Apical Approach Research Articles

Apical Whorl Treatment for Exogenous Application of Hormones in Maize.

Plant hormones play an essential role in both development and stress responses. These organic natural compounds have critical functions in plant-related processes, including but not limited to seed development, anther formation, root elongation, and responses to abiotic and biotic stress. One way to study the impact of hormones on these processes is by external application, followed by evaluation of parameters of interest. Here, we describe one such method for the exogenous application of hormones in maize: the apical whorl treatment approach, which is well suited for evaluating the role of these compounds in reproductive stages (e.g., when the target organ is the inflorescence meristem). This method involves direct application of a hormone solution to the apical part of the plants every 2 days until the tassel emerges, which takes 15-20 days, or until the treated plants show noticeable phenotypic changes for evaluation. This method is ideal for observing effects on the apical meristem, and it may be scaled up for analyzing large numbers of plants.

Transcatheter versus surgical aortic valve replacement in aortic stenosis patients requiring mechanical circulation support: a nationwide Japanese study

Abstract Introduction Transcatheter aortic valve replacement (TAVR) has demonstrated comparable clinical outcomes to surgical aortic valve replacement (SAVR) in patients with aortic stenosis (AS). However, previous trials excluded patients who had required mechanical circulatory support (MCS) for cardiogenic shock. Thus, the clinical feature of aortic valve replacement requiring MCS and the efficacy of TAVR compared to SAVR has not been fully exhibited in AS patients. Purpose This study investigated the demography and clinical outcomes comparing TAVR and SAVR for AS demanding MCS. Methods The current study was an observational retrospective study using Japanese nationwide data from the Japanese Registry Of All cardiac and vascular Diseases-Diagnostic Procedure Combination (JROAD-DPC). Between April 1, 2012, and March 31, 2022, AS patients undergoing TAVR or SAVR who required MCS were evaluated. The primary outcome was 30-day mortality. In addition, we assessed ischemic stroke, hemorrhagic stroke during hospitalization. Result During the period, 80,752 patients (TAVR=36,546 and SAVR=44,206) were identified. The frequency of MCS (intra-aortic balloon pumping and/or extracorporeal membrane oxygenation) was 3.0% (1,097 patients) of the TAVR group and 4.8% (2,133 patients) of the SAVR group. In the TAVR group, 78% of patients were implanted balloon-expandable valve and 7.1% of patients were transapical apical approach. TAVR was performed in older (median age: 85 years vs. 76 years, p<0.001), lower body mass index (BMI) (median BMI: 21.5 kg/m2 vs. 22.7 kg/m2, p<0.001), and more female patients (42% vs. 27%, p<0.001) than SAVR. The 30-day mortality was lower in TAVR than SAVR (12% in TAVR and 19% in SAVR, p<0.001) (Figure). After adjusting age, gender, TAVR was significantly associated with decreased 30-day mortality compared to SAVR (adjusted HR 0.52 (0.41–0.67), p<0.001). In contrast, the incidence of ischemic stroke and hemorrhagic stroke were comparable in 2 groups (ischemic stroke; 4.2% in TAVR vs. 4.1% in SAVR, p=0.93 and hemorrhagic stroke; 0.3% vs. 0.3%, respectively). Conclusion According to nationwide real-world clinical data on aortic valve replacement for AS, the frequency of patients requiring MCS due to cardiogenic shock was 3.0% in the TAVR group and 4.8% in the SAVR group. Our findings demonstrated short-term outcomes following TAVR for patients requiring MCS for cardiogenic shock was better than those following SAVR.

Major aspects of minimally invasive endodontic surgery using microsurgery: a systematic review

Introduction: Knowledge about endodontic infections has increased significantly over the last 50 years and, although many issues still require elucidation, endodontics has become the dental science that has the most improved approaches and technologies to increase the success and longevity of treatments dental organs. Endodontic microsurgery has produced highly successful results in preserving teeth with persistent or recurrent cases of periapical periodontitis that could not be successfully treated by non-surgical endodontic approaches. Objective: It was to list the main clinical considerations of minimally invasive endodontic surgery using apical microsurgery, as well as point out the success rate of this technique. Methods: The PRISMA Platform systematic review rules were followed. The search was carried out from January to March 2024 in the Scopus, PubMed, Science Direct, Scielo, and Google Scholar databases. The quality of the studies was based on the GRADE instrument and the risk of bias was analyzed according to the Cochrane instrument. Results and Conclusion: A total of 117 articles were found, 50 articles were evaluated in full and 20 were included and developed in the present systematic review study. Considering the Cochrane tool for risk of bias, the overall assessment resulted in 10 studies with a high risk of bias and 21 studies that did not meet GRADE and AMSTAR-2. Most studies did not show homogeneity in their results, with X2=58.5%<50%. It was concluded that the success of apical endodontic surgery in terms of healing existing periapical pathology, together with a good long-term prognosis, depends on correct diagnosis and planning, as well as the association of surgical techniques, well-executed protocols, and biocompatible materials. The apical endodontic microsurgery approach is predictable and has a high success rate, which resulted from the introduction of cone beam computed tomography, microscope, ultrasonic instruments, and materials such as mineral trioxide aggregate (MTA) and bioceramics for retro-fillings.

