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Coronary artery fistulas (CAFs) are rare coronary anomalies that are usually diagnosed incidentally with cardiac imaging. Small CAFs are generally asymptomatic and can close over time, while some untreated medium or large CAFs can enlarge, leading to clinical sequelae such as cardiac chamber enlargement or myocardial ischemia. With the advancement of transcatheter equipment and techniques, CAFs have been increasingly closed using a percutaneous approach. However, the procedure is not free of limitations given the risk for myocardial infarction, device embolization, and fistula recanalization. In this review, the authors illustrate the contemporary procedural considerations, techniques, and outcomes of transcatheter CAF closure.

A 49-year-old female Qatari woman, with no past medical history, presented at a hospital complaining of a history of cough and shortness of breath. The patient tested positive for severe acute respiratory syndrome (ARDS) and COVID-19. Subsequently, her course of treatment was complicated by severe acute respiratory distress syndrome, pulmonary embolism and severe myocarditis requiring treatment with venous-arterial extracorporeal membrane oxygenation as a bridge to complete recovery.

The safety and feasibility of radial access in patients undergoing percutaneous coronary intervention (PCI) prior to transcatheter aortic valve replacement (TAVR) has not been studied.This study included consecutive patients who underwent PCI within 30 days before TAVR at Mayo Clinic. Vascular access was left to the discretion of the operator. Baseline demographics, procedural data, PCI outcomes, and subsequent transfemoral TAVR outcomes were extracted from patient charts.A total of 331 patients were included in this study, with 107 patients undergoing PCI via radial access (rPCI), and 224 via femoral access (fPCI). Mean age was 80.6 years and 35.6% were females (35.5% rPCI vs 35.3% fPCI). More patients in the fPCI group had previous coronary artery bypass graft surgery (13.1% rPCI vs 34.4% fPCI; P.001). Fluoroscopy time (13.36 minutes vs 18.86 minutes; P.001) and contrast use (115 mL vs 140 mL; P.01) were lower in the rPCI group than in the fPCI group. Crossover rate from radial to femoral was 6.5%. There were more access-site hematomas in the fPCI group (2.8% rPCI vs 14.3% fPCI; P.001), with no statistically significant rate of other access-related complications. There was no difference in stroke, myocardial infarction, cardiac arrest, or unplanned surgery. There was no difference in bleeding or stroke between both groups during subsequent transfemoral TAVR.Radial access for pre-TAVR PCI is feasible and safe and is associated with a lower rate of access-site hematoma. This study supports the increased use of transradial access for pre-TAVR PCI.

BACKGROUND Change in left atrial pressure (LAP) has been shown to be associated with symptom improvement post-MitraClip; however, the association between acute procedural changes in transmitral diastolic mean gradient (MG) compared to LAP and symptom improvement is not well established. METHODS 164 consecutive patients undergoing MitraClip at Mayo Clinic between June 2014 and May 2018 were included. Preclip and postclip MG and LAP were recorded. Baseline demographics, clinical, and echocardiographic outcomes, including 30-day New York Heart Association (NYHA) functional status were obtained from patient charts. RESULTS Median age was 81.5 years (IQR: 76.3, 87), 34% were female and 94.5% had NYHA class III and IV functional status at baseline. At baseline, median MG was 4 mmHg (IQR: 3, 5) and LAP was 19 mmHg (IQR: 16, 23.5). Following MitraClip deployment, the median MG was 4 mmHg (IQR: 3, 6) and the median LAP was 17 mmHg (IQR: 14, 21), 69.5% of patients had less than moderate MR. There was no statistically significant association between change in MG and NYHA functional class at 30 days (OR = 0.95, 95% CI: 0.76-1.20). However, a reduction in LAP following MitraClip deployment was significantly associated with improvement in NYHA functional status at 30 days following adjustments for age and sex (aOR 3.36, 95% CI: 1.34-8.65). There was no significant correlation between change in mean LAP and change in MG (p = .98). CONCLUSION Unlike change in left atrial pressure, change in MG post-MitraClip was not associated with patient reported outcomes at 30 days and did not correlate with change in left atrial pressure. Long-term follow up is needed to evaluate the impact of LA pressure on symptoms.

