Approximately 40% of patients with aortic stenosis (AS) show discordant Doppler-echocardiographic parameters with aortic valve area (AVA) <1 cm 2 and/or index iAVA <0.6 cm 2 /m 2 (consistent with severe AS) and the mean gradient (MG) <40 mmHg, consistent with mild/moderate AS. Accurate diagnosis of true severe low flow low gradient AS versus pseudo-severe aortic stenosis is important for prognosis and optimal timing for intervention. Doppler echocardiography using intravenous low dose dobutamine challenge is widely used for differentiating pseudo-severe from true severe aortic stenosis. However, relying on echocardiography alone may have limitations in accurate diagnosis. Reliable diagnosis using echocardiography is dependent on multiple factors like the angle of interrogation of the aortic jet, the assumption that the LVOT area is circular in cross section, optimal echo windows, the presence of underlying subclinical coronary artery disease prior to dobutamine challenge etc. In this chapter, we describe non-invasive and invasive strategies to assess the aortic valve using dobutamine stress. Direct measurement of gradients across the aortic valve while estimating the change in cardiac output and aortic valve area with increments of dobutamine infusion dose is complementary, safe and useful when conventional echocardiography techniques are inconclusive. Finally, the chapter describes effective strategies of treatment for low gradient severe aortic stenosis, including the role for diagnostic balloon valvuloplasty, in the era of transcatheter valve replacement (TAVR).

withdrawn http://dx.Background: The management of cryptogenic stroke (CS) patients with a patent foramen ovale (PFO) is topical following the release of ten-year data supporting PFO closure. The Risk of Paradoxical Embolism (RoPE) score is a 1 to 10 scale Abstracts S33

may be a useful tool in identifying those high-risk patients who need aggressive therapy.http://dx. Conclusion:Despite the significantly higher radiation and fluoroscopy used in complex PCI, operator exposure was not significantly higher.http://dx.

In multivariate analyses, the MI criteria to independently and most strongly predict operative mortality was hs-TnT>500ng/L+ECG and/or echocardiographic changes odds ratio 15.9 (95% confidence interval 2.33-109); and for mortality during follow-up the same criteria hazards ratio 7.05 (2.40-20.7). Conclusion: Hs-TnT>500ng/L+ECG and/or echocardiographic criteria was strongly prognostic of short and longterm mortality after AVR+CABG. Our findings suggest higher hs-TnT threshold for defining MI after AVR+CABG than isolated CABG is more appropriate.

usage occurred in 58% of cases; the rest were bail-out procedures due to suboptimal initial balloon predilation. S-IVL was most commonly used in the left anterior descending coronary artery (50%), with 1.3 ± 0.5 stents implanted/target vessel. Angiographic success (<20% residual stenosis) occurred in all cases, with no procedural complications.Conclusion: S-IVL appears to be a useful modality in coronary calcium modification to optimise stent expansion. This device obviates the need for more complex lesion preparation strategies such as rotational atherectomy. Further study is warranted to compare different calcium modification devices with conventional balloon angioplasty. http://dx. Background:With increasing life expectancy, very elderly patients (≥85 years old) presenting with acute coronary syndrome (ACS) are increasingly likely to undergo percutaneous coronary intervention (PCI). Benefit of PCI in this group is less predictable, particularly in the frail.Method: Very elderly patients who underwent PCI for ACS in the Auckland region between 2014-2016 were retrospectively assessed for frailty using the Essential Frailty Toolset (EFT). Demographics, angiographic data, and clinical outcomes were extracted from the All New Zealand Acute Coronary Syndrome-Quality Improvement (ANZACS-QI) database and hospital electronic records.Results: Percutaneous coronary intervention was performed in 180 very elderly patients with ACS during this period (52% men; mean age, 87.6 ± 2.8 years). Frailty, defined as EFT ≥3 of 5, was present in 26% of patients. Frailty was associated with increased length of hospital stay (8.9 vs 5.6 days; p = 0.015) and with increased mortality (43% vs 13%; HR, 4.4; 95% CI, 2.3-8.4; p < 0.0001) at a mean follow-up of 23.4 months. Frailty was predictive of death, and independent of demographics and comorbidities. Medically managed patients were older than the PCI group (88.9 vs 87.6 years; p = 0.011) and more frail (mean EFT score 2.1 vs 1.8; p = 0.027). Although PCI was associated with reduced mortality compared with medical management overall (21% vs 53%; HR 0.4; 95% CI, 0.2-0.6; p < 0.0001), there was no difference in mortality when patients were frail (43% vs 54%; HR, 1.0; 95% CI, 0.5-2.0; p = ns).Conclusion: Frailty is an important predictor of length of hospital stay and mortality amongst very elderly patients undergoing PCI for ACS. Although PCI improves mortality, there appears to be no benefit when patients are frail. http://dx.