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Objectives The authors sought to prospectively determine the safety and efficacy of next-day discharge using the Vancouver 3M (Multidisciplinary, Multimodality, but Minimalist) Clinical Pathway. Background Transfemoral transcatheter aortic valve replacement (TAVR) is an alternative to surgery in high- and intermediate-risk patients; however, hospital stays average at least 6 days in most trials. The Vancouver 3M Clinical Pathway is focused on next-day discharge, made possible by the use of objective screening criteria as well as streamlined peri- and post-procedural management guidelines. Methods Patients were enrolled from 6 low-volume ( 200 TAVR/year) centers in Canada and the United States. The primary outcomes were a composite of all-cause death or stroke by 30 days and the proportion of patients successfully discharged home the day following TAVR. Results Of 1,400 screened patients, 411 were enrolled at 13 centers and received a SAPIEN XT (58.2%) or SAPIEN 3 (41.8%) valve (Edwards Lifesciences, Irvine, California). In centers enrolling exclusively in the study, 55% of screened patients were enrolled. The median age was 84 years (interquartile range: 78 to 87 years) with a median STS score of 4.9% (interquartile range: 3.3% to 6.8%). Next-day discharge home was achieved in 80.1% of patients, and within 48 h in 89.5%. The composite of all-cause mortality or stroke by 30 days occurred in 2.9% (95% confidence interval: 1.7% to 5.1%), with neither component of the primary outcome affected by hospital TAVR volume (p = 0.51). Secondary outcomes at 30 days included major vascular complication 2.4% (n = 10), readmission 9.2% (n = 36), cardiac readmission 5.7% (n = 22), new permanent pacemaker 5.7% (n = 23), and >mild paravalvular regurgitation 3.8% (n = 15). Conclusions Adherence to the Vancouver 3M Clinical Pathway at low-, medium-, and high-volume TAVR centers allows next-day discharge home with excellent safety and efficacy outcomes.

Patch clamping studies using non-cardiomyocytes revealed that the human connexin40 mutations P88S, G38D, and A96S are associated with reduced gap junction conductances compared to wild type connexin40 (wtCx40). Their effects within myocytes however are unclear. We aimed to characterise P88S, G38D, and A96S after expression in rat hearts and primary cardiomyocyte cultures.Adult Sprague-Dawley rat atria were transduced with a lentivector containing a transgene encoding wtCx40, P88S, G38D, A96S, or eGFP (n=6 per transgene). Electrophysiology studies (EPS) were performed just prior to and 7 days after surgery. Left atria were assessed for connexin expression, mRNA levels, inflammation and fibrosis. Primary cardiomyocyte cultures were also transduced with the abovementioned vectors (n=6 per transgene) and monolayer conduction velocities (CV) and protein expression were assessed at 96hours.At day 7 EPS, P wave and induced atrial fibrillation (AF) durations were significantly longer in the mutant groups when compared to wtCx40 controls (p0.05). There were no significant differences in inflammation, fibrosis, or heart to body weight ratios. Monolayer CV's were reduced in the A96S group compared to the wtCx40 group. While similar to wtCx40 controls, P88S velocities were reduced compared to eGFP controls. G38D monolayers possessed spontaneous fibrillatory activity and could not be paced. Immunofluorescence revealed that P88S and G38D reduced native connexin43 myocyte coupling while A96S appeared to co-localise with connexin43 in gap junctions. Connexin43 mRNA levels were similar between groups.The A96S, G38D, and P88S Cx40 mutations slow conduction and increased the propensity for inducible AF.

Objectives To evaluate the association between markers of precapillary pulmonary hypertension (PH) and survival in transcatheter aortic valve replacement (TAVR). Background The importance of precapillary PH has been sparsely investigated in patients undergoing TAVR. It may prove an important risk factor for poor outcomes. Methods We identified patients at our institution undergoing TAVR with a baseline right heart catheterization (RHC) demonstrating PH. We evaluated the association between markers of precapillary PH and survival including the diastolic pulmonary gradient (DPG), transpulmonary gradient (TPG), and pulmonary vascular resistance (PVR). A multivariable analysis was performed using Cox Proportional Hazards Models, adjusting for age, gender, body mass index, and pulmonary artery systolic pressure (PASP) on echocardiography. Results We identified 133 patients with PH on RHC. Of these 111 had low DPG and 22 had high DPG. All 3 markers of precapillary PH were associated with worse survival post TAVR, with OR of 2.1 (95% CI 1.1–3.9, P = 0.02), 3.4 (95% CI 1.8–6.4, P