PURPOSE To investigate and compare the translucency and color stability of a newly introduced polymer-infiltrated ceramic network (PICN) material (Crystal Ultra) to those of clinically well-established restorative materials. MATERIALS AND METHODS A total of 80 specimens measuring (12 × 14 × 1 mm ± 0.05 mm) were prepared from five CAD/CAM (IPS e.max (IPS), Lava Ultimate (LU), Cerasmart (CS), Vita Enamic (VE), Crystal Ultra (CU)) high translucency (HT) blocks in A2 or equivalent shades. Specimens were randomly allocated into two groups (A and B) (n = 8), and were subjected to 5,000 thermal-cycles (TC). This was followed by one-week immersion of group A specimens in coffee (staining) solution and group B specimens in distilled water. Following immersion, the specimens from both groups were further subjected to 5,000 TC. A spectrophotometer was used to measure the translucency parameter (TP) and color change (ΔE00 ) of the samples using CIELAB color coordinates at baseline, after 5,000 TC, following immersion, and after further 5,000 TC. Color stability was evaluated using the CIEDE2000 formula. Data were analyzed by non-parametric tests (α = 0.05). RESULTS The TP values of the CAD/CAM materials ranged from 18.0-22.0. Following the initial TC, the changes in TP values were significant for VE (p = 0.012). Coffee immersion and further TC significantly impacted the TP values of PICN (VE and CU) materials compared to glass- ceramics (IPS), and resin nanoceramic (CS and LU) materials (p = 0.012). The comparison between CAD/CAM materials at different intervals showed a significant difference in the TP values (p < 0.01). The materials showed perceptible color changes following the initial TC except for PICN materials which demonstrated acceptable color changes. The major color difference was noticed for the resin nanoceramic specimens immersed in coffee; LU and CS showed higher color changes (ΔE00 = 2.45 and 2.09, respectively) than VE and CU (ΔE00 < 1.8). CONCLUSIONS The translucency of the newly introduced Crystal Ultra PICN material was low compared to the resin nanoceramics and lithium disilicate glass-ceramic. The Crystal Ultra material exhibited better color stability compared to resin nanoceramics, but higher color change when compared with Vita Enamic PICN and lithium disilicate glass-ceramic CAD/CAM materials.

Cardiovascular disease (CVD) disproportionately affects older adults. It is expected that by 2030, one in five people in the United States will be older than 65 years. Individuals with CVD now live longer due, in part, to current prevention and treatment approaches. Addressing the needs of older individuals requires inclusion and assessment of frailty, multimorbidity, depression, quality of life, and cognition. Despite the conceptual relevance and prognostic importance of these factors, they are seldom formally evaluated in clinical practice. Further, although these constructs coexist with traditional cardiovascular risk factors, their exact prevalence and prognostic impact remain largely unknown. Development of the right decision tools, which include these variables, can facilitate patient-centered care for older adults. These gaps in knowledge hinder optimal care use and underscore the need to rigorously evaluate the optimal constructs for providing care to older adults. In this review, we describe available tools to examine the prognostic role of age-related factors in patients with CVD.

