripheral vascular disease, morbid obesity, diabetes, hypertension, hyperlipidemia and duplicated IVC that had severe symptomatic aortic stenosis. The patient had diffuse bilateral iliac disease precluding the arterial access required for TAVR. Other comorbidities made transthoracic access less desirable. We report the first successful Transcaval TAVR in a patient with DIVC., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Transcatheter closure of the left atrial appendage (LAA) is increasingly considered as an alternative to oral anticoagulation in patients with previous major bleeding or at high-risk of bleeding. Device embolization with transcatheter LAA closure is a rare complication. Most cases are asymptomatic, but it can be life threatening. Depending on the location of embolization, percutaneous retrieval is feasible. Snares are usually used for retrieval, but other devices may be used. We report the case of a 63-year gentleman who underwent an uneventful LAA closure with Watchman device and routine testing next day showed embolization to the abdominal aorta. Retrieval was performed using a modified Cook vascular retrieval forceps., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Reducing readmissions and improving metrics of care are a national priority. Supplementing traditional care with care management may improve outcomes. The Bridges program was an initial evaluation of a care management platform (CareLinkHub), supported by information technology (IT) developed to improve the quality and transition of care from hospital to home after percutaneous coronary intervention (PCI) and reduce readmissions., Methods: CareLink is comprised of care managers, patient navigators, pharmacists and physicians. Information to guide care management is guided by a middleware layer to gather information, PLR (ColdLight Solutions, LLC) and presented to CareLink staff on a care management platform, Aerial™ (Medecision). An additional analytic engine [Neuron™ (ColdLight Solutions, LLC)] helps, evaluates and guide care., Results: The "Bridges" program enrolled a total of 2054 PCI patients with 2835 admission from April, 1st 2013 through March 1st, 2015. The data of the program was compared with those of 3691 PCI patients with 4414 admissions in the 3years prior to the program. No impact was seen with respect to inpatient and observation readmission, or emergency department visits. Similarly no change was noticed in LDL control. There was minimal improvement in BP control and only in the CTM-3 and SAQ-7 physical limitation scores in the patients' reported outcomes. Patient follow-up with physicians within 1week of discharge improved during the Bridges years., Conclusions: The CareLink hub platform was successfully implemented. Little or no impact on outcome metrics was seen in the short follow-up time. The Bridges program suggests that population health management must be a long-term goal, improving preventive care in the community., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Reducing readmissions following hospitalization is a national priority. Identifying patients at high risk for readmission after coronary artery bypass graft surgery (CABG) early in a hospitalization would enable hospitals to enhance discharge planning., Methods: We developed different models to predict 30-day inpatient readmission to our institution in patients who underwent CABG between January 2010 and April 2013. These models used data available: 1) at admission, 2) at discharge 3) from STS Registry data. We used logistic regression and assessed the discrimination of each model using the c-index. The models were validated with testing on a different patient cohort who underwent CABG between May 2013 and September 2015. Our cohort included 1277 CABG patients: 1159 in the derivation cohort and 1018 in the validation cohort., Results: The discriminative ability of the admission model was reasonable (C-index of 0.673). The c-indices for the discharge and STS models were slightly better. (C-index of 0.700 and 0.714 respectively). Internal validation of the models showed a reasonable discriminative admission model with slight improvement with adding discharge and registry data (C-index of 0.641, 0.659 and 0.670 respectively). Similarly validation of the models on the validation cohort showed similar results (C-index of 0.573, 0.605 and 0.595 respectively)., Conclusions: Risk prediction models based on data available early on admission are predictive for readmission risk. Adding registry data did not improved the performance of these models. These simplified models may be sufficient to identify patients at highest risk of readmission following coronary revascularization early in the hospitalization., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: To investigate whether a prediction model based on data available early in percutaneous coronary intervention (PCI) admission can predict the risk of readmission., Background: Reducing readmissions following hospitalization is a national priority. Identifying patients at high risk for readmission after PCI early in a hospitalization would enable hospitals to enhance discharge planning., Methods: We developed 3 different models to predict 30-day inpatient readmission to our institution for patients who underwent PCI between January 2010 and April 2013. These models used data available: 1) at admission, 2) at discharge 3) from CathPCI Registry data. We used logistic regression and assessed the discrimination of each model using the c-index. The models were validated with testing on a different patient cohort who underwent PCI between May 2013 and September 2015., Results: Our cohort included 6717 PCI patients; 3739 in the derivation cohort and 2978 in the validation cohort. The discriminative ability of the admission model was good (C-index of 0.727). The c-indices for the discharge and cath PCI models were slightly better. (C-index of 0.751 and 0.752 respectively). Internal validation of the models showed a reasonable discriminative admission model with slight improvement with adding discharge and registry data (C-index of 0.720, 0.739 and 0.741 respectively). Similarly validation of the models on the validation cohort showed similar results (C-index of 0.703, 0.725 and 0.719 respectively)., Conclusion: Simple models based on available demographic and clinical data may be sufficient to identify patients at highest risk of readmission following PCI early in their hospitalization., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: The potential benefit of long-term dual antiplatelet therapy (DAPT) for secondary prevention of atherothrombotic events is unclear. Data from different randomized controlled trials (RCT) using different agents in different subgroups showed inconsistent results., Methods: We performed a systematic review and meta-analysis from RCTs that tested different prolonged durations of DAPT for secondary prevention. Long term DAPT arm was defined as those receiving DAPT for more than 12months. Long-term aspirin arm was defined as those receiving either aspirin alone long term or DAPT for less than 12months., Results: The use of long term DAPT was associated with a significant decrease in composite of death, myocardial infarction (MI) and stroke (6.08% vs. 6.71%; odds ratio OR=0.86 [0.78-0.94]; P=0.001). This reduction of death, MI and stroke was mainly noticed in patients with prior MI or stroke, but not with PAD or multiple risk factors. The reduction was seen with post PCI patients with prasugrel and only in those with prior MI with clopidogrel and ticagrelor. Long-term use of DAPT was associated with significant increase in major bleeding (1.47% vs. 0.88%; OR=1.65 [1.23-2.21]; P=0.001)., Conclusion: Long-term use of DAPT for secondary prevention is associated with lower risk of death, MI and stroke beneficial especially in patients with prior MI and stroke, but it is associated with increased risk of bleeding. Prolonging DAPT requires careful assessment of the trade-off between ischemic and bleeding complications and should probably be reserved for patients with higher risk for atherothrombotic events., Competing Interests: Drs. Fanari, Malodiya, Weiss, Hammami and Kolm report no conflicts of interest., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: To investigate the impact of integrating a medical intensivist into a cardiac care unit (CCU) multidisciplinary team on the outcomes of CCU patients., Patients and Methods: We conducted a retrospective cohort study of 2239 CCU admissions between July 1, 2011, and July 1, 2013, which constituted patients admitted in the 12 months before and 12 months after the introduction of intensivists into the CCU multidisciplinary team. This team included a cardiologist, a medical intensivist, medical house staff, nurses, a pharmacist, a dietitian, and physical and respiratory therapists. The primary outcome was CCU mortality. Secondary outcomes included hospital mortality, CCU length of stay, hospital length of stay, and duration of mechanical ventilation., Results: After the implementation of a multidisciplinary team approach, there was a significant decrease in both adjusted CCU mortality (3.5% vs 5.9%; P=.01) and hospital mortality (4.4% vs 11.1%; P<.01). A similar impact was observed on adjusted mean CCU length of stay (2.5±2.0 vs 2.9±2.0 days; P<.01), adjusted mean hospital length of stay (7.0±4.5 vs 7.5±4.5 days; P<.01), and adjusted mean ventilation duration (2.0±1.0 vs 4.3±2.5 days; P<.01)., Conclusion: The implementation of a multidisciplinary team approach in which an intensivist and a cardiologist comanage the critical care of CCU patients is feasible and may result in better patient outcomes., (Copyright © 2016 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.)