Predominant determinants for evaluation of right parasternal approach in transthoracic echocardiography in aortic stenosis: a study based on three-dimensional cardiac computed tomography analysis.

The maximum blood flow velocity through the aortic valve (AVmax) using Doppler transthoracic echocardiography (TTE) is important in assessing the severity of aortic stenosis (AS). The right parasternal (RP) approach has been reported to be more useful than the apical approach, but the anatomical rationale has not been studied. We aimed to clarify the influence of the angle formed by the ascending aorta and left ventricle on Doppler analysis by TTE (Sep-Ao angle) and three-dimensional multidetector computed tomography (3D-MDCT) in patients with AS. A total of 151 patients evaluated using the RP approach and 3D-MDCT were included in this study. The Sep-Ao angle determined using TTE was compared with that determined using 3D-MDCT analysis. In MDCT analysis, the left ventricular (LV) axis was measured in two ways and the calcification score was calculated simultaneously. The Sep-Ao angle on TTE was consistent with that measured using 3D-MDCT. In patients with an acute Sep-Ao angle, the Doppler angle in the apical approach was larger, potentially underestimating AVmax. Multivariate analysis revealed that an acute Sep-Ao angle, large Doppler angle in the apical approach, smaller Doppler angle in the RP approach, and low aortic valve calcification were independently associated with a higher AVmax in the RP approach than in the apical approach. The Sep-Ao angle measured using TTE reflected the 3D anatomical angle. In addition to measurements using the RP approach, technical adjustments to minimize the Doppler angle to avoid bulky calcification should always be noted for accurate assessment.

An Ex-vivo Comparative Study to Evaluate the Efficacy of Three Root Canal Irrigation Systems in Reduction of Enterococcus Faecalis.

The purpose of this ex-vivo study is to evaluate the efficacy of three irrigation techniques in the reduction of E. faecalis in root canal. Eighty healthy maxillary anteriors were employed in this investigation. The bacteria E. faecalis was left on teeth for 7 days while they were kept. Once teeth were contaminated, they were randomly divided into three groups of 20 for experimentation and a control group of 20 for comparison. NaviTip FX was used to irrigate Group I, the Max-I-probe was used to water Group II, and the Endovac system was used to water Group III. The number of colony forming units (CFUs) was determined by growing bacteria from root canal samples for 2 days in Brain heart infusion agar after chemo-mechanical operations. There was a substantial decrease in bacterial numbers across all experimental groups compared to group IV (control). Group III (Endovac) had the fewest bacterial colonies among the test groups. There were no discernible changes between Group I (the Navitip FX) and Group II (the Max I probe). Endovac was the most effective of the three irrigation methods for reducing CFUs. This study's findings lend credence to the idea that the apical negative pressure approach has more potential than the conventional irrigation delivery system for achieving an enhanced antibacterial impact.

Major factors for the effectiveness of apical endodontic microsurgery: a systematic review

Introduction: Apical endodontic microsurgery is a technique developed by the evolution of traditional apical endodontic surgery approaches and technologies. This enhancement was possible since the introduction of equipment like cone beam computed tomography, microscope, ultrasonic instruments, and biocompatibility root-end material filling, increasing the predictability and long-term success rates and survival of teeth. Objective: It explored and developed the main factors for the effectiveness of apical endodontic microsurgery. Methods: The PRISMA Platform systematic review rules were followed. The search was carried out from October to December 2023 in the Scopus, PubMed, Science Direct, Scielo, and Google Scholar databases. The quality of the studies was based on the GRADE instrument and the risk of bias was analyzed according to the Cochrane instrument. Results and Conclusion: A total of 118 articles were found, 43 articles were evaluated in full and 36 were included and developed in the present systematic review study. Considering the Cochrane tool for risk of bias, the overall assessment resulted in 28 studies with a high risk of bias and 21 studies that did not meet GRADE and AMSTAR-2. Most studies did not show homogeneity in their results, with X2=57.5%<50%. It was concluded that the success of apical endodontic surgery in terms of healing existing periapical pathology, together with a good long-term prognosis, depends on correct diagnosis and planning, as well as the association of surgical techniques, well-executed protocols, and biocompatible materials. The apical endodontic microsurgical approach is predictable and has a high success rate, which resulted from the introduction of cone beam computed tomography, microscope, ultrasonic instruments, and materials such as MTA and bioceramics for retro-fillings.