To assess the impact of pulmonary hypertension (PH) on outcomes of patients with severe mitral annular calcification (MAC) undergoing transcatheter mitral valve replacement (TMVR).PH is associated with poor outcomes after mitral valve surgery. Whether the presence of PH in patients with MAC undergoing (TMVR) is associated with poor outcomes, is unknown.Retrospective evaluation of 116 patients from 51 centers in 11 countries who underwent TMVR with valve in mitral annular calcification (ViMAC) using balloon-expandable aortic transcatheter valves (THVs) from September 2012 to March 2017. Pulmonary artery systolic blood pressure (PASP) by echocardiogram was available in 90 patients. The subjects were stratified based on PASP: No PH = PASP ≤35 mmHg (n = 11); mild to moderate PH = PASP 36-49 mmHg (n = 21) and severe PH = PASP ≥50 mmHg (n = 58). Clinical, procedural, and echocardiographic outcomes were assessed.Mean age was 72.7 (±12.8) years, 59 (65.6%) were female, Society of Thoracic Surgeons score was 15.8 + 11.8% and 90.0% where in New York Heart Association (NYHA) class III-IV. There was no significant difference in all-cause mortality at 30 days (no PH = 27.3%, mild-moderate PH = 19.0%, severe PH = 31.6%; p = 0.55) or at 1 year (no PH = 54.5%, mild-moderate PH = 38.1%, severe PH = 56.1%; p = 0.36). No difference in adverse events, NYHA class or amount of residual mitral regurgitation at 1 year were observed between the groups.This study suggests that the presence of PH in patients with predominantly mitral stenosis with MAC undergoing TMVR does not impact mortality or adverse events. Further studies are needed to fully understand the effect of PH in this group of patients.

Background Visual expertise refers to advanced visual skills demonstrated when performing domain-specific visual tasks. Prior research has emphasized the fact that medical experts rely on such perceptual pattern-recognition skills when interpreting medical images, particularly in the field of electrocardiogram (ECG) interpretation. Analyzing and modeling cardiology practitioners’ visual behavior across different levels of expertise in the health care sector is crucial. Namely, understanding such acquirable visual skills may help train less experienced clinicians to interpret ECGs accurately. Objective This study aims to quantify and analyze through the use of eye-tracking technology differences in the visual behavior and methodological practices for different expertise levels of cardiology practitioners such as medical students, cardiology nurses, technicians, fellows, and consultants when interpreting several types of ECGs. Methods A total of 63 participants with different levels of clinical expertise took part in an eye-tracking study that consisted of interpreting 10 ECGs with different cardiac abnormalities. A counterbalanced within-subjects design was used with one independent variable consisting of the expertise level of the cardiology practitioners and two dependent variables of eye-tracking metrics (fixations count and fixation revisitations). The eye movements data revealed by specific visual behaviors were analyzed according to the accuracy of interpretation and the frequency with which interpreters visited different parts/leads on a standard 12-lead ECG. In addition, the median and SD in the IQR for the fixations count and the mean and SD for the ECG lead revisitations were calculated. Results Accuracy of interpretation ranged between 98% among consultants, 87% among fellows, 70% among technicians, 63% among nurses, and finally 52% among medical students. The results of the eye fixations count, and eye fixation revisitations indicate that the less experienced cardiology practitioners need to interpret several ECG leads more carefully before making any decision. However, more experienced cardiology practitioners rely on their skills to recognize the visual signal patterns of different cardiac abnormalities, providing an accurate ECG interpretation. Conclusions The results show that visual expertise for ECG interpretation is linked to the practitioner’s role within the health care system and the number of years of practical experience interpreting ECGs. Cardiology practitioners focus on different ECG leads and different waveform abnormalities according to their role in the health care sector and their expertise levels.