Background: Accurate assessment of cardiac output (CO) is essential for the hemodynamic assessment of aortic valve area (AVA). Estimation of oxygen consumption (VO2) and Thermodilution (TD) is employed in many cardiac catheterization laboratories (CCL) given the historically cumbersome nature of direct continuous VO2 measurement, the "gold standard" for this technique. A portable facemask device simplifies the direct continuous measurement of VO2, allowing for relatively rapid and continuous assessment of CO and AVA., Methods and Materials: Seventeen consecutive patients undergoing right heart catheterization had simultaneous determination of CO by both direct continuous and assumed VO2 and TD. Assessments were only made when a plateau of VO2 had occurred. All measurements of direct continuous and assumed VO2, as well as, TD CO were obtained in triplicate., Results: Direct continuous VO2 CO and assumed VO2 CO correlated poorly (R= 0.57; ICC =0.59). Direct continuous VO2 CO and TD CO also correlated poorly (R= 0.51; ICC=0.60). Similarly AVA derived from direct continuous VO2 correlated poorly with those of assumed VO2 (R= 0.68; ICC=0.55) and TD (R=0.66, ICC=0.60). Repeated direct continuous VO2 CO and AVA measurements were extremely correlated and reproducible [(R=0.93; ICC=0.96) and (R=0.99; ICC>0.99) respectively], suggesting that this was the most reliable measurement of CO., Conclusions: CO calculated from direct continuous VO2 measurement varies substantially from both assumed VO2 and TD based CO, which are widely used in most CCL. These differences may significantly impact the CO and AVA measurements. Furthermore, continuous, rather than average, measurement of VO2 appears to give highly reproducible results., Competing Interests: All authors reports no conflict of interest to disclose.