Treatment of esthetic complications with peri-implant soft tissue: A description of the "apical approach" surgical technique and presentation of two clinical cases.

Peri-implant soft tissue deformities are an increasingly common phenomenon in the esthetic zone. While the most widely studied esthetic complications are peri-implant soft tissue dehiscences, there are other esthetic concerns in routine clinical practice that require investigation and treatment. Against this backdrop, this report on two clinical cases aimed to describe a surgical approach using the apical access technique for treatment of peri-implant soft tissue discoloration and fenestration. In both clinical scenarios the defect was accessed via a single horizontal apical incision, without removing the cement-retained crowns. A bilaminar technique using apical access with a simultaneous connective tissue graft seems to offer promising results for the treatment of peri-implant soft tissue deformities. After the 12-month reevaluation, an increase in peri-implant soft tissue thickness was observed, resolving the pathologies presented.

A Pacing-Controlled Procedure for the Assessment of Heart Rate-Dependent Diastolic Functions in Murine Heart Failure Models.

Heart failure with preserved ejection fraction (HFpEF) is a condition characterized by diastolic dysfunction and exercise intolerance. While exercise-stressed hemodynamic tests or MRI can be used to detect diastolic dysfunction and diagnose HFpEF in humans, such modalities are limited in basic research using mouse models. A treadmill exercise test is commonly used for this purpose in mice, but its results can be influenced by body weight, skeletal muscle strength, and mental state. Here, we describe an atrial-pacing protocol to detect heart rate (HR)-dependent changes in diastolic performance and validate its usefulness in a mouse model of HFpEF. The method involves anesthetizing, intubating, and performing pressure-volume (PV) loop analysis concomitant with atrial pacing. In this work, a conductance catheter was inserted via a left ventricular apical approach, and an atrial pacing catheter was placed in the esophagus. Baseline PV loops were collected before the HR was slowed with ivabradine. PV loops were collected and analyzed at HR increments ranging from 400 bpm to 700 bpm via atrial pacing. Using this protocol, we clearly demonstrated HR-dependent diastolic impairment in a metabolically induced HFpEF model. Both the relaxation time constant (Tau) and the end-diastolic pressure-volume relationship (EDPVR) worsened as the HR increased compared to control mice. In conclusion, this atrial pacing-controlled protocol is useful for detecting HR-dependent cardiac dysfunctions. It provides a new way to study the underlying mechanisms of diastolic dysfunction in HFpEF mouse models and may help develop new treatments for this condition.

Beat-by-beat volume calibration refines pressure-volume derived indices of left ventricular function in the rat

Objective: Cardiac pressure-volume studies have advanced much of our understanding of mammalian cardiovascular physiology. Using admittance or conductance technology, the advantage of this technology over other methods to assess cardiovascular function is the ability to derive beat-by-beat pressure-volume loops and generate estimations of myocardial work (stroke work), as well as load-independent systolic (i.e., contractility) and diastolic (i.e., compliance) function from a caval occlusion. While these catheters are capable of extremely accurate recordings of cardiac pressure, volume measurement relies on a series of calibration steps that are oft-performed in isolation or at discrete timepoints. We propose a novel method that enables the refinement of ventricular volume measurement by enabling a beat-by-beat calibration of stroke volume (SV) at baseline and, most importantly, during caval occlusion where both the shape and characteristics of the ventricle are dynamically changing. Hypothesis: We hypothesised that beat-by-beat calibration of SV has a significant effect on PV-catheter derived indices of left ventricle (LV) function. Methodology: Data were collected from 10 rodents that were intubated, ventilated, and urethane anesthetized. We placed an admittance pressure-volume catheter (1.6F Scisense, Transonic Systems, Inc.) into the LV via an apical approach following thoracotomy, a perivascular flow probe (Transonic Systems, Inc.) was placed around the ascending aorta, a blood pressure catheter in the iliac artery, femoral venous lines for fluid/drug infusions, and an arterial line for blood gas analysis. We then assessed baseline and load-independent systolic function using the admittance catheter with and without beat-by-beat volume corrections obtained by integration of the perivascular flow data. Results: Firstly, we confirmed that the standard metrics of load-independent systolic function were increased in response to dobutamine (β1 agonist) and reduced in response to esmolol (β1 blocker). We then found that beat-by-beat volume correction from the perivascular flow probe increased baseline measures of SV and stroke work (SW). Comparing indices of load-independent systolic function calculated from corrected vs. uncorrected values of SV and SW, we found that beat-by-beat volume correction resulted in no significant change in d P/dt max - V ed (P=0.339) but a significant increase in PRSW (from 116±18 to 129±20 mmHg, P=0.020). Conclusions: Standard approaches to PV studies are able to accurately discern changes in contractile state. However, beat-by-beat calibration of the volume signal improves the absolute determination of volume indices and therefore influences derived measures of contractility. This research was funded by an NSERC Alliance grant to CRW and Mitacs Accelerate Postdoctoral Fellowship to OHW. This is the full abstract presented at the American Physiology Summit 2023 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.