BACKGROUND Visual expertise refers to advanced visual skills demonstrated when performing domain-specific visual tasks. Prior research has emphasized the fact that medical experts rely on such perceptual pattern-recognition skills when interpreting medical images, particularly in the field of electrocardiogram (ECG) interpretation. Analyzing and modeling cardiology practitioners’ visual behavior across different levels of expertise in the health care sector is crucial. Namely, understanding such acquirable visual skills may help train less experienced clinicians to interpret ECGs accurately. OBJECTIVE This study aims to quantify and analyze through the use of eye-tracking technology differences in the visual behavior and methodological practices for different expertise levels of cardiology practitioners such as medical students, cardiology nurses, technicians, fellows, and consultants when interpreting several types of ECGs. METHODS A total of 63 participants with different levels of clinical expertise took part in an eye-tracking study that consisted of interpreting 10 ECGs with different cardiac abnormalities. A counterbalanced within-subjects design was used with one independent variable consisting of the expertise level of the cardiology practitioners and two dependent variables of eye-tracking metrics (fixations count and fixation revisitations). The eye movements data revealed by specific visual behaviors were analyzed according to the accuracy of interpretation and the frequency with which interpreters visited different parts/leads on a standard 12-lead ECG. In addition, the median and SD in the IQR for the fixations count and the mean and SD for the ECG lead revisitations were calculated. RESULTS Accuracy of interpretation ranged between 98% among consultants, 87% among fellows, 70% among technicians, 63% among nurses, and finally 52% among medical students. The results of the eye fixations count, and eye fixation revisitations indicate that the less experienced cardiology practitioners need to interpret several ECG leads more carefully before making any decision. However, more experienced cardiology practitioners rely on their skills to recognize the visual signal patterns of different cardiac abnormalities, providing an accurate ECG interpretation. CONCLUSIONS The results show that visual expertise for ECG interpretation is linked to the practitioner’s role within the health care system and the number of years of practical experience interpreting ECGs. Cardiology practitioners focus on different ECG leads and different waveform abnormalities according to their role in the health care sector and their expertise levels.

Background: Several studies have evaluated preprocedural imaging predictors of left ventricular outflow tract obstruction (LVOTO) after transcatheter mitral valve replacement. The patient cohorts in these studies were heterogeneous and included patients with transcatheter mitral valve replacement in failed bioprostheses, annuloplasty rings, and severe mitral annular calcification (MAC). The goal of this study was to evaluate predictors of LVOTO specific to patients undergoing valve-in-MAC. Methods: This study included patients with severe MAC who underwent valve-in-MAC and had optimal quality preprocedural multidetector row computed tomography scans eligible for retrospective analysis. Baseline demographic, echocardiographic, and procedural data on these patients were collected. multidetector row computed tomography parameters were analyzed for association with LVOTO, defined as increase in mean LVOT gradient by ≥10 mm Hg with accompanying hemodynamic instability. Results: Seventy-one patients with optimal preprocedural computed tomography scans were included in this study (mean age, 72.5±13.5 years), 9 of which developed LVOTO (all female). Baseline mean LVOT area, neo-LVOT area (145.3 versus 270.9 mm 2 ; P =0.006), indexed neo-LVOT area (90.1 versus 157.4; P =0.05), and virtual transcatheter heart valve to septum distance (3.1 versus 6.9 mm; P =0.002) were lower in the LVOTO group. Expected % LVOT area reduction was higher in the latter group (58.3 versus 42.7%; P =0.008). In the univariable analysis, the baseline mean LVOT area, neo-LVOT area, indexed neo-LVOT area, and valve to septum distance were all significantly associated with LVOTO. Conclusions: The systolic mean LVOT area, neo-LVOT area, indexed neo-LVOT, expected percentage LVOT area reduction, and the valve to septum distance were associated with LVOTO after valve-in-MAC.

Transcatheter mitral valve (MV) edge-to-edge repair provided alternative solutions to high surgical risk patients with degenerative MV regurgitation (MR) and patients with functional MR leading to symptomatic heart failure. However, the procedure cannot be performed in certain MV anatomy such as excessive mitral annular or leaflet calcification with coexisting stenosis or excessive flail leaflet with wide gap and width. The introduction of MitraClip XTR system with its extended arms provided a wider range of MV anatomies that can be treated with MV edge-to-edge repair. In this report, we present the successful treatment of excessive flail posterior leaflet with MitraClip XTR device.

Intravascular coronary imaging has facilitated the field of interventional cardiology with multiple studies showing the superiority of intravascular image-guided percutaneous coronary interventions for the reduction of lesion revascularization rates. It also aids in understanding the mechanism of myocardial infarction with nonobstructive coronary artery disease. Despite such results, there is a slow adaptation of intravascular imaging use in the real world. We present two cases where intravascular imaging helped in the rapid understanding of the etiology of acute coronary syndrome and facilitated the management of both patients.

