NEUROLOGIC COMPLICATIONS OF TRANSAXILLARY ACCESS IN TAVR - A CASE OF POSTPROCEDURAL ULNAR AND MEDIAN NERVE INJURY

Background: Peripheral nerve injuries secondary to endovascular procedures are relatively rare but cause significant functional impairment. With transaortic valve replacement (TAVR), these injuries more commonly occur during axillary access compared to femoral and radial access (due to its proximity to brachial plexus). While hematoma and pseudoaneurysm formation are the more common complications, nerve injury may occur secondary to compression or direct needle puncture. Case: A 76-year-old male with severe aortic stenosis underwent two failed TAVR attempts due to poor access. Initial attempts at femoral access and transcaval access were aborted due to existing abdominal aortic endograft. Further attempts via carotid access were aborted due to stenosis. An attempt at left axillary access was then performed and TAVR was successful. Postoperatively (day 0), the patient developed left upper extremity (LUE) numbness over the 4th and 5th digits, medial palm, and dorsum of the hand with weakness when holding objects. Our neurological evaluation identified a total ulnar nerve (UN) and partial median nerve (MN) injury. Decision-making: Transaxillary access for TAVR is a disfavored approach due to the better outcomes when performed with other access sites. After out identification of a postprocedural nerve injury, we ordered a LUE arterial duplex ultrasound (US) and CT angiogram which excluded hematoma or pseudoaneurysm formation. US of the left brachial plexus revealed questionable edematous change at the take-off of the left UN and MN. Patient’s symptoms did not improve postoperatively until his discharge from the hospital (day 3) and an outpatient nerve conduction study was scheduled. Conclusion: We report a rare case of proximal UN and MN injury in a patient who underwent transaxillary TAVR due to the lack of alternative access. Prompt evaluation to rule-out vascular mechanism of injury in this patient was critical as early intervention results reduce further morbidity. With symptoms of motor and sensory brachial plexopathy and concerning imaging findings, the patient was scheduled for outpatient follow-up

Shrinking Lung Syndrome in a Young Female: A Rare Pulmonary Manifestation of Systemic Lupus Erythematosus

Shrinking lung syndrome (SLS) is a rare pulmonary complication of autoimmune conditions. It has been sparsely described in the literature and its pathophysiology remains unclear. SLS is typically reported in patients with a history of systemic lupus erythematosus (SLE) who present with shortness of breath and chest pain associated with breathing. Chest imaging demonstrates no alveolar, interstitial, or pleural abnormalities. Pulmonary function tests (PFTs) are characterized by a restrictive pattern with reduced lung volumes. SLS is a diagnosis of exclusion and there are no validated criteria for the diagnosis. Evaluation requires extensive testing to rule out alternative causes of dyspnea and pleuritic chest pain. In this report, we present a case of SLS in a young African American woman

Sleep duration, baseline cardiovascular risk, inflammation and incident cardiovascular mortality in ambulatory U.S. Adults: National health and nutrition examination survey

Introduction: The interplay between sleep duration and inflammation on the baseline and incident cardiovascular (CV) risk is unknown. We sought to evaluate the association between sleep duration, C-reactive protein (CRP), baseline CV risk, and incident CV mortality. Methods: We used data from the National Health and Nutrition Examination Survey 2005-2010 linked with the cause of death data from the National Center for Health Statistics for adults aged ≥18 years. The associations between self-reported sleep duration and CRP, 10-year atherosclerotic CV disease risk score (ASCVD) and CV mortality were assessed using Linear, Poisson and Cox proportional hazard modeling as appropriate. Results: There were 17,635 eligible participants with a median age of 46 years (interquartile range [IQR] 31, 63). Among them, 51.3% were women and 46.9% were non-Hispanic Whites. Over a median follow-up of 7.5 years (IQR 6.0, 9.1), 350 CV deaths occurred at an incident rate of 2.7 per 1000-person years (IQR 2.4, 3.0). We observed a U-shaped associations between sleep duration and incident CV mortality rate (P-trend=0.011), sleep duration and 10-year ASCVD risk (P-trend \u3c0.001), as well as sleep duration and CRP (P-trend \u3c0.001). A self-reported sleep duration of 6-7 hours appeared most optimal. We observed that those participants who reported \u3c6 or \u3e7 hours of sleep had higher risk of CV death attributable to inflammation after accounting for confounders. Conclusions: There was a U-shaped relationship of incident CV mortality, 10-year ASCVD risk, and CRP with sleep duration. These findings suggest an interplay between sleep duration, inflammation, and CV risk