Transorbital drillout to the cavernous sinus: an approach for squamous cell carcinoma with perineural spread. Illustrative cases

This study describes a transorbital apical approach to the cavernous sinus, where the greater wing of sphenoid (GWS) and superior orbital fissure (SOF) are drilled out to access the interdural incision zone and lateral wall of the cavernous sinus. This was a retrospective series of 3 patients with periocular squamous cell carcinoma (SCC) and radiological evidence of perineural spread to the cavernous sinus. Following an orbital exenteration, the GWS was drilled to reach the lateral border of the SOF. The meningo-orbital band, a periosteal transition between the frontotemporal basal dura and periorbita, was incised to enter the lateral wall of the cavernous sinus. The relevant cranial nerves were biopsied to provide an accurate zonal classification of disease. The transorbital apical approach via the SOF provides a corridor of access to the cranial nerves within the lateral wall of the cavernous sinus. This technique was successfully performed on 3 patients with periocular SCC. One case had radiological evidence of intracavernous oculomotor nerve involvement, 1 patient demonstrated nasociliary nerve enlargement at the SOF, and another had frontal nerve involvement extending into the cavernous sinus. Cerebrospinal fluid leak occurred in 1 case addressed with fat packing and fascial closure.

1004 AN UNUSUAL, UNAVOIDABLE BUT SUCCESSFUL MANAGEMENT OF TYPE A AORTIC DISSECTION. A CASE REPORT

Abstract Background Cardiac tamponade complicates 18,7% of patients with type A aortic dissection and is associated with dramatically worse outcome and a nearly doubling of in-hospital mortality. Immediate surgical repair with intra-operative pericardial drainage is the treatment of choice. Nevertheless, the management of unstable patients who cannot undergo cardiac surgery in short time is controversial. Case report Here we present a case report of an 82-year woman with type A aortic dissection complicated by cardiac tamponade. The patient alerted the emergency system because of a sudden epigastric pain. On her arrival to the hospital, her systolic blood pressure was 50 mmHg; despite intravenous fluids and inotropic support, she remained hypotensive. Transthoracic echocardiography revealed an intimal flap involving ascending aorta and aortic arch, and a hemodynamically significant pericardial effusion. Immediate surgical repair was not possible due to the lack of available operating rooms. To stabilize the patient, percutaneous pericardiocentesis from apical approach was attempted, unsuccessfully. A second attempt of percutaneous pericardiocentesis was made from substernal approach, with removal of just 150 cc of pericardial fluid and insertion of a pigtail drainage catheter. Thanks to this procedure systolic blood pressure raised up to 100 mmHg and the patient was stabilized. A CT Angiography scan was performed, showing an aortic dissection extending from the aortic valvular plane to the origin of the right iliac artery. The patient maintained hemodynamical stability until surgical intervention, which started four hours later her arrival. The patient underwent substitution of ascending aorta, aortic hemiarch, non-coronary sinus and aortic valve. There were no complications related to the pericardial drainage and in 34th post-operative day she was discharged in good condition. Conclusion Percutaneous pericardiocentesis should be considered in unstable patients with type A dissection complicated by cardiac tamponade who cannot await surgical treatment, providing that very small amount of pericardial fluid is removed, in order to maintain systolic blood pressure around 90 mmHg.

Utilization of Two- and Three-Dimensional Transesophageal Echocardiography in Successfully Guiding Transcatheter Mitral Valve in Bioprosthetic Mitral Valve/Mitral Ring Implantation without Complications in Patients with Thrombus in Left Atrium/Left Atrial Appendage.

