376 Incomplete functional revascularization is associated with adverse clinical outcomes after TAVI

Aims Whether incomplete functional revascularization has an impact on the clinical outcome of patients treated with transcatheter aortic valve implantation (TAVI) is still unknown. We aim to assess the prognostic value of residual functional Syntax score (rFSS) in a cohort of patients undergoing TAVI. Methods and results One-hundred-twenty-four patients (229 lesions) with severe aortic stenosis and coronary artery disease (CAD) underwent fractional flow reserve (FFR)-guided revascularization. The primary endpoint of the study was the composite of cardiac death, myocardial infarction and revascularization at last available follow-up after TAVI. Median Syntax score (SS) and Functional Syntax score (FSS) at baseline were 7 (range 5–12) and 0 (range 0–7) respectively. After revascularization or deferral according to FFR, residual SS (rSS) and rFSS were 5 (range 0–8) and 0 (range 0–0), respectively. At COX regression analysis, angiographic incomplete revascularization (rSS = 0) was not associated with the primary endpoint (HR: 1.26; 95% CI: 0.40; 3.95; P-value 0.698), whereas functional incomplete revascularization was associated with worse event-free survival at Follow-up after adjusting for clinical confounders (HR: 3.74, 95% CI: 1.02–13.75, P = 0.047). Conclusions Incomplete functional revascularization is associated with adverse clinical outcome after TAVI. rFSS may be regarded as a treatment goal for patients with CAD undergoing TAVI. Further studies are warranted to confirm our hypothesis. 376 Central FigureMACEs free survival analysis of patients stratified according to complete revascularization vs. incomplete revascularization assessed according to anatomy (residual SYNTAX score) (A) or physiology (residual functional SYNTAX score) (B).

Transcavernous Approach to the Anteromedial Triangle for Residual Functional Pituitary Adenoma

Surgical treatment of functional pituitary adenomas is as rule performed by transsphenoidal approach. However, when then lesion invades the parasellar structures and the cavernous sinus, the transsphenoidal removal of these adenomas is usually incomplete. In this video, we present the technical nuances of a transcavernous approach to the anterio-medial triangle for the resection of a residual functional pituitary adenoma. The patient is a 40-year-old male who was diagnosed with growth hormone secreting pituitary macroadenoma. He underwent two transsphenoidal resections in 2013 and 2016 with a small residue in the left cavernous sinus. Subsequently, due to a failure of biochemical remission despite medical management, a transcranial transcavernous surgery was performed. Brain magnetic resonance imaging showed a mass in the roof of the left cavernous sinus, located at the level of the anteromedial triangle, adherent to the clinoidal segment of the internal carotid artery (ICA). The computed tomographic scan showed an osteolysis of the inferior surface of the anterior clinoidal process. After performing an extended pterional craniotomy and an extradural clinoidectomy, the cleavage plane is extended between the temporal dura and the inner layer of the lateral wall of the cavernous sinus. Intraoperative Doppler and stimulation are used to localize the clinoidal segment of the ICA and the third cranial nerve, delimiting the anteromedial triangle. The lesion is progressively dissected and removed. An optic neuropexy with the previously harvested fat is performed in case of a complementary radio surgical treatment. The patient had an uneventful postoperative course and showed a biochemical remission at the 3-month follow-up.The link to the video can be found at: https://youtu.be/oHfugVtU-Nc.

SIMULATION AND PARAMETERS-IDENTIFICATION METHODS OF HETEROGENEOUS ABNORMAL NEUROLOGICAL MOVEMENTS IN MULTICOMPONENT NEURO-BIOSYSTEMS WITH COGNITIVE FEEDBACK

The foundations of mathematical modeling and identification of parameters of heterogeneous abnormal neurological movements (ANM) in multicomponent neuro-biosystems with cognitive feedback have been developed. Based on the methods of integral transformations and spectral analysis developed by the authors for heterogeneous media, a new approach to the construction of hybrid models of wave signal propagation is proposed that describes unwanted tremors of the patient's arm (T-object) as a result of an unconstrained contraction of skeletal muscles due to the cognitive effects of a certain group of neural nodes in the cortex cerebral (CC). A hybrid model of a neuro-biosystem is developed, which describes the state and behavior, namely, the segment-by-segment description of 3D elements of the ANM trajectories of the T-object, taking into account the matrix of cognitive influences of the groups of neuro nodes of the CC. On the basis of hybrid integral Fourier transforms a high-speed analytical vector solution of the model is obtained, which describes the elements of the trajectories on each AND-segment. A new method for calculating of hybrid spectral function, spectral values and matrix of cognitive influences of CC neuronodes is proposed, which determine hybrid integral transformation of solution construction. New non-classical problems of multi-parameter identification of neuro-feedback systems in heterogeneous media based on minimization of the residual functional between observation trajectories and their model analogs are formulated and solved. High-performance algorithms of the amplitude-frequency characteristics identifying of a feedback-system in analytical expressions for the gradients of the residual functional have been constructed, which allow parallel-computations on multicore computers. Computer modeling and identification of ANM trajectories of the studied neuro-feedback-system have been performed.