Percutaneous Left Atrial Appendage ClosureBackground There are limited data with WATCHMAN (Boston Scientific Corporation, Natick, MA, USA) for left atrial appendage (LAA) closure in patients with nonvalvular atrial fibrillation (AF) and contraindications to anticoagulation. The purpose of this study was to evaluate the safety and efficacy of WATCHMAN in our early Canadian experience. Methods We report our pooled consecutive series of patients who underwent WATCHMAN implantation at four major Canadian centers. Indications for LAA closure were CHADS2 ≥ 1 or CHA2DS2-VASc ≥ 2, and contraindication/intolerance to or failure on anticoagulation. Follow-up imaging was typically performed 1–6 months postprocedure. Results One hundred and six patients underwent LAA closure with WATCHMAN from May 2013 to October 2015. The mean age was 74.8 ± 7.7, mean CHADS2 score was 2.8 ± 1.2, CHA2DS2-VASc score was 4.3 ± 1.5, and HASBLED score was 3.2 ± 1.2. Permanent AF was present in 67.9% and paroxysmal AF in 32.1%. Indications for LAA closure were prior bleeding 89.6% (87 major bleeding and 8 minor bleeding), 9.4% were deemed high risk for bleeding, and 0.9% with recurrent strokes on warfarin. Procedural success was 97.2% (103 of 106), with one device embolization (snared percutaneously), one implant failure due to inadequate LAA depth, and one cardiac perforation requiring surgical repair before WATCHMAN implantation. The composite major safety event-rate was 1.9% (1 death and 1 device embolization). Mean hospital stay was 1.8 ± 4.7 days. Antithrombotic therapy postimplant included dual antiplatelet therapy in 76 of 103 (73.8%). Mean follow-up was 210 ± 182 days; there were two transient ischemic attacks, with estimated 66% reduction in thromboembolic events relative to CHADS2 predicted risk. Conclusion In our early Canadian experience, WATCHMAN for LAA closure in patients contraindicated to anticoagulation appeared safe and effective.

Percutaneous left atrial appendage (LAA) closure is gaining interest as an alternative option for prevention of strokes in patients with Atrial Fibrillation (AF), especially for those with contraindications to anticoagulation. Complications from these procedures are well described in the medical literature. LAA closures may lead to pericardial effusion, device-associated thrombus, and device embolization. Understanding the reasons for embolization, strategies to avoid embolization, and the techniques for retrieval of LAA devices (ACP/AMULET and WATCHMAN) should be appreciated by endovascular implanters. We describe two cases of LAA device embolization that were both successfully retrieved percutaneously and other percutaneous techniques to safely retrieve embolized LAA devices. © 2016 Wiley Periodicals, Inc.

Background Stent thrombosis (ST) is rare, but is associated with significant morbidity and mortality. Methods We analyzed data from the British Columbia (BC) Registry from April 2011–January 2012. Results 101 ST cases were reported and verified. Based on timing, ST was considered early (≤30days) in 35.6%, late (>30days–1year) in 17.8% and very late (>1year) in 46.5%. The majority (68.5%) presented with STEMI, and the remaining with non-STEMI (31.5%). Most vessels were functionally occluded (TIM1 flow grade ≤1 in 67.1%). Thrombus burden was high (TIMI thrombus grade ≥4 in 77.2%). Aspiration thrombectomy was performed in 41% of cases. New stents were implanted in 62.4% cases. Intra-coronary imaging was low (11%). At the original stent implantation, STEMI was the clinical presentation in 39.6%, the lesion was complex in 62.1%, and thrombus was visualized in 23.0%. Prognosis after ST was unfavorable with high mortality (11.9% at 30days and 16.8% at one year), and further revascularization (5.0% repeat PCI and 6.9% coronary artery bypass graft surgery). Early ST was associated with worse clinical outcome compared to late/very late ST: 30-day mortality at 22.2% versus 6.2% (p=0.02), and 1-year mortality at 27.8% versus 10.8% (p=0.05). Conclusions In this prospective registry from BC, all ST presented with myocardial infarction, and the majority was treated with emergency PCI. Additional stents were commonly implanted with infrequent use of intracoronary imaging. Mortality rate was higher for early ST in comparison with late/very late ST. A comprehensive approach should be developed to treat this difficult complication.