The aim of this study is to describe, for the first time to our knowledge, the utilization of both two-dimensional (2D) and three-dimensional (3D) transesophageal echocardiography (TEE) in successfully performing transcatheter mitral valve (MV) in bioprosthetic MV/MV annulopasty ring implantation using the apical approach in 12 patients (pts) with co-existing left atrial appendage (LAA) and/or LA (left atrium) body thrombus, which is considered a contraindication for this procedure. All pts were severely symptomatic with severe bioprosthetic MV stenosis/regurgitation except one with a previous MV annuloplasty ring and severe native MV stenosis. Thrombus in LAA and/or LA body was noted in all by 2D and 3DTEE. All were at high/prohibitive risk for redo operation and all refused surgery. Utilizing both 2D and 3DTEE, especially 3DTEE, guidewires and the prosthesis deployment system could be manipulated under direct vision into the LA avoiding any contact with the thrombus. The procedure was successful in all with amelioration of symptoms and no embolic or other complications over a mean follow-up of 21 months. Our study demonstrates the feasibility of successfully performing this procedure in pts with thrombus in LAA and/or LA body without any complications.

P81 SIMULTANEOUS TRANS–APICAL AORTIC AND MITRAL VALVE IMPLANTATION IN A PATIENT WITH A DEGENERATED MITRAL BIOPROSTHESIS AND SEVERE AORTIC STENOSIS

Abstract Transcatheter Valve–in–Valve implantation has shown promising results in high–risk patients suffering from structural valve deterioration (SVD) of a previously implanted heart valve bioprosthesis. This is a case of a 82–year–old man, with history of multiple previous mitral valve replacement, admitted to the hospital for heart failure. During diagnostic work out he was diagnosed with a severe aortic stenosis and structural degeneration of a mitral valve bioprostheses Epic 29mm, St Jude Medical, (Inc, St Paul, Minn, USA). The heart team defined the patient at high surgical risk profile and was therefore scheduled for a simultaneous mitral and aortic transcatheter valve implantation. Through a double trans–apical approach (Figure A and B), the patient underwent two balloon expandable valves (Sapien 3, Edwards Lifesciences, Irvine, CA, USA) deployment in native aortic (Figure C) and mitral bioprosthesis (Figure D), respectively. Final angiography showed lack of aortic (Figure E) and left atrial (Figure E) regurgitation. The procedure was uneventful as well as the following hospital stay. Post–procedural transesophageal echocardiography confirmed the absence of paravalvular leakage nor aortic or mitral regurgitation. The patient was discharged at home on day 7. Simultaneous transapical transcatheter aortic and mitral valve replacement is technically feasible with the current available technology and can be a possible alternative in patients with high surgical risk.

V07-11 VARYING APPROACHES TO THE PROSTATE APEX TO OPTIMIZE URETHRAL STABILITY AND EARLY CONTINENCE RECOVERY AFTER ROBOTIC RADICAL PROSTATECTOMY

You have accessJournal of UrologyCME1 May 2022V07-11 VARYING APPROACHES TO THE PROSTATE APEX TO OPTIMIZE URETHRAL STABILITY AND EARLY CONTINENCE RECOVERY AFTER ROBOTIC RADICAL PROSTATECTOMY Claudia Mercader, J. Francisco Lopez, Nitesh Ranasinha, Mutie Raslan, Ruth McPherson, Richard Bell, Tom Leslie, Richard Bryant, Freddie Hamdy, Alastair, and Lamb Claudia MercaderClaudia Mercader More articles by this author , J. Francisco LopezJ. Francisco Lopez More articles by this author , Nitesh RanasinhaNitesh Ranasinha More articles by this author , Mutie RaslanMutie Raslan More articles by this author , Ruth McPhersonRuth McPherson More articles by this author , Richard BellRichard Bell More articles by this author , Tom LeslieTom Leslie More articles by this author , Richard BryantRichard Bryant More articles by this author , Freddie HamdyFreddie Hamdy More articles by this author , AlastairAlastair More articles by this author , and Lamb Lamb More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002598.11AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Pre-operative membranous urethral length (MUL) is a well-known non-modifiable factor predicting continence recovery after surgery, but there are also refinements in surgical techniques to optimize early continence after robotic-assisted radical prostatectomy (RARP). These include modifications in apical dissection to maximize urethral length and maximizing preservation of periurethral structures responsible for urethral stability. METHODS: We reviewed data of patients who underwent RARP between January 2018 and October 2021. MUL, anterior Retzius sparing approach and continence (pads) 6-weeks after surgery were recorded. We present five surgical scenarios often encountered while planning the apical dissection in RARP: non urethral preservation, half-supported full or non-full-length urethral preservation, full length unstable urethra, full length stable urethra and full-length stable preservation in the context of unusual apical anatomy. All patients consented to data storage and video-recording. RESULTS: Following on from the video footage of this surgical scenarios, we present 342 patients for quantitative analysis. Those patients with a MUL >10 mm had 9.7 increased chance of being completely dry at 6-weeks (OR 9.7 CI 95% 2.2–42.1). Those patients with a MUL >10 mm who also had anterior Retzius sparing their chances increased by a further 4.3 (OR 4.3 IC 95% 2.1–8.8). CONCLUSIONS: The apical approach in a RARP can be planned and tailored for each case depending on both patients and tumour anatomy to optimize urethral stability post-RARP and early continence recovery. We advocate both preservation of urethral length and those structures responsible for urethral stability. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e662 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Claudia Mercader More articles by this author J. Francisco Lopez More articles by this author Nitesh Ranasinha More articles by this author Mutie Raslan More articles by this author Ruth McPherson More articles by this author Richard Bell More articles by this author Tom Leslie More articles by this author Richard Bryant More articles by this author Freddie Hamdy More articles by this author Alastair More articles by this author Lamb More articles by this author Expand All Advertisement PDF downloadLoading ...