Percutaneous transcatheter closure of a patent foramen ovale (PFO) remains challenging when femoral venous approach is not available. We describe the successful closure of a PFO using the right internal jugular venous approach and a catheter delivery system with a reshaped tip in a patient with a PFO, recurrent stroke, recurrent gastrointestinal bleeding, bilateral deep venous thrombosis and thrombosed bilateral inferior vena cava filter.

Background: Accurate assessment of Cardiac Output (CO) is a critical measurement in the calculation of aortic valve area (AVA). Due to the known inaccuracy of estimated Fick calculations, many measure thermodilution (TD) CO as well due to previous studies showing better correlation with the gold standard direct CO. Previous studies showed suboptimal correlation between both methods. Most physicians assume that the TD CO is chosen by catheterization laboratory software for AVA evaluation. Our study was performed to check which CO method is assigned by our popular computer software system [Philips Xper Connect (XIM)] for the AVA calculation and the impact of that on clinical decision., Methods: We studied one hundred consecutive patients who underwent right and left heart catheterization from 2009 to 2012 for assessment of AVA and who had both estimated Fick and TD CO calculated. Correlation of direct continuous VO2, assumed VO2 and TD based CO measurements were assessed by linear regression analysis and by variance component analysis., Results: We found that whichever CO calculation was entered first to the software system became the determinative output used to calculate the AVA appearing on the final report. This was the estimated Fick method in 32 patients and TD in 68 patients. The CO used for the final report depended solely on the timing of the oxygen saturation samples. The Correlation between AVA based on both methods correlated poorly (Pearson R=0.73, Intra-Class Correlation (ICC) =0.72). This discrepancy affects recommendation for surgery (AVA <1.0 cm2) in 18 cases (18% of patients)., Conclusion: Our widely used software has an arbitrary method of selecting the determinative CO to calculate the final AVA. For TD CO to 'trump' the Fick CO a complex series of computer commands needs to be performed. None of the physicians or technicians was aware of this software selection process, which affects critical treatment decisions.

Background: Accurate assessment of cardiac output (CO) is essential for the hemodynamic assessment of valvular heart disease. Estimation of oxygen consumption (VO2) and thermodilution (TD) are employed in many cardiac catheterization laboratories (CCL) given the historically cumbersome nature of direct continuous VO2 measurement, the "gold standard" for this technique. A portable facemask device simplifies the direct continuous measurement of VO2, allowing for relatively rapid and continuous assessment of CO., Methods and Materials: Thirty consecutive patients undergoing right heart catheterization had simultaneous determination of CO by both direct continuous and assumed VO2 and TD. Assessments were only made when a plateau of VO2 had occurred. All measurements of direct continuous and assumed VO2, as well as, TD CO were obtained in triplicate., Results: Direct continuous VO2 CO and assumed VO2 CO correlated poorly (R=0.57; ICC=0.59). Direct continuous VO2 CO and TD CO also correlated poorly (R=0.51; ICC=0.60). Repeated direct continuous VO2 CO measurements were extremely correlated and reproducible [(R=0.93; ICC=0.96) suggesting that this was the most reliable measurement of CO., Conclusions: CO calculated from direct continuous VO2 measurement varies substantially from both assumed VO2 and TD based CO, which are widely used in most CCL. These differences may significantly impact the CO measurements. Furthermore, continuous, rather than average, measurement of VO2 appears to give highly reproducible results., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objectives: The goal of this article is to examine the correlation of catheter (cath) based and echocardiographic assessment of aortic stenosis (AS) in a community-based academic hospital setting, particularly in the degree that decision to refer for surgery is altered., Background: Current guidelines discourage AS evaluation by invasive pressure measurement if echocardiography (echo) is adequate, but several studies show sizable differences between echo and cardiac catheterization lab (CCL) measurements. We examine this correlation using high quality CCL techniques., Methods: Sequential patients with suspected AS by echo (n = 40) aged 61-94 underwent catheterization with pressure gradients via left ventricular pressure wire and ascending aorta catheter. The echos leading to the catheterization were independently reviewed by an expert panel to assess the quality of community-based readings., Results: CCL changed assessment of severity of aortic valve area (AVA) by more than 0.3 cm(2) in 25% and 0.5 cm(2) in 8%. Values changed to over or under the surgical threshold of AVA < 1 cm(2) in 30% of the patients. Pearson correlation of 0.35 between measurements of AVA by echo and CCL is lower than earlier studies, which often reported correlation values of 0.90 or greater. Echo expert reviews provided minimal improvement in discrepancies (Pearson correlation of 0.46), suggesting quality of initial interpretation was not the issue., Conclusions: Cath-echo correlation of AS severity is lower in contemporaneous practice than previously assumed. This can alter the decision for aortic valve replacement. Sole reliance on echo-derived assessment of AS may at times be problematic., (© 2015 Wiley Periodicals, Inc.)