Background Atrial fibrillation (AF) affects 1%-2% of the general population and 13% of individuals older than 80 years of age. Anticoagulation has been the mainstay therapy to reduce stroke risk. Patients with previous intracranial hemorrhage (ICH) or intraocular hemorrhage (IOH) are at increased risk of recurrence if anticoagulation is continued or initiated. Left atrial appendage (LAA) closure may obviate the need for long-term anticoagulation in these patients. Methods We report our consecutive series of patients with nonvalvular AF with previous ICH or IOH who underwent LAA closure with the AMPLATZER Cardiac Plug (ACP; St Jude Medical, St Paul, MN), AMPLATZER Amulet, or WATCHMAN (Boston Scientific, Natick, MA) device. Demographics, clinical status, procedural outcomes, and complications were collected at baseline, during the procedure, at 3 months, at 1 year, and annually thereafter. Results Twenty-six patients with previous ICH (n = 24) or IOH (n = 2) underwent LAA closure (9 with the ACP, 3 with the Amulet, and 7 with the WATCHMAN). The mean age was 76 ± 7 years, and 61.5% were men with a mean CHADS 2 ( C ongestive Heart Failure, H ypertension, A ge, D iabetes, S troke/Transient Ischemic Attack) score of 3.2 ± 1.4 and CHA 2 DS 2 -VASc ( C ongestive Heart Failure, H ypertension, A ge [≥ 75 years], D iabetes, S troke/Transient Ischemic Attack, Va scular Disease, A ge [65-74 years], S ex [Female] sc ore) of 4.9 ± 1.7. No procedure-related complications occurred. Mean follow-up was 11.9 ± 13.3 months. One patient died at 13 months (this death was not related to the procedure), and 1 patient had a transient ischemic attack at 20.6 months after the procedure. No ischemic stroke, haemorrhagic stroke, or bleeding problems occurred during follow-up. Conclusions In our consecutive series, LAA closure was found to be safe and effective in patients with AF and a history of ICH or IOH.

Comparing Measurements of CT Angiography, TEE, and FluoroscopyBackground Left atrial appendage (LAA) closure requires accurate preprocedural measurements, and trans-esophageal echocardiography (TEE), cardiac computed tomography angiography (CCTA) and fluoroscopy can be utilized. However, correlations between these measurements remain inadequately assessed. Methods Patients who underwent LAA closure at Vancouver General Hospital who had baseline LAA measurements by CCTA, TEE, and fluoroscopy were included in this analysis. CCTAs were performed with prospective-ECG-gating with Toshiba 320-detector or Siemens second generation 128-slice dual-source scanners, and images interpreted with VitreaWorkstation.™ LAA maximal dimensions were obtained for all patients at: (1) Amplatzer Cardiac Plug (ACP)/Amulet landing zone 10 mm within orifice, (2) WATCHMAN ostium, and (3) WATCHMAN depth measurements. Correlations and agreements were compared. Results We report 50 consecutive patients who underwent LAA closure (8 ACP, 10 Amulet, 32 WATCHMAN). Average age was 75.2 ± 8.7 years, mean CHADS2 score 3.0 ± 1.3, and CHA2DS2-VASc 4.7 ± 1.5. Procedural device implantation success was 100%. For ACP landing zone, mean maximal measurements were 24.1 ± 4.7 mm with CCTA, 22.3 ± 4.9 mm TEE, and 19.9 ± 5.6 mm fluoroscopy (P < 0.001); R value 0.81 fluoroscopy/CTA, 0.67 fluoroscopy/TEE, and 0.80 CTA/TEE. For WATCHMAN ostium, mean maximal measurements were 25.8 ± 4.7 mm CCTA (P < 0.001 vs. fluoroscopy, P = 0.16 vs. TEE), 25.1 ± 4.4 mm TEE (P = 0.016 vs. fluoroscopy), and 23.8 ± 4.9 mm fluoroscopy; R value 0.71 fluoroscopy/CTA, 0.65 fluoroscopy/TEE, and 0.74 CTA/TEE. Depth measurements were 34.3 ± 5.7 mm with CCTA, 31.1 ± 6.5 mm TEE, and 27.8 ± 7.1 mm fluoroscopy (all P < 0.01); and correlations with R value 0.28 fluoroscopy/CTA, 0.22 fluoroscopy/TEE, and 0.56 CTA/TEE. Conclusions All 3 imaging modalities correlated with ACP landing zone and WATCHMAN ostium measurements, with CCTA providing the largest measurements, followed by TEE and fluoroscopy.