Feasibility and safety of CT-aided pericardiocentesis from a subxiphoid anterior approach by using fluoroscopy in patients with chronic pericardial effusions.

BackgroundPericardiocentesis is an essential procedure for the diagnosis and treatment of pericardial effusions. The purpose of this study was to evaluate the feasibility and safety of a subxiphoid anterior approach using fluoroscopy aided by a sagittal axis chest computed tomography (CT) view in comparison with an ultrasound‐guided apical approach in patients with chronic pericardial effusion.MethodsAmong 72 consecutive patients (68.8 ± 14.4 years old, 52 males) with hemodynamically stable chronic pericardial effusions, a total of 85 procedures were retrospectively analyzed. We divided them into two groups according to the site of the approach for the pericardiocentesis.ResultsA subxiphoid anterior approach (n = 53) was performed guided by fluoroscopy. The sagittal axis view of the chest CT was constructed to determine the puncture angle and direction for the subxiphoid anterior approach. An apical approach (n = 32) was performed by ultrasound guidance. The success rates of the anterior and apical approaches were 98.1% and 93.8%, respectively. There were two cases with cardiac perforations in the apical approach group, while no cases developed perforations in the subxiphoid anterior approach group.ConclusionThe subxiphoid anterior approach for pericardiocentesis was feasible and safe for managing chronic pericardial effusions. A reconstruction of the sagittal axis view of the chest CT imaging was helpful to identify the direction and depth to access the pericardial space from the subxiphoid puncture site before the pericardiocentesis using the lateral fluoroscopic view.

Mitral Annular Plane Systolic Excursion (MAPSE) as a Simple Index for Assessing Left Ventricular Function: An Observational Study

Background: Mitral annular plane systolic excursion (MAPSE) has been proposed as a parameter for assessing left ventricular function. The assessment of LVF has major diagnostic and prognostic implications in patients with cardiovascular diseases. LVF is measured by Left Ventricular Ejection Fraction, however the accuracy of LVEF estimation by two dimensional echocardiography is limited especially in patients with poor image quality. Mitral annular plane systolic excursion (MAPSE) measurement predicts left ventricular function even in conditions with suboptimal echo window.
 Objective: To assess the correlation of MAPSE derived LVEF with LVEF measured by Modified Simpson’s method.
 Methods: This is a cross sectional study which included 279 patients admitted at our tertiary care hospital from December 2019 to March 2020 and the patients were divided in two groups. Group A – Patients with LVEF>= 50% and Group B – Patients with LVEF<50%. All patients underwent 2D echocardiographic examination using Modified Simpsons’ method and MAPSE measurement. The VIVID E9, VIVID T8, VIVID E95 and PHILIPS echocardiography machine was used for the non-invasive measurements. MAPSE was recorded at medial and lateral mitral annuli in the apical four-chamber approach.
 Results: On analysis, a cut off value for average MAPSE-S (medial mitral annuli) was 8.5 was obtained, denoting preserved LV function with sensitivity of 81.7%, specificity of 84.9%, positive predictive value of 91.6% and negative predictive value of 84.9%. The AUC for MAPSE-S was 0.822. Similarly, the cut off value of average MAPSE-L (lateral mitral annuli) was 7.5 denoting impaired LV functions with an AUC of 0.826, sensitivity of 82.8%, specificity of 72.0%, positive predictive value of 85.6% and negative predictive value of 72.0%. The AUC of 82.6% was observed for MAPSE-L.
 Conclusion: MAPSE reflects longitudinal myocardial shortening. MAPSE is a rapid and sensitive echocardiographic parameter for assessing normal LV function and global LV systolic dysfunction.

Apical approach of pericardiocentesis for pericardial effusion in advanced breast cancer patient

Malignant pericardial effusion is the end stage of breast cancer. Pericardiocentesis is the most useful therapeutic emergency procedure for the management of symptomatic pericardial effusion and cardiac tamponade. There are three main approaches: apical, subcostal or parasternal approach.