There are many changes in the demographics of patients admitted to Cardiac Care Unit (CCU) due to the aging of US population and coexistence of chronic illnesses, such as diabetes mellitus, hypertension, renal dysfunction, and obstructive lung disease. There is increasing evidence that intensivist staffing in the critical care settings is associated with not only improvements in both Intensive Care Unit (ICU) and in-hospital mortality, but also with better medical resource use. Evidence for decreased mortality has led to increased involvement of critical care trained physicians in multidisciplinary care teams in both medical and surgical ICUs, a trend that has not been adopted to any significant extent in CCUs. A partnership between cardiologists and critical care specialists may offer a better roadmap to deal with cardiac critical care crisis, provide better care for our patients, and prepare the next generation of cardiologists to deal with emerging challenges in the field.

Transcatheter management of valvular and structural heart disease is the most growing aspect of interventional cardiology. While the early experience was limited to patients who were not candidate for surgery, the continuous improvement in the efficacy and safety expanded its use to different degree depending on the procedure and the disease involved. The cost of these procedures is a major concern for health care in developed world. Cost-effectiveness of these transcatheter structural procedures varies depending on the procedure itself, the burden of the underlying disease, the feasibility and cost of both the Transcatheter and surgical procedures. In this review, we turn now to a specific discussion of the medical economics of percutaneous valvular and structural interventions., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Aneurysmal dilatation of aortocoronary saphenous vein grafts (SVG) is a rare but known complication after coronary artery bypass grafting (CABG). They are most commonly found incidentally, although some may present with unstable angina or myocardial infarction (MI). Rarely, these aneurysms can develop into fistulas to the neighboring cardiac chambers. We report the case of a 66-year old woman with a history of CABG in 1996 with a left internal mammary artery (LIMA) graft to the left anterior descending and a SVG to distal right coronary artery presenting with non-ST segment elevation myocardial infarction (NSTEMI) complicated with congestive heart failure. Selective Coronary and Graft angiography showed an aneurysm in the mid SVG with a fistula into the right atrium (RA) resulting in a significant left to right shunt. The significant left to right shunt diverted blood flow from right coronary artery territory resulting in recurrent ischemia and angina and introduced a significant volume overload on the right ventricle resulting in over heart failure. Secondary to the course of LIMA graft along the sternum, surgery was not an option. Secondary to continued symptoms percutaneous intervention was performed with placement of two 6.0 x 50 mm Viabahn self-expanding covered stent with aggressive post-dilation resulting in successful closure with no residual flow. Percutaneous intervention is shown to be an effective approach to manage both aortocoronary fistula and grafts ruptures and is associated with better outcomes than surgical and conservative options. To the best of our knowledge, this is the first reported case of a successful closure of fistulous communication of a SVG aneurysm to the RA utilizing multiple peripheral covered stents.

Background: Accurate assessment of cardiac structures, ventricular function, and hemodynamics is essential for any echocardiographic laboratory. Quality improvement (QI) processes described by the American Society of Echocardiography (ASE) and the Intersocietal Commission (IAC) should be instrumental in reaching this goal., Methods: All patients undergoing transthoracic echocardiogram (TTE) followed by cardiac catheterization within 24 hours at Christiana Care Health System in 2011 and 2012 were identified, with 126 and 133 cases, respectively. Hemodynamic parameters of diastolic function and pulmonary artery systolic pressure (PASP) on TTE correlated poorly with catheterization in 2011. An educational process was developed and implemented at quarterly QI meetings based on ASE and IAC recommendations to target frequently encountered errors and provide methods for improved performance. The hemodynamic parameters were then reexamined in 2012 postintervention., Results: Following the QI process, there was significant improvement in the correlation between invasive and echocardiographic hemodynamic measurements in both systolic and diastolic function, and PASP. This reflected in significant better correlations between echo and cath LVEF [R = 0.88, ICC = 0.87 vs. R = 0.85, ICC = 0.85; P < 0.001], average E/E' and of left ventricle end-diastolic pressure (LVEDP) [R = 0.62 vs. R = 0.09, P = 0.006] and a better correlation for PASP [R = 0.77, ICC = 0.77 vs. R = 0.30, ICC = 0.31; P = 0.05] in 2012 compared to 2011., Conclusion: The QI process, as recommended by ASE and IAC, can allow for identification as well as rectification of quality issues in a large regional academic medical center hospital., (© 2015, Wiley Periodicals, Inc.)