ObjectivesThis study sought to determine whether volume loading alters the left atrial appendage (LAA) dimensions in patients undergoing percutaneous LAA closure.BackgroundPercutaneous LAA closure is increasingly performed in patients with atrial fibrillation and contraindications to anticoagulation, to lower their stroke and systemic embolism risk. The safety and efficacy of LAA closure relies on accurate device sizing, which necessitates accurate measurement of LAA dimensions. LAA size may change with volume status, and because patients are fasting for these procedures, intraprocedural measurements may not be representative of true LAA size.MethodsThirty-one consecutive patients undergoing percutaneous LAA closure who received volume loading during the procedure were included in this study. After an overnight fast and induction of general anesthesia, patients had their LAA dimensions (orifice and depth) measured by transesophageal echocardiography before and after 500 to 1,000 ml of intravenous normal saline, aiming for a left atrial pressure >12 mm Hg.ResultsSuccessful implantation of LAA closure device was achieved in all patients. The average orifice size of the LAA at baseline was 20.5 mm at 90°, and 22.5 mm at 135°. Following volume loading, the average orifice size of the LAA increased to 22.5 mm at 90°, and 23.5 mm at 135°. The average increase in orifice was 1.9 mm (p < 0.0001). The depth of the LAA also increased by an average of 2.5 mm after volume loading (p < 0.0001).ConclusionsIntraprocedural volume loading with saline increased the LAA orifice and depth dimensions during LAA closure. Operators should consider optimizing the left atrial pressure with volume loading before final device sizing.

Transcatheter aortic valve replacement (TAVR) is a minimally invasive treatment strategy for patients with symptomatic aortic stenosis, and is a non-inferior alternative to surgical valve replacement. Leadless right ventricular pacing is an alternative to traditional transvenous pacing with the

The authors sought to prospectively determine the safety and efficacy of next-day discharge using the Vancouver 3M (Multidisciplinary, Multimodality, but Minimalist) Clinical Pathway.Transfemoral transcatheter aortic valve replacement (TAVR) is an alternative to surgery in high- and intermediate-risk patients; however, hospital stays average at least 6 days in most trials. The Vancouver 3M Clinical Pathway is focused on next-day discharge, made possible by the use of objective screening criteria as well as streamlined peri- and post-procedural management guidelines.Patients were enrolled from 6 low-volume (100 TAVR/year), 4 medium-volume, and 3 high-volume (200 TAVR/year) centers in Canada and the United States. The primary outcomes were a composite of all-cause death or stroke by 30 days and the proportion of patients successfully discharged home the day following TAVR.Of 1,400 screened patients, 411 were enrolled at 13 centers and received a SAPIEN XT (58.2%) or SAPIEN 3 (41.8%) valve (Edwards Lifesciences, Irvine, California). In centers enrolling exclusively in the study, 55% of screened patients were enrolled. The median age was 84 years (interquartile range: 78 to 87 years) with a median STS score of 4.9% (interquartile range: 3.3% to 6.8%). Next-day discharge home was achieved in 80.1% of patients, and within 48 h in 89.5%. The composite of all-cause mortality or stroke by 30 days occurred in 2.9% (95% confidence interval: 1.7% to 5.1%), with neither component of the primary outcome affected by hospital TAVR volume (p = 0.51). Secondary outcomes at 30 days included major vascular complication 2.4% (n = 10), readmission 9.2% (n = 36), cardiac readmission 5.7% (n = 22), new permanent pacemaker 5.7% (n = 23), andmild paravalvular regurgitation 3.8% (n = 15).Adherence to the Vancouver 3M Clinical Pathway at low-, medium-, and high-volume TAVR centers allows next-day discharge home with excellent safety and efficacy outcomes.

Aims Left atrial appendage (LAA) device imaging after endovascular closure is important to assess for device thrombus, residual leak, positioning, surrounding structures, and pericardial effusion. Cardiac CT angiography (CCTA) is well suited to assess these non-invasively. Methods and results We report our consecutive series of non-valvular atrial fibrillation patients who underwent CCTA post-LAA closure with Amplatzer Cardiac Plug (ACP), Amulet (second generation ACP), or WATCHMAN devices. Patients underwent CCTA typically 1–6 months post-implantation. Prospective cardiac-gated CCTA was performed with Toshiba 320-detector or Siemens 2nd generation 128-slice dual-source scanners, and images interpreted with VitreaWorkstation™. GFR

Spontaneous coronary artery dissection (SCAD) is an infrequent but important cause of myocardial infarction (MI) in younger women. The underlying cause, presentation, and natural history of SCAD in women are increasingly being described because >90% of cases affect women. However, SCAD in men is

Access to left atrial appendage closure (LAAC) in Canada is limited due to funding restrictions. This work aimed to assess Canadian clinical practice on patient selection, post-procedural antithrombotic therapy, and safety and/or efficacy with WATCHMAN implantation. All Canadian centers implanting

Although rates of atrial septal defect (ASD) closure are stable, dramatic increases in the rates of patent foramen ovale (PFO) closure have placed greater demands on existing catheterization laboratory resources. The Vancouver PFO/ASD Clinical Pathway (Figure 1) was designed to facilitate same-day