INITIAL EXPERIENCE WITH LITHOTRIPSY FOR MITRAL BALLOON VALVULOPLASTY

Background: Mitral annular calcification (MAC) causes degeneration of the mitral valve function. Since these patients are poor surgical candidates, options are limited to percutaneous solutions. Use of balloon lithotripsy (BL) to augment mitral balloon valvuloplasty (MBV) is a novel technique for treatment of MAC-related mitral stenosis (MS). Methods: Single-center retrospective review of 35 consecutive MBV for MAC cases at Henry Ford from 3/2013 to 4/2021. Outcome variables are reported as median and interquartile ranges (IQR). Chi-squared and Wilcoxon-signed rank tests were used to compare categorical and continuous variables respectively using 95% confidence intervals for statistical significance. Procedural success was defined as a final mitral valve area ≥1.5 cm2 or ≥50% reduction in gradient. Results: Of 35 MBV cases done for MAC, 5 utilized lithotripsy balloons to augment valvuloplasty results (Table). Mean baseline gradients were similar and right ventricular systolic pressures trended higher for BL cases. Cases utilizing lithotripsy were longer and utilized more fluoroscopy time but the final invasive gradient trended lower (non-BL 7mmHg [4, 9] vs. BL 1 mmHg [0,5] p=0.113), therefore, higher rates of procedural success were seen (non-BL 47% vs. BL 80%, p=0.2). Survival analysis was hampered due to loss of follow-up in the BL group. Conclusion: BL appears to augment immediate valvuloplasty results. Further studies regarding the durable impact of balloon lithotripsy on MBV are warranted

SURVIVAL OF PATIENTS WITH RHEUMATIC AND NON-RHEUMATIC MITRAL VALVE STENOSIS AFTER VALVULOPLASTY

Background: Non-rheumatic (NR) mitral stenosis (MS) due to mitral annular calcification (MAC) presents in elderly patients and is difficult to treat due elevated surgical risk. In search for alternative treatments, mitral balloon valvuloplasty (MBV) has been performed in non-rheumatic mitral stenosis but no outcomes have been described in this cohort. Methods: Single center retrospective review of 85 consecutive MBV cases at Henry Ford from 3/2013 to 4/2021. Clinical and procedural outcome variables are reported as median and interquartile ranges (IQR). Kaplan-Meier method was used to estimate survival. Chi-squared and Wilcoxon-signed rank tests were used to compare categorical and continuous variables respectively using 95% confidence intervals for statistical significance. Results: Of 85 MBV cases, 50 and 35 were performed for rheumatic (R) and NR MS respectively. NR patients tended to be older and were more likely to have hypertension, diabetes, coronary artery disease, chronic kidney disease, aortic valve procedures. Rates of ≥moderate-severe mitral regurgitation (MR) (R 18% vs. NR 12% p=0.4) and procedure success (R 57% vs NR 42.9% p=0.2) were similar. Median follow up for the entire cohort was 0.5 yrs [0.1, 2.1]. Survival was significantly better for rheumatic cases (Figure). Conclusion: Survival of NR MS post-valvuloplasty is significantly attenuated as compared to those with R MS. Larger prospective studies are necessary in understanding optimal bridging therapies for patients with MAC

2021 Update for the Diagnosis and Management of Acute Coronary Syndromes for the Perioperative Clinician

In this review, recent key publications related to acute coronary syndrome (ACS) are summarized and placed into context of contemporary practice. Landmark trials examining vascular access in ST-elevation myocardial infarction, the management of multivessel disease, acute myocardial infarction and cardiac arrest are discussed. An update in pharmacology for ACS provides updates in major trials relating to P2Y12 inhibitor initiation, deescalation, and use in special populations. Additional updates in the use of lipid-lowering agents and adjunctive medications in ACS are reviewed. Finally, cardiac pathology related to coronavirus disease 2019 (COVID-19), as well as the impact of the COVID-19 global pandemic on the care of patients with ACS, is summarized

Python-Based Land Suitability Analysis for Wheat Cultivation Using MCE and Google Earth Engine in Punjab-Pakistan

The present study aims to examine the suitability of wheat crops in the four districts of Sheikhupura, Gujranwala, Hafizabad, and Nankana Sahib by conducting a thorough examination of various environmental parameters. The study utilizes the Google Earth Engine and advanced mapping techniques to employ a comprehensive Land Use and Land Cover (LULC) categorization, effectively capturing the prevailing terrain characteristics. The integration of temperature-based and soil-based suitability maps provides a comprehensive understanding of the intricate geographical patterns governing the growth circumstances of wheat. The study highlights a significant finding regarding the identification of very appropriate zones, which encompass around 28% of the total land area (4243 square kilometers) out of complete study site. These zones are particularly noteworthy as they emphasize places that are best for the growing of wheat. Approximately 45% (6819 square kilometers) of the overall land area is classified as moderately suitable, while 15% (2273 square kilometers) of the land area is categorized as less suitable. Furthermore, 16% of the total land area, encompassing 2444 square kilometers, is deemed unsuitable. The rigorous examination of soil parameters, such as pH, drainage, electrical conductivity, and soil type, contributes to a comprehensive comprehension of the soil-related elements that influence the adaptability of wheat crops. The study utilizes a Classification and Regression Tree (CART) methodology to classify crops, resulting in accurate outcomes with a ground truthing accuracy rate of 82%. This study employs a comprehensive approach by integrating temperature and soil-based data to provide a suitability map that enhances the identification of places suitable for wheat growing. Notwithstanding the accuracy of the findings, the research acknowledges certain constraints, including the necessity for heightened farmer consciousness and the incorporation of climate change ramifications. This study offers a comprehensive framework for sustainable agricultural planning, focusing on identifying certain regions that are most suitable for wheat growth. The findings of this research will serve as a valuable resource for guiding future initiatives and decision-making processes related to agricultural development in the studied area