Left ventricular pseudoaneurysm is an infrequent but potentially fatal complication following cardiac surgery, with spontaneous rupture being the most feared result. Moreover, surgical repair is associated with significant morbidity and mortality. We present a successful transapical percutaneous closure of a post-surgical rapidly expanding left ventricular outflow tract (LVOT) pseudoaneurysm utilizing Amplatz Vascular Plug-II (AVP-II) (St. Jude Medical, St. Paul, MN) with the aid of 3D prototyping for pre-procedural planning.

Aging is associated with progressive loss of muscle mass, as well as replacement of muscle with fat and fibrous tissue. We studied the contribution of muscle fat content, a surrogate marker of biological aging, to frailty and Length of Hospital Stay (LOS) following Transcatheter Aortic Valve Replacement (TAVR).We evaluated 415 patients who underwent TAVR from February 2012 to December 2016 at Mayo Clinic, MN, USA. Densities between -190 to -30 Hounsfield Units within the abdominal muscle area were determined as muscle fat. Muscle Fat Index (MFI) was defined as muscle fat mass divided by height squared. LOS was considered as the primary outcome. Stepwise multivariable linear regression was used to identify the predictors of LOS.Mean age ± SD of the study population was 81.2 ± 9.6 years and 58.07% were male. Seventy-two patients (17.35%) had frailty. Median (IQR) LOS was 4 (3-6) days. MFI was higher in patients with frailty (median (IQR); 18.1 [13.8-24.2] vs 14.4 [10.6-18.7], p 0.001) and was positively correlated with LOS (r = 0.129, p = 0.009). In multivariable analysis of predictors of LOS, MFI (β = 0.06, p = 0.022), pre-TAVR atrial fibrillation/flutter (β = 0.5, p = 0.015), and post-TAVR complications (β = 0.91, p 0.001) were directly, and femoral access route (β = -1.13, p 0.001) and pre-TAVR hemoglobin (β = -0.35, p = 0.002) were inversely associated with LOS.MFI can be determined from pre-TAVR CT scans and is a novel predictor of LOS following TAVR. This objective indicator can potentially be used in a pre-TAVR clinic to plan for rehabilitation programs in selected patients.

Paravalvular prosthetic leak (PVL) is a serious condition that can occur in 6% to 15% of surgical prosthetic valves or annuloplasty rings secondary to degeneration and loss of integrity of the annular tissue. Moderate-to-severe PVL is associated with increased morbidity and mortality if left untreated. Patients with chronic mitral PVL usually present with clinical heart failure and/or hemolytic anemia. PVL can be treated with surgical repair or replacement or with percutaneous closure. This chapter will focus on mitral PVL closure and the different techniques involved in the procedure.

Pseudoaneurysms are an uncommon complication of surgical procedures and are associated with a high risk of complications. The diagnosis is most often made incidentally on imaging. Multimodality imaging including CT scan, MRI, TEE, and 3D printing is key for diagnosis and management. Percutaneous closure of pseudoaneurysms can be performed safely with proper planning and execution. This book chapter describes various percutaneous techniques for pseudoaneurysm closure.

Paravalvular leak (PVL) closure has emerged as a safe and effective alternative to repeat surgery in selected patients. Aortic PVLs have distinctive characteristics compared with PVLs of mitral prostheses. This chapter focuses on the contemporary techniques and outcomes of percutaneous closure of aortic PVL.