To evaluate the association between markers of precapillary pulmonary hypertension (PH) and survival in transcatheter aortic valve replacement (TAVR).The importance of precapillary PH has been sparsely investigated in patients undergoing TAVR. It may prove an important risk factor for poor outcomes.We identified patients at our institution undergoing TAVR with a baseline right heart catheterization (RHC) demonstrating PH. We evaluated the association between markers of precapillary PH and survival including the diastolic pulmonary gradient (DPG), transpulmonary gradient (TPG), and pulmonary vascular resistance (PVR). A multivariable analysis was performed using Cox Proportional Hazards Models, adjusting for age, gender, body mass index, and pulmonary artery systolic pressure (PASP) on echocardiography.We identified 133 patients with PH on RHC. Of these 111 had low DPG and 22 had high DPG. All 3 markers of precapillary PH were associated with worse survival post TAVR, with OR of 2.1 (95% CI 1.1-3.9, P = 0.02), 3.4 (95% CI 1.8-6.4, P 0.001) and 2.5 (95% CI 1.4-4.5, P = 0.003) for high DPG, TPG, and PVR, respectively. On multivariable analysis, both TPG and PVR remained predictors of worse survival, with OR of 3.4 (95% CI 1.7-6.9, P = 0.001) and 2.5 (95% CI 1.4-4.5, P = 0.003). Echocardiographic PASP and DPG were not predictive of survival.In patients undergoing TAVR, parameters of precapillary PH are associated with lower survival, and provide incremental prognostication over echocardiographic PASP. RHC should continue to play an important role in risk stratification prior to TAVR. © 2017 Wiley Periodicals, Inc.

There are limited data with WATCHMAN (Boston Scientific Corporation, Natick, MA, USA) for left atrial appendage (LAA) closure in patients with nonvalvular atrial fibrillation (AF) and contraindications to anticoagulation. The purpose of this study was to evaluate the safety and efficacy of WATCHMAN in our early Canadian experience.We report our pooled consecutive series of patients who underwent WATCHMAN implantation at four major Canadian centers. Indications for LAA closure were CHADSOne hundred and six patients underwent LAA closure with WATCHMAN from May 2013 to October 2015. The mean age was 74.8 ± 7.7, mean CHADSIn our early Canadian experience, WATCHMAN for LAA closure in patients contraindicated to anticoagulation appeared safe and effective.

Background: There is limited data with WATCHMAN for left atrial appendage (LAA) closure in patients with nonvalvular atrial fibrillation (AF) and contraindications to anticoagulation. The purpose of this study was to evaluate the safety and efficacy of WATCHMAN in our early Canadian experience. Methods: We report our consecutive series of patients who underwent WATCHMAN implantation at 4 Canadian centers (Vancouver General Hospital, Montreal Heart Institute, Hamilton General Hospital and Ottawa Heart Institute). Indications for LAA closure were CHADS2≥1, and contraindication/intolerance to or failure on anticoagulation. All cases were done under general anesthesia and TEE guidance. Majority of patients received dual antiplatelet therapy (DAPT) for 3-6 months after implant. Follow-up TEE was typically performed at 1-6 months post-procedure. Results: Ninety patients underwent LAA closure with WATCHMAN from May 2013 to June 2015. The mean age was 75.0 ± 7.9. The mean CHADS2 score was 2.9 ± 1.2, CHADS-VASc score was 4.4 ± 1.5, and HASBLED score was 3.2 ± 1.2. Permanent AF was present in 66.7% and paroxysmal AF in 33.3%. Indications for LAA closure were prior bleeding in 81 patients (90.0%; 74 major bleeding, and 7 minor bleeding), 9 were deemed high-risk for bleeding (renal failure, cirrhosis, labile INR, esophageal ulcers, on DAPT), and 1 with recurrent strokes on warfarin. Procedural success was 97.8% (88/90), with one device embolization (snared percutaneously) and one implant failure due to inadequate LAA depth. There was no procedural stroke/TIA, death, MI, or cardiac tamponade. There were 3 major bleeding that required transfusions. Mean hospital stay was 1.4 ± 1.8 days. Antithrombotic therapy post-implant included DAPT in 66/90 (73.3%), anticoagulant in 21/90 (5 warfarin, 16 direct anticoagulant), and aspirin alone in 3/90. Follow-up TEE was available in 53 patients, there was 1 device-associated thrombus (treated successfully with anticoagulation), and 18 peri-device leaks (all Conclusion: In our early Canadian experience, WATCHMAN for LAA closure in patients contraindicated to anticoagulation is safe and effective.