Objective: To assess the impact of an aggressive protocol to decrease the time from hospital arrival to onset of reperfusion therapy ("door to balloon [DTB] time") on the incidence of false-positive (FP) diagnosis of ST-segment elevation myocardial infarction (STEMI) and in-hospital mortality., Patients and Methods: The study population included 1031 consecutive patients with presumed STEMI and confirmed ST-segment elevation who underwent emergent catheterization between July 1, 2008, and December 1, 2012, On July 1, 2009, we instituted an aggressive protocol to reduce DTB time. A quality improvement (QI) initiative was introduced on January 1, 2011, to maintain short DTB while improving outcomes. Outcomes were compared before and after the initiation of the DTB time protocol and similarly before and after the QI initiative. Outcomes were DTB time, the incidence of FP-STEMI, and in-hospital mortality. A review of the emergency catheterization database for the 10-year period from January 1, 2001, through December 31, 2010, was performed for historical comparison., Results: Of the 1031 consecutive patients with presumed STEMI who were assessed, 170 were considered to have FP-STEMI. The median DTB time decreased significantly from 76 to 61 minutes with the aggressive DTB time protocol (P=.001), accompanied by an increase of FP-STEMI (7.7% vs 16.5%; P=.02). Although a nonsignificant reduction of in-hospital mortality occurred in patients with true-positive STEMI (P=.60), a significant increase in in-hospital mortality was seen in patients with FP-STEMI (P=.03). After the QI initiative, a shorter DTB time (59 minutes) was maintained while decreasing FP-STEMI in-hospital mortality., Conclusion: Aggressive measures to reduce DTB time were associated with an increased incidence of FP-STEMI and FP-STEMI in-hospital mortality. Efforts to reduce DTB time should be monitored systematically to avoid unnecessary procedures that may delay other appropriate therapies in critically ill patients., (Copyright © 2015 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.)

Acute coronary syndromes (ACS) are associated with high rates of morbidity and mortality. The advances of antiplatelet and anticoagulation therapy over several years time have resulted in improved in cardiac outcomes, but with increased health care costs. Multiple cost-effectiveness studies have been performed to evaluate the use of available antiplatelet agents and anticoagulation in the setting of both ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation acute coronary syndrome (NSTE-ACS). Early on, the use of glycoprotein IIb/IIIa receptor inhibitors (GPIs) proved to be economically attractive in the management of ACS; however, the introduction of P2Y12 receptor antagonists limited their use to a bail out agents in complex interventions. Generic clopidogrel is probably still an economically attractive P2Y12 receptor antagonist choice, especially in low-risk ACS, while both ticagrelor and prasugrel present an economically attractive alternative option, especially in high-risk ACS and patients at risk for stent thrombosis. While enoxaparin presents an economically dominant alternative to heparin in NSTE-ACS, its role in STEMI in the contemporary era is unclear. During percutaneous coronary intervention (PCI), bivalirudin monotherapy was shown to be an economically dominant alternative to the combination of heparin and GPI in ACS. However, new studies may suggest that using heparin monotherapy may offer an attractive alternative. The comparative and cost effectiveness of different combinations of antiplatelet and antithrombotic therapy will be the focus of future expected clinical and economic assessments.

Obstruction of the left ventricular outflow tract (LVOT) occurs in six out of 10,000 live births. The obstruction occurs in the aortic valve level in 71 percent, in subvalvular level in 14 percent, and supravalvular level in 8 percent of cases. Subvalvular aortic stenosis (AS) can be either a fixed stenosis resulting from subaortic membrane or a dynamic stenosis because of hypertrophic cardiomyopathy. Here, we report a patient with subaortic membrane who became symptomatic in her sixth decade of life. Echocardiography is the preferred diagnostic modality. Indications for surgery include symptoms, LVOT gradient of 50 mmHg or more, and development of significant aortic regurgitation.