Background Accurate interpretation of a 12-lead electrocardiogram (ECG) demands high levels of skill and expertise. Early training in medical school plays an important role in building the ECG interpretation skill. Thus, understanding how medical students perform the task of interpretation is important for improving this skill. Objective We aimed to use eye tracking as a tool to research how eye fixation can be used to gain a deeper understanding of how medical students interpret ECGs. Methods In total, 16 medical students were recruited to interpret 10 different ECGs each. Their eye movements were recorded using an eye tracker. Fixation heatmaps of where the students looked were generated from the collected data set. Statistical analysis was conducted on the fixation count and duration using the Mann-Whitney U test and the Kruskal-Wallis test. Results The average percentage of correct interpretations was 55.63%, with an SD of 4.63%. After analyzing the average fixation duration, we found that medical students study the three lower leads (rhythm strips) the most using a top-down approach: lead II (mean=2727 ms, SD=456), followed by leads V1 (mean=1476 ms, SD=320) and V5 (mean=1301 ms, SD=236). We also found that medical students develop a personal system of interpretation that adapts to the nature and complexity of the diagnosis. In addition, we found that medical students consider some leads as their guiding point toward finding a hint leading to the correct interpretation. Conclusions The use of eye tracking successfully provides a quantitative explanation of how medical students learn to interpret a 12-lead ECG.

BACKGROUND Accurate interpretation of a 12-lead electrocardiogram (ECG) demands high levels of skill and expertise. Early training in medical school plays an important role in building the ECG interpretation skill. Thus, understanding how medical students perform the task of interpretation is important for improving this skill. OBJECTIVE We aimed to use eye tracking as a tool to research how eye fixation can be used to gain a deeper understanding of how medical students interpret ECGs. METHODS In total, 16 medical students were recruited to interpret 10 different ECGs each. Their eye movements were recorded using an eye tracker. Fixation heatmaps of where the students looked were generated from the collected data set. Statistical analysis was conducted on the fixation count and duration using the Mann-Whitney U test and the Kruskal-Wallis test. RESULTS The average percentage of correct interpretations was 55.63%, with an SD of 4.63%. After analyzing the average fixation duration, we found that medical students study the three lower leads (rhythm strips) the most using a top-down approach: lead II (mean=2727 ms, SD=456), followed by leads V1 (mean=1476 ms, SD=320) and V5 (mean=1301 ms, SD=236). We also found that medical students develop a personal system of interpretation that adapts to the nature and complexity of the diagnosis. In addition, we found that medical students consider some leads as their guiding point toward finding a hint leading to the correct interpretation. CONCLUSIONS The use of eye tracking successfully provides a quantitative explanation of how medical students learn to interpret a 12-lead ECG.

Background Transcatheter aortic valve-in-valve replacement (ViV) has been widely accepted as a less invasive alternative to treat failed aortic surgical or transcatheter bioprosthetic valves. Angulated aortas present an additional challenge, particularly when using self-expanding transcatheter heart valves (SE-THV). Methods Two patients with failed surgical bioprosthetic aortic valves and one patient with a failed transcatheter bioprosthetic aortic valve underwent transcatheter aortic ViV using SE-THV. All were deemed high-risk for surgical aortic valve replacement by a heart team. All three patients had initial failed SE-THV delivery using a conventional approach with subsequent successful delivery using the endovascular snare technique. Results In Cases 1 and 2, the SE-THV was biased towards the greater curve of the angulated aorta and behind the outer frame of the bioprosthetic valve frame. An endovascular snare was deployed through a secondary left femoral artery access, and the valve delivery system was advanced through the snare in the ascending aorta. The snare was tightened around the SE-THV capsule proximal to the hat-marker, allowing deflection of the SE-THV and successful delivery. In Case 3, the SE-THV interacted with the tall frame of a failed SE-THV. A snare via the left femoral artery was deployed in the descending artery. The SE-THV was advanced through the snare, and both the snare and SE-THV were advanced together to the ascending aorta where the SE-THV was deflected and successfully delivered. Conclusions The endovascular snare technique is a feasible option for successful delivery of SE-THV during transcatheter aortic ViV in failed transcatheter or surgical bioprosthetic valves in angulated aortas.