Left atrial appendage (LAA) closure requires accurate preprocedural measurements, and trans-esophageal echocardiography (TEE), cardiac computed tomography angiography (CCTA) and fluoroscopy can be utilized. However, correlations between these measurements remain inadequately assessed.Patients who underwent LAA closure at Vancouver General Hospital who had baseline LAA measurements by CCTA, TEE, and fluoroscopy were included in this analysis. CCTAs were performed with prospective-ECG-gating with Toshiba 320-detector or Siemens second generation 128-slice dual-source scanners, and images interpreted with VitreaWorkstation.™ LAA maximal dimensions were obtained for all patients at: (1) Amplatzer Cardiac Plug (ACP)/Amulet landing zone 10 mm within orifice, (2) WATCHMAN ostium, and (3) WATCHMAN depth measurements. Correlations and agreements were compared.We report 50 consecutive patients who underwent LAA closure (8 ACP, 10 Amulet, 32 WATCHMAN). Average age was 75.2 ± 8.7 years, mean CHADS2 score 3.0 ± 1.3, and CHA2 DS2 -VASc 4.7 ± 1.5. Procedural device implantation success was 100%. For ACP landing zone, mean maximal measurements were 24.1 ± 4.7 mm with CCTA, 22.3 ± 4.9 mm TEE, and 19.9 ± 5.6 mm fluoroscopy (P0.001); R value 0.81 fluoroscopy/CTA, 0.67 fluoroscopy/TEE, and 0.80 CTA/TEE. For WATCHMAN ostium, mean maximal measurements were 25.8 ± 4.7 mm CCTA (P0.001 vs. fluoroscopy, P = 0.16 vs. TEE), 25.1 ± 4.4 mm TEE (P = 0.016 vs. fluoroscopy), and 23.8 ± 4.9 mm fluoroscopy; R value 0.71 fluoroscopy/CTA, 0.65 fluoroscopy/TEE, and 0.74 CTA/TEE. Depth measurements were 34.3 ± 5.7 mm with CCTA, 31.1 ± 6.5 mm TEE, and 27.8 ± 7.1 mm fluoroscopy (all P0.01); and correlations with R value 0.28 fluoroscopy/CTA, 0.22 fluoroscopy/TEE, and 0.56 CTA/TEE.All 3 imaging modalities correlated with ACP landing zone and WATCHMAN ostium measurements, with CCTA providing the largest measurements, followed by TEE and fluoroscopy.

Purpose: To evaluate the patterns of origin and anatomical localization of histologically verified metastases in the ophthalmic region in Denmark during 1969–98, and to compare the findings with those of a similar study for the period 1944–68. Methods: All metastatic lesions presented at the Eye Pathology Institute, University of Copenhagen during the period 1968–98 were investigated. Results: Metastases were found in 81 specimens from the eye and eye region in 76 patients (32 men, 44 women). Five patients had bilateral involvement. The most frequent site of involvement was the uvea (63%), followed by the orbit (26%) and the eyelids (10%). Breast cancer accounted for the most frequent primary tumour (38%), followed by lung cancer (24%) and skin melanoma (14%). Conclusion: The pattern of anatomical location of metastases in the ocular region has not changed since 1944. The incidence of metastases has fallen significantly throughout the period.

Background: There is limited data with WATCHMAN for left atrial appendage (LAA) closure in patients with nonvalvular atrial fibrillation (AF) and contraindications to anticoagulation. The purpose of this study was to evaluate the safety and efficacy of WATCHMAN in our early Canadian experience. Methods: We report our consecutive series of patients who underwent WATCHMAN implantation at 4 Canadian centers (Vancouver General Hospital, Montreal Heart Institute, Hamilton General Hospital and Ottawa Heart Institute). Indications for LAA closure were CHADS2≥1, and contraindication/intolerance to or failure on anticoagulation. All cases were done under general anesthesia and TEE guidance. Majority of patients received dual antiplatelet therapy (DAPT) for 3-6 months after implant. Follow-up TEE was typically performed at 1-6 months post-procedure. Results: Ninety patients underwent LAA closure with WATCHMAN from May 2013 to June 2015. The mean age was 75.0 ± 7.9. The mean CHADS2 score was 2.9 ± 1.2, CHADS-VASc sc...

