Case report: Concomitant MitraClip implantation for severe mitral regurgitation and plug closure of endocarditis induced fistula between aortic root and left atrium after transcatheter aortic valve implantation

Background: Infective endocarditis (IE) after transcatheter aortic valve implantation (TAVI) occurs in up to 1.5% of patients within the first year. The development of an aorto-atrial fistula (AAF) is a rare but problematic complication of IE, which can be confirmed with transoesophageal echocardiography (TOE). We present an exceptional case of occluding an aorto-left atrial fistula only diagnosed with intraprocedural TOE during a subsequent procedure of MitraClip implantation. Case summary: A 79-year-old symptomatic male patient with multiple comorbidities was referred due to severe mitral regurgitation (MR). He has had prior TAVI which was complicated with streptococcal IE for which he had received prolonged antibacterial therapy. Transthoracic echocardiography (TTE) revealed severe MR. The patient was accepted for a MitraClip procedure by the heart team. Intra-procedural TOE revealed also a significant continuous shunt through an AAF which was likely caused by the endocarditis. The strategy was therefore defined as to occlude the fistula with an Amplatzer Vascular Plug II 12 mm. The plug was released in the fistula leaving an insignificant residual shunt. After the transseptal puncture one MitraClip XTR was implanted, reducing the MR to mild. After the procedure, the patient's general clinical condition improved without signs of haemolysis. The pre-discharge TTE confirmed trace residual shunt, mild residual MR and mild paravalvular leakage. Discussion: Our case illustrates a complex transcatheter structural heart intervention with improvised procedural strategies based on the intra-procedural TOE findings. We conclude that the pre-procedural TOE needs to be comprehensive rather than exclusive, particularly in the context of bioprosthesis-related endocarditis

Cluster observations of the midaltitude cusp under strong northward interplanetary magnetic field

We report on a multispacecraft cusp observation lasting more than 100 min. We determine the cusp boundary motion and reveal the effect on the cusp size of the interplanetary magnetic field (IMF) changing from southward to northward. The cusp shrinks at the beginning of the IMF rotation and it reexpands at the rate of 0.40° invariant latitude per hour under stable northward IMF. On the basis of plasma signatures inside the cusp, such as counterstreaming electrons with balanced fluxes, we propose that pulsed dual lobe reconnection operates during the time of interest. SC1 and SC4 observations suggest a long-term regular periodicity of the pulsed dual reconnection, which we estimate to be ~1–5 min. Further, the distances from the spacecraft to the reconnection site are estimated on the basis of observations from three satellites. The distance determined using SC1 and SC4 observations is ~15 RE and that determined from SC3 data is ~8 RE. The large-scale speed of the reconnection site sunward motion is ~16 km s-1. We observe also a fast motion of the reconnection site by SC1, which provides new information about the transitional phase after the IMF rotation. Finally, a statistical study of the dependency of plasma convection inside the cusp on the IMF clock angle is performed. The relationship between the cusp stagnation, the dual lobe reconnection process, and the IMF clock angle is discussed

Low cost, SPF aluminum cryogenic tank structure for ALS

Past production work has shown that cryogenic tank structure for the Shuttle Booster Rockets and the Titan system have very high life cycle costs for the fuel tank structure. The tanks are machined stiffener-skin combination that are subsequently formed into the required contour after machining. The material scrap rate for these configurations are usually high, and the loss of a tank panel due to forming or heat treatment problems is very costly. The idea of reducing the amount of scrap material and scrapped structural members has prompted the introduction of built-up structure for cryogenic tanks to be explored on the ALS program. A build-up structure approach that has shown improvements in life cycle cost over the conventional built-up approach is the use of superplastically formed (SPF) stiffened panels (reducing the overall part count and weight for the tank) resistance spot welded (RSW) to outer tank skin material. The stiffeners provide for general stability of the tank, while the skin material provides hoop direction continuity for the loads

2014-2015 Master Class - Claire Wachter (Piano)

https://spiral.lynn.edu/conservatory_masterclasses/1033/thumbnail.jp

Echocardiography Core Laboratory Validation of a Novel Vendor-Independent Web-Based Software for the Assessment of Left Ventricular Global Longitudinal Strain

BACKGROUND: Global longitudinal strain (GLS) is an accurate and reproducible parameter of left ventricular (LV) systolic function which has shown meaningful prognostic value. Fast, user-friendly, and accurate tools are required for its widespread implementation. We aim to compare a novel web-based tool with two established algorithms for strain analysis and test its reproducibility. METHODS: Thirty echocardiographic datasets with focused LV acquisitions were analyzed using three different semi-automated endocardial GLS algorithms by two readers. Analyses were repeated by one reader for the purpose of intra-observer variability. CAAS Qardia (Pie Medical Imaging) was compared with 2DCPA and AutoLV (TomTec). RESULTS: Mean GLS values were −15.0 ± 3.5% from Qardia, −15.3 ± 4.0% from 2DCPA, and −15.2 ± 3.8% from AutoLV. Mean GLS between Qardia and 2DCPA were not statistically different (p = 0.359), with a bias of −0.3%, limits of agreement (LOA) of 3.7%, and an intraclass correlation coefficient (ICC) of 0.88. Mean GLS between Qardia and AutoLV were not statistically different (p = 0.637), with a bias of −0.2%, LOA of 3.4%, and an ICC of 0.89. The coefficient of variation (CV) for intra-observer variability was 4.4% for Qardia, 8.4% 2DCPA, and 7.7% AutoLV. The CV for inter-observer variability was 4.5%, 8.1%, and 8.0%, respectively. CONCLUSIONS: In echocardiographic datasets of good image quality analyzed at an independent core laboratory using a standardized annotation method, a novel web-based tool for GLS analysis showed consistent results when compared with two algorithms of an established platform. Moreover, inter- and intra-observer reproducibility results were excellent.</p