Coronary artery fistulas (CAFs) are rare coronary anomalies that are usually diagnosed incidentally with cardiac imaging. Small CAFs are generally asymptomatic and can close over time, while some untreated medium or large CAFs can enlarge, leading to clinical sequelae such as cardiac chamber enlargement or myocardial ischemia. With the advancement of transcatheter equipment and techniques, CAFs have been increasingly closed using a percutaneous approach. However, the procedure is not free of limitations given the risk for myocardial infarction, device embolization, and fistula recanalization. In this review, the authors illustrate the contemporary procedural considerations, techniques, and outcomes of transcatheter CAF closure.

ObjectivesCoronavirus Disease 2019 (COVID-19) is a rapidly expanding global pandemic resulting in significant morbidity and mortality. COVID-19 patients may present with acute myocardial infarction (AMI). The aim of this study is to conduct detailed analysis on patients with AMI and COVID-19.MethodsWe included all patients admitted with AMI and actively known or found to be COVID-19 positive by PCR between the 4th February 2020 and the 11th June 2020 in the State of Qatar. Patients were divided into ST-elevation myocardial infarction (STEMI) and Non-STE (NSTEMI).ResultsThere were 68 patients (67 men and 1 woman) admitted between the 4th of February 2020 and the 11th of June 2020 with AMI and COVID-19. The mean age was 49.1±9 years, 46 patients had STEMI and 22 had NSTEMI. 38% had diabetes mellitus, 31% had hypertension, 16% were smokers, 13% had dyslipidemia, and 14.7% had prior cardiovascular disease. Chest pain and dyspnea were the presenting symptoms in 90% and 12% of patients, respectively. Fever (15%) and cough (15%) were the most common COVID-19 symptoms, while the majority had no viral symptoms. Thirty-nine (33 STEMI and 6 NSTEMI) patients underwent coronary angiography, 38 of them had significant coronary disease. In-hospital MACE was low; 1 patient developed stroke and 2 died.ConclusionContrary to previous small reports, in-hospital adverse events were low in this largest cohort of COVID-19 patients presenting with AMI. We hypothesize patient’s demographics and profile including younger age contributed to these findings. Further studies are required to confirm this observation.Key questionsWhat is already known on this subject?COVID-19 patients may present with acute myocardial infarction (AMI).What might this study add?Contrary to previous small reports, most COVID-19 patients presenting with AMI have significant obstructive coronary artery disease and favorable in-hospital outcome.How might this impact on clinical practice?COVID-19 patients presenting with AMI should be treated according to the standard practice.

Purpose The study compared the color change, lightness, and translucency of hybrid resin ceramics exposed to toothbrush abrasion and surface treatment. Materials and methods Four hybrid ceramics [Lava Ultimate (LU), Vita Enamic (EN), Shofu HC (SH), and Crystal Ultra (CU)] were compared with a glass-ceramic (Vita Mark II) control. One hundred and twenty specimen blocks were prepared using a precision saw machine. Specimens in each material were divided into four subgroups based on the surface treatment (polishing or staining) and a storage medium (water or citric acid). Simulated tooth brushing with a mixture of 100 RDA (radioactive abrasives) with 0.3 ml distilled water was used for 3650 cycles (7300 strokes) for each specimen. Measurements for the color change, lightness, and translucency were measured after toothbrushing using a spectrophotometer. Statistical analysis compared outcomes using paired t-test, ANOVA, and Tukey post hoc test. Results The maximum color change was identified in SH (stained acid) [1.44 (0.40)], whereas the lowest was identified in EN (polished water) [0.66 (0.16)] material. The maximum and minimum loss of surface translucency was observed in SH (polished water) [12.3 (0.52)] and EN (stained acid) [6.5 (0.55)] specimens, respectively. Lastly, loss of lightness was the highest in VM (polished acid) [69 (0.95)], whereas the lowest was observed in CU (stained water) [56.7 (0.86)]. Conclusion The comparison presented a significant effect of toothbrush abrasion on translucency and lightness of the hybrid resin ceramics. Color change was not significantly influenced irrespective of the storage medium employed. Surface staining demonstrated the preservation and stability of color and optical properties under the influence of toothbrush abrasion and chemical trauma.