Background— Collagen has been attributed as the principal structural substrate of ventricular tachycardia (VT) after myocardial infarction (MI), even though adiposity of myocardium after MI is well recognized histologically. We investigated the effects of intramyocardial adiposity compared with collagen on electrophysiological properties, connexin43 expression, and VT induction after MI. Methods and Results— Simultaneous left ventricular plunge-needle, noncontact mapping was performed in sheep without MI (MI−; n=5), with MI and inducible VT (MI+VT+; n=7), and with MI and no inducible VT (MI+VT−; n=8). Histological intramyocardial quantity of adipose and collagen and degree of discontinuity were coregistered with electrophysiological parameters (MI+; 290 specimens). Additional assessment of connexin43 expression was performed. Left ventricular scar contained a body mass–independent abundance of adipocytes (adipose:collagen=0.8). Increased adipose density and discontinuity contributed to a greater inverse correlation ( r ) with conduction velocity ( r for adipose=0.39, r for discontinuity=0.45, r for collagen=0.26) and electrogram amplitude ( r for adipose=0.73, r for contiguity=0.77, r for collagen=0.68) compared with collagen. Collagen density was similar between the MI+ groups ( P >0.29). However, the MI+VT+ group demonstrated a significant (all P ≤0.01) increase in adipose (8%) and discontinuity (qualitative) and decrease in conduction velocity (13%) and electrogram amplitude (21%) at MI borders compared with the MI+VT− group. In scar, myocytes adjacent to fibrofatty interfaces demonstrated increased connexin43 lateralization. A gradient increase in adipose was observed at sites that supported preferential presystolic VT activation and exhibited attenuation of excitation wavelength ( P Conclusions— Intramyocardial adiposity, in association with myocardial discontinuity within left ventricular scar borders, is a significant factor associated with altered electrophysiological properties, aberrant connexin43 expression, and increased propensity for VT after MI.

Timely review and interpretation of 12-lead electrocardiogram (ECG) reduces the time to reperfusion in acute ST-segment elevation myocardial infarction (STEMI). Smartphones are becoming an integral part of a wide variety of medical disciplines, and may be an ideal tool for timely assessment of ECG

Atrial fibrillation (AF) is the most common cardiac arrhythmia with increasing prevalence. AF is associated with considerable morbidity and mortality. Cardioembolic stroke results as a consequence of thrombus formation within the left atrial appendage (LAA) in patients with AF and has a significant impact on our health system. Oral anticoagulation with either vitamin K antagonists or the novel anticoagulants is an effective medical therapy for prophylaxis against strokes in patients suffering from AF. Unfortunately, bleeding complications and compliance issues limit their use. A need for newer approaches have thereby been developed and studied such as percutaneous occlusion of the LAA. Several LAA occlusion devices have been developed, and with improved operator experience, they have been successful in stroke prevention in patients with nonvalvular AF and fewer periprocedural complications. This article reviews the use of percutaneous LAA occlusion devices in the prevention of cardioembolic stroke.

To evaluate the patterns of origin and anatomical localization of histologically verified metastases in the ophthalmic region in Denmark during 1969-98, and to compare the findings with those of a similar study for the period 1944-68.All metastatic lesions presented at the Eye Pathology Institute, University of Copenhagen during the period 1968-98 were investigated.Metastases were found in 81 specimens from the eye and eye region in 76 patients (32 men, 44 women). Five patients had bilateral involvement. The most frequent site of involvement was the uvea (63%), followed by the orbit (26%) and the eyelids (10%). Breast cancer accounted for the most frequent primary tumour (38%), followed by lung cancer (24%) and skin melanoma (14%).The pattern of anatomical location of metastases in the ocular region has not changed since 1944. The incidence of metastases has fallen significantly throughout the period.

BACKGROUND: Sustained transcatheter aortic valve implantation (TAVI) program success requires processes of care to support careful case selection, determine peri-procedural requirements, facilitate early recovery and decrease length of stay. The Vancouver Program initiated multidisciplinary and multimodality risk stratification to determine patients’ suitability for a transfemoral (TF) minimalist peri-procedural approach, and implemented risk-stratified clinical pathways to facilitate discharge and reduce length of stay. METHODS: Standardized and streamlined screening was implemented to conduct multimodality assessments, including cardiac catheterization, transthoracic echocardiography, computed tomography, functional assessment and medical consultations. Following multidisciplinary eligibility decision for TF TAVI by the Heart Team, additional risk stratification was discussed to determine individuals’ appropriateness for a peri-procedural minimalist approach and/or early discharge. Risk-stratified clinical pathways were developed to support the patient cohorts. RESULTS: In 2013, 144 consecutive patients were accepted for TF TAVI and assigned to risk-stratified protocols (see Table 1). The mean age was 82 7 years, with the proportion of women ranging from 37% to 42% in the four cohorts, and mean STS risk scores between 6.3 and 7.1. The burden of comorbidities and functional impairment was similar across groups. The overall in-hospital outcomes included 2.1% mortality, 0% myocardial infarction, 0.7% stroke, 2.1% life threatening bleeding, 0.7% new dialysis, and 4.2% conduction disturbances requiring a new permanent pacemaker. Risk-stratified outcomes are presented in Table 1. The median length of stay for all patients was 3 days (IQR 2-3), 2 days (IQR 1-3) in the Awake cohort and 2 (IQR 1-2) in the Early Discharge cohort; 95.8% of patients were discharged home. The 30-day all-cause hospital readmission rate was 11.1%, ranging from 7% and 8% in the Awake and Early Discharge cohorts respectively, to 13% in the GA/TEE and Regular Discharge cohorts; no new deaths occurred between discharge and 30 days. CONCLUSION: The refined understanding of TAVI risk profiles and their mitigation with improved case selection, imaging, procedural expertise and clinical pathways offer opportunities to improve outcomes while ensuring patient safety and the sustained success of TAVI programs. Early experience with TAVI risk stratification, individualized procedure planning and tailored clinical pathways supported by multimodality screening and multidisciplinary case selection and care results in excellent outcomes and optimized length of stay. Canadian Pediatric Cardiology Association (CPCA) Oral SURGERY AND INTERVENTIONAL CATHETERISM IN CONGENITAL HEART DISEASE Sunday, October 26, 2014