Apical approach in periodontal reconstructive surgery with enamel matrix derivate and enamel matrix derivate plus bone substitutes: a randomized, controlled clinical trial

ObjectivesThis parallel, randomized controlled clinical trial evaluated the influence of bone substitutes (BS) on the efficacy of the non-incised papillae surgical approach (NIPSA) with enamel matrix derivate (EMD) in resolving deep, isolated, combined non-contained intrabony and supra-alveolar periodontal defects, preserving the soft tissue.Material and methodsTwenty-four patients were randomized to treatment with NIPSA and EMD or NIPSA plus EMD and BS. Bleeding on probing (BoP), interproximal clinical attachment level (CAL), interproximal probing depth (PD), recession (REC), location of the tip of the papilla (TP), and width of the keratinized tissue (KT) were evaluated before surgery and at 1 year post-surgery (primary outcomes). Wound closure was assessed at 1 week post‐surgery, and supra‐alveolar attachment gain (SUPRA-AG) was recorded at 1 year post‐surgery.ResultsAt 1 week, 87.5% of cases registered complete wound closure and there were no cases of necrosis, without differences between groups (p > .05). At 1 year, all cases showed negative BoP. A significant PD reduction (NIPSA + EMD 8.25 ± 2.70 mm vs. NIPSA + EMD + BS 6.83 ± 0.81 mm) and CAL gain (NIPSA + EMD 8.33 ± 2.74 mm vs. NIPSA + EMD + BS 7.08 ± 2.68 mm) were observed (p < .001) in both groups, without significant between-group differences (p > .05). The residual PD was < 5 mm in all defects (NIPSA + EMD 2.50 ± 0.67 mm vs. NIPSA + EMD + BS 2.67 ± 0.78 mm). Soft tissues were preserved without significant between-group differences (REC: NIPSA + EMD 0.25 ± 0.45 mm vs. NIPSA + EMD + BS 0.17 ± 0.58 mm, p > .05; KT: 0.00 ± 0.43 mm vs. 0.08 ± 0.67 mm, p > .05). There were improvements in the papilla in both groups (TP: NIPSA + EMD 0.33 ± 0.49 mm vs. NIPSA + EMD + BS 0.45 ± 0.52 mm, p > .05), which was only significant in the NIPSA EMD + BS group (0.45 ± 0.52 mm; p < .05). In both groups, CAL gain was recorded in the supra-alveolar component, showing full resolution of the intrabony component of the defect in all cases (SUPRA-AG: NIPSA + EMD 1.83 ± 1.11 mm vs. NIPSA + EMD + BS 2.00 ± 1.76 mm, p > .05).ConclusionsNIPSA and EMD with or without BS seem to be a valid surgical approach in the treatment of isolated, deep non-contained periodontal defects. In our study, both treatments resulted in significant PD reduction and CAL gain, that extended in the supra-alveolar component, without differences with the use of BS. Both treatments resulted in soft tissue preservation. However, the addition of BS may improve interdental papillary tissue.Clinical relevanceNIPSA, with or without bone substitutes, resulted in significant periodontal improvement, with soft tissue preservation in isolated, deep non-contained periodontal defects. The application of bone substitutes may provide interproximal soft tissue gain.Clinical trial registrationClinicaltrials.gov: NCT04712630.

Abstract 13023: Contemporary Echocardiography-Guided Pericardiocentesis Outcomes in a High-Volume Tertiary Teaching Hospital

Introduction: First performed in the 1970s, echo-guided pericardiocentesis has become the preferred approach for draining pericardial effusions. After identifying the largest pocket, a cardiology attending and fellow use a micropuncture needle kit, confirm placement with agitated saline, and leave a side and end hole 8 French drain stocked with sterile saline. This is drained every 8 hours by nursing and never left to gravity or else it tends to clot. The drain is removed when output is &lt;25 cc in 24 hours, or by 7 days. Methods: We prospectively maintained an IRB approved database of pericardiocenteses performed by three experienced cardiology attendings directly supervising a multitude of fellows between 2009-2021 at Thomas Jefferson University Hospital. Results: Of 391 pericardiocenteses, 61% were for tamponade. 66% were done from an apical approach, 18% subcostal, 11% left parasternal, and 2% right parasternal. Drains were left in for an average of 3.1 days (range 1-10 days). An average of 578 mL were drained with the initial procedure (range 5-2670 mL), and 62% of effusions were bloody. A total of 42% were deemed idiopathic, without an identifiable cause, 27% were associated with malignancy (56% of these had positive cytology with remaining unlikely from any other cause), 9% after open heart surgery (valve replacement, heart transplant, dissection repair), 8% post-procedural (electrophysiology, cardiac catheterization, line placement), 5% were in chronic dialysis patients, and the remainder were due to a combination of hemorrhage not related to a procedure, rheumatic, post-radiation, or medication-induced. The rate of serious complications was 3% and included 4 pneumothoraces, 3 hemothoraces, 3 cases of pericardial decompression syndrome, 1 RV microperforation, and one PEA arrest resulting from cardiac perforation. There were no mortalities. The rate of non-serious complications was 4% and included pleural placement of drain in 8, severe pain remitting with drain removal in 5, prolonged bleeding from puncture site in 2, and SVT during placement in 1. Conclusion: Overall, echocardiography-guided pericardiocentesis by experienced providers supervising fellows-in-training is a safe and effective means of draining pericardial effusions.