Python-Based Land Suitability Analysis for Wheat Cultivation Using MCE and Google Earth Engine in Punjab-Pakistan

The present study aims to examine the suitability of wheat crops in the four districts of Sheikhupura, Gujranwala, Hafizabad, and Nankana Sahib by conducting a thorough examination of various environmental parameters. The study utilizes the Google Earth Engine and advanced mapping techniques to employ a comprehensive Land Use and Land Cover (LULC) categorization, effectively capturing the prevailing terrain characteristics. The integration of temperature-based and soil-based suitability maps provides a comprehensive understanding of the intricate geographical patterns governing the growth circumstances of wheat. The study highlights a significant finding regarding the identification of very appropriate zones, which encompass around 28% of the total land area (4243 square kilometers) out of complete study site. These zones are particularly noteworthy as they emphasize places that are best for the growing of wheat. Approximately 45% (6819 square kilometers) of the overall land area is classified as moderately suitable, while 15% (2273 square kilometers) of the land area is categorized as less suitable. Furthermore, 16% of the total land area, encompassing 2444 square kilometers, is deemed unsuitable. The rigorous examination of soil parameters, such as pH, drainage, electrical conductivity, and soil type, contributes to a comprehensive comprehension of the soil-related elements that influence the adaptability of wheat crops. The study utilizes a Classification and Regression Tree (CART) methodology to classify crops, resulting in accurate outcomes with a ground truthing accuracy rate of 82%. This study employs a comprehensive approach by integrating temperature and soil-based data to provide a suitability map that enhances the identification of places suitable for wheat growing. Notwithstanding the accuracy of the findings, the research acknowledges certain constraints, including the necessity for heightened farmer consciousness and the incorporation of climate change ramifications. This study offers a comprehensive framework for sustainable agricultural planning, focusing on identifying certain regions that are most suitable for wheat growth. The findings of this research will serve as a valuable resource for guiding future initiatives and decision-making processes related to agricultural development in the studied area

A CASE OF MARANTIC ENDOCARDITIS OF THE AORTIC VALVE IN A PATIENT WITH METASTATIC COLON CANCER

Background: A 74-year-old male with history of coronary artery disease and complex peripheral arterial disease presented to our emergency department with shortness of breath and melena. Case: The patient presented with a two-week history of shortness of breath and melena. Physical exam was significant for a 4/6 systolic ejection murmur at the left sternal border and cold lower extremities with diminished pedal pulses. Laboratory evaluation revealed hemoglobin of 5.8 g/dL and CEA level \u3e 950 ng/mL. CT scan of the abdomen demonstrated findings concerning for metastatic disease to the liver and concern for peritoneal carcinomatosis. Subsequently, colonoscopy demonstrated a large ascending colonic mass with biopsy revealing invasive, poorly-differentiated carcinoma. A transesophageal echocardiogram (TEE) revealed large (1.35 cm x 0.29 cm) highly mobile sub-valvular and valvular-proper aortic vegetations. Serial blood cultures were negative, including HACEK organisms. Patient\u27s course was complicated with development of scattered, punctate erythematous macules of the right foot consistent with emboli. Decision-making: Given TEE findings and diagnosis of colonic adenocarcinoma, the initial leading diagnosis was aortic valve endocarditis. After infectious etiologies were excluded, the presumptive diagnosis of marantic endocarditis with thromboemboli was made. Antibiotics were stopped and the patient was started on anticoagulation. Conclusion: Marantic endocarditis is a rare, noninfectious endocarditis. It predominantly affects the mitral and aortic valves, with deposition of platelet thrombi. Advanced malignancies of the lung and gastrointestinal tract comprise a majority of cases, yet most cases are diagnosed at autopsy. Antemortem cases most commonly present with thromboembolic phenomena. We describe an antemortem case of aortic valve marantic endocarditis in a patient with advanced colon adenocarcinoma who developed thromboembolic sequela