Cancer and cardiovascular diseases are the two leading causes of death in industrialized countries. Optimal management of life-threatening presentations of both of their diseases can pose significant challenges. The current study aimed to address the incidence, management, and outcome of acute coronary syndromes (ACS) in patients with active hematological malignancies.This retrospective registry-based cohort study included adults with active leukemia or lymphoma who were hospitalized at Mayo Clinic Rochester from 01/01/2004 to 12/31/2014. The diagnosis of ST-segment elevation MI (STEMI) or non-ST-segment elevation MI (NSTEMI) was made based on the 3rd Universal Definition for MI, or of unstable angina (UA) in the absence of cardiac troponin elevation. Main outcome measures included all-cause, cardiac, and non-cardiac death in-hospital and at one year.Of 5300 adult patients with active hematological malignancies, 73 (1.4%) were diagnosed with an ACS (78.1% NSTEMI and 13.7% STEMI). 17.5% and 40% of NSTEMI and STEMI patients underwent coronary angiography, with percutaneous coronary intervention in 5.3% and 30%, respectively. While80% of patients received β-blocker therapy, only half of all and50% of patients managed "medically" received antiplatelet, anticoagulant, and/or statin therapy. The in-hospital and 1-year mortality was 21.9% and 58.9%, respectively, of which 25% and 15% were cardiac in etiology. Aspirin, beta-blocker, statins, and angiotensin-converting enzyme inhibitor/angiotensin-II receptor blocker were associated with better mortality outcomes.In a large, contemporary study of adults with active hematologic malignancies, ACS was uncommon, but commonly managed not in keeping with societal guideline recommendations.

An 83-year-old man with a history of cerebral amyloid angiopathy and subarachnoid hemorrhage underwent uncomplicated left atrial appendage (LAA) occlusion using a 30-mm WATCHMAN device (Boston Scientific, Marlborough, Massachusetts). He was treated with aspirin and Eliquis (apixaban; Bristol-Myers

Cardiac masses can be caused by various etiologies [(1)][1]. Current practice relies on imaging to characterize masses without providing a definitive diagnosis, which is often made after surgical resection. In some cases, it would be prudent to have a definitive diagnosis before subjecting the

Objectives Patients with symptomatic severe mitral annular calcification present a therapeutic challenge. Direct transatrial implantation of SAPIEN valve has emerged as an alternative to surgical mitral valve (MV) replacement for high-risk surgical candidates. Methods This series includes 6 consecutive patients with symptomatic severe mitral annular calcification deemed to be at high risk for standard surgery. All patients underwent direct transatrial implantation of balloon-expandable SAPIEN valve in the mitral position. Results Mean age was 81 years [3 (50%) female], with an average Society of Thoracic Surgeons score of 10.3%. All patients had at least New York Heart Association Class III symptoms. Procedure was performed using normothermic cardiopulmonary bypass. The MV was approached through a standard left atriotomy in 4 patients and via a vertical trans-septal approach in the remaining 2 patients. Resection of the anterior leaflet of the MV was performed in 4 patients. The valve was successfully deployed in all patients. The diastolic mean gradient across the MV decreased from an average of 14 ± 3 to 5 ± 1 mmHg post deployment. There was no left ventricular outflow tract obstruction. MV periprosthetic regurgitation was severe in 3 patients and moderate to severe in 1 patient. In-hospital mortality occurred in 3 (50%) patients due to a non-cardiac cause in 1 patient and cardiogenic shock in the other 2 patients. Conclusions Early experience with direct transatrial balloon-expandable implantation for severe mitral annular calcification revealed feasibility of this approach but significant morbidity and mortality primarily related to periprosthetic regurgitation that requires further refinement of the technique.