A RARE POST-SURGICAL EMPYEMA AFTER AN APICAL APPROACH TRANSCATHETER AORTIC VALVE REPLACEMENT

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: First introduced in 2002, the anterograde Transcatheter Aortic Valve Replacement (TAVR) procedure continues to grow in popularity, given its efficacy in patients with high surgical risk suffering from severe aortic stenosis. Although a less invasive procedure than previous techniques, various potential complications can occur causing severe morbidity and death. Post-operative infections occur in for 13-15% of all post TAVR complications. However acute pulmonary complications (APC) after a TAVR procedure only occur in 1.5% of cases. Post TAVR empyema is extremely uncommon. If not emergently diagnosed and treated it may be fatal. CASE PRESENTATION: A 74-year-old male with a past medical history significant for COPD and aortic valve replacement in 2002 underwent a transapical TAVR after presenting with severe aortic insufficiency. 11 days later, the patient developed acute pleuritic chest pain and dyspnea prompting him to return to the emergency department. He was found to be hypoxic requiring 4 liters of nasal cannula and hypotensive requiring Norepinephrine. Initial work-up revealed a leukocytosis of 39.2 K and a large left pleural effusion on CT imaging. A pig-tail catheter was placed with 2 liters of straw-colored fluid removed from the left pleural space. Fluid studies revealed LDH 1163, pH 7.32, glucose of <5, and WBC 2128 suggesting empyema. Fluid cultures were sent and the patient was started on empiric antibiotics. A repeat chest CT found persistent left sided pleural effusion despite pig-tail catheter with concern for complex appearance of residual fluid. Thoracic surgery was consulted who recommended video-assisted thoracoscopic surgery (VATS) with total decortication. During his procedure a large amount of gelatinous and fibrinopurulent debris were found encasing the entire left lung. A sample of pleural peel was obtained and sent for pathology which showed fibrinopurulent exudate and granulation tissue consistent with empyema. After his procedure, the patient's clinical status continued to improve and he remained stable on room air. He was subsequently discharged home. DISCUSSION: Empyema is a rare post-surgical complication following a TAVR procedure, with few reported cases. Patients with underlying pulmonary disease are at increased risk for APCs following a TAVR procedure. APCs are most common from a trans apical approach. Patients suffering an APC following a TAVR procedure have been shown to have poorer outcomes. Because of this, Empyemas are associated with high morbidity and mortality in post TAVR patients. If not urgently treated it may be fatal. CONCLUSIONS: Empyema is an extremely uncommon complication of a trans apical approach TAVR procedure and is associated with high mortality. Physicians must keep empyema on their differential when treating acute hypoxic respiratory failure in patients with a recent TAVR. REFERENCE #1: Baillot, Richard et al. "Surgical site infections following transcatheter apical aortic valve implantation: incidence and management." Journal of cardiothoracic surgery vol. 7 122. 13 Nov. 2012, doi:10.1186/1749-8090-7-122 REFERENCE #2: Mali, Shahriar, and Hasan Haghaninejad. "Pulmonary complications following cardiac surgery." Archives of medical sciences. Atherosclerotic diseases vol. 4 e280-e285. 31 Dec. 2019, doi:10.5114/amsad.2019.91432 REFERENCE #3: Tetsuro Shimura et al. "The incidence, predictive factors and prognosis of acute pulmonary complications after transcatheter aortic valve implantation, Interactive CardioVascular and Thoracic Surgery, Volume 25, Issue 2, August 2017, Pages 191–197, https://doi.org/10.1093/icvts/ivx075 DISCLOSURES: No relevant relationships by Katie Abney, source=Web Response No relevant relationships by Zachary Fyffe, source=Web Response No relevant relationships by Kelly Rodman, source=Web Response No relevant relationships by Jon Simala, source=Web Response