TAVR is an alternative to surgery in high risk operable patients; however, complications and cost currently limit expansion into lower risk populations. Although mortality, morbidity and length of stay (LOS) are expected to improve, we sought to determine if a multidisciplinary, multimodality, but

Introduction: Cancer-cachexia state promotes intense involuntary weight loss, wasting skeletal muscle protein due to higher proteolysis and/or decreased protein synthesis. This process can be improved by branched-chain amino acids, as leucine, which provides energy source by skeletal muscle and acts as a cell signaling. Objectives: This work aim to evaluate whether the leucine-rich diet (3%>leu) can modulate theelectrocardiogram (ECG) and cardiac biomarkers in the cachectic tumorbearing rats. Methods: Adult rats were distributed into 4 groups: C–control rats; WWalker-256 tumor tumor-bearing rats; L–leucine supplemented diet (leu-3%) and LW-leucine supplemented diet tumor-bearing rats (5 animals per group). The electrocardiogram was evaluated after anesthesia (ketamine 100mg/Kg. plus xelazine 7mg/Kg intramuscular) during pre-agonic state assayed by LabChart software. Cardiac biomarkers (MPO, TIMP, PAI-total) were evaluated in heart muscle homogenate assayed by multiplex assay (Millipore-Luminex). Difference among groups used one-way ANOVA analyses followed by Bonferroni’s test (P

myocytes of diabetic rabbits as indicated by increase in co-immunoprecipitation (co-ip) of p47phox with p22phox subunits of NADPH oxidase and in glutathionylation of endothelial nitric oxide synthase (eNOS) (58± 6%) known to uncouple eNOS. Diabetes reduced co-ip of 1 Na+-K+ pump subunit with glutaredoxin 1 (Grx1) that reverses glutathionylation of proteins. Consistent with this, glutathionylation of the 1 subunit was increased (52± 9%) and electrogenic Na+-K+ pump current measured in voltage-clamped myocytes was reduced (0.26± 0.04 vs 0.44± 0.04 pA/pF). Administration of CL (40 g/kg/h) had no effect on glucose or insulin levels but reduced lipid peroxidation. It also reduced p47phox/p22phox co-ip, reduced glutathionylation of eNOS (51± 1%) and 1 pump subunit (74± 13%), increased Grx1/ 1 pump subunit co-ip and increased Na+-K+ pump current (0.6± 0.1 vs 0.26± 0.04 pA/pF). Diabetes inducedmolecular remodelling in anoxidative pathway that is determinant of the functionally important oxidativemodification of Na+–K+ pump. Reversal of these changes by 3 AR stimulation suggests that 3 ARagonists may have cardiovascular protective effects in diabetes. http://dx.doi.org/10.1016/j.hlc.2013.05.239

M.Carrington1, S.Stewart 1,∗, T.Marwick2, P.Davidson3, P. Macdonald4, J. Horowitz 5, H. Krum6, P. Newton3, C. Reid6 1 Baker IDI Heart and Diabetes Institute, Australia 2 University of Queensland, Australia 3 University of Technology/Curtin University, Australia 4 St. Vincent’s Hospital and Victor Chang Cardiac Research Institute, Australia 5 The Queen Elizabeth Hospital and University of Adelaide, Australia 6 Monash University, Australia

Left atrial appendage (LAA) closure device sizing requires accurate pre-procedural measurements. Presently, multimodality imaging with trans-esophageal echocardiography (TEE), computed tomography angiography (CTA) and fluoroscopy can be utilized for this purpose. Correlation between measurements