Evaluation of Surgical Complications in a University Hospital: A Novel Root Cause Analysis Classification

Objective: To analyze general surgery morbidity and mortality in King Chulalongkorn Memorial Hospital to identify the preventability and root causes of the complications using a novel root cause analysis (RCA) classification according to the period that the corrective action could have been introduced to prevent the complications. Materials and Methods: The authors retrospectively reviewed the morbidity and mortality between October 2012 and October 2016. The data collection included diagnostic groups, organ systems, severity, preventability, and RCA of the complications. Functional outcomes of the patients were also obtained such as full recovery, residual functional impairment, and death. Results: Six hundred seventy-six surgical complications occurred out of 19,440 surgeries performed (3.47%) during the study period. The most common organ system involved was gastrointestinal system (42.8%), followed by wound complications (18.9%). According to the Clavien-Dindo classification, the severity of the complications was 20.7% as grade 1, 18.9% as grade 2, 41.6% as grade 3, 3.7% as grade 4, and 15.1% as grade 5. The authors classified 27 complications as preventable (4.0%), 573 as potentially preventable (84.8%), and 76 as unpreventable (11.2%). RCA of the preventable and potentially preventable complications using the present RCA classification revealed that root causes were defect in the diagnoses (0.5%), defect in management decision making (5.0%), defect in preoperative management (6.1%), defect in intraoperative management (61.3%), and defect in postoperative management (27.0%). The most common defect in intraoperative management was inappropriate surgical approach or technique (58.7%). Most patients (80.2%) fully recovered from the complications, while 4.7% had residual functional impairment, and 15.1% died. Conclusion: The present study demonstrated that most complications in general surgery were preventable or potentially preventable. RCA showed that the most common root cause was the defect is intraoperative management, especially inappropriate surgical approach or technique. Keywords: Surgical complications; Root cause analysis; Morbidity and mortality conference

A Common Approach and Low Vision Rehabilitation in Patients with Hereditary Retinal Diseases

The goal of low vision rehabilitation is to produce people who are independent, have an economically viable profession or skill, and are able to enjoy their lives. Patients with hereditary retinal dystrophies are candidates for low vision rehabilitation from the time of diagnosis, since their disease shows a progressive course, there is no proven precise treatment and the disease especially seriously affects the vision of individuals of school age and productive age. The stages of modern low vision rehabilitation include the intake interview, assessment of residual visual functions, assessment of residual functional vision, interventions and recommendations, and vision rehabilitation therapies.

Analysis on hospitalizations for cerebral vascular accident in the several regions of Brazil: Epidemiological Study

Introduction: Stroke is one of the most relevant public health problems, be ing one of the most prevalent pathologies and one of the main causes of tem porary or permanent disability. Stroke patients are discharged from the hospi tal with sequelae such as inability to communicate, triggering social isolation and consequent depressive conditions. In addition, you may develop residual functional disability that is a source of dependency in activities of daily living. Objective: To analyze the prevalence of hospitalizations for stroke in different regions of Brazil, for a better understanding of this pathology. Methods: The study carried out was an epidemiological study. Statistical data from the database of the Department of Informatics of the Unified Health System (DATASUS), from February 2020 to February 2021, were used, using the unspecified hemorrhagic or ischemic stroke filters, North region, Northeast, South, Southeast and Midwest. Results: The regions with the highest incidence were the Southeast region, followed by the Northeast region, between February 2020 and February 2021. The total number of cases was 163209. Thus, the representative percentage of hospitalizations in the Southeast region was 43, 11% of total hospitalizations for the entire period. In the Northeast region, it was 27.26%. Conclusion: Thus, according to the results presented, it is concluded that the high est incidence of cases is in the Southeast, followed by the Northeast. This fact may be closely related to risk factors and quality of life. Therefore, the knowledge of this statistic is extremely important so that interventions can be developed to mitigate this case.

Cognitive Fatigue Is Associated with Altered Functional Connectivity in Interoceptive and Reward Pathways in Multiple Sclerosis

Cognitive fatigue is common and debilitating among persons with multiple sclerosis (pwMS). Neural mechanisms underlying fatigue are not well understood, which results in lack of adequate treatment. The current study examined cognitive fatigue-related functional connectivity among 26 pwMS and 14 demographically matched healthy controls (HCs). Participants underwent functional magnetic resonance imaging (fMRI) scanning while performing a working memory task (n-back), with two conditions: one with higher cognitive load (2-back) to induce fatigue and one with lower cognitive load (0-back) as a control condition. Task-independent residual functional connectivity was assessed, with seeds in brain regions previously implicated in cognitive fatigue (dorsolateral prefrontal cortex (DLPFC), ventromedial prefrontal cortex (vmPFC), dorsal anterior cingulate cortex (dACC), insula, and striatum). Cognitive fatigue was measured using the Visual Analogue Scale of Fatigue (VAS-F). Results indicated that as VAS-F scores increased, HCs showed increased residual functional connectivity between the striatum and the vmPFC (crucial in reward processing) during the 2-back condition compared to the 0-back condition. In contrast, pwMS displayed increased residual functional connectivity from interoceptive hubs—the insula and the dACC—to the striatum. In conclusion, pwMS showed a hyperconnectivity within the interoceptive network and disconnection within the reward circuitry when experiencing cognitive fatigue.

Residual functional SYNTAX score by quantitative flow ratio and improvement of exercise capacity after revascularization in patients with stable ischemic heart disease

Background In patients with stable ischemic heart disease (SIHD), the efficacy of percutaneous coronary intervention (PCI) in improving exercise capacity has been under debate and the differential effect of PCI for exercise capacity, according to functional completeness of revascularization, has not been evaluated. Purpose This study aimed to evaluate the association between improvement in exercise capacity and functional completeness of revascularization, determined by residual functional SYNTAX score (rFSS), which is the sum of residual SYNTAX score of the vessels with post-PCI quantitative flow ratio (QFR)≤0.80. Methods Among patients enrolled in the QFR multicenter registry, 110 patients who underwent prespecified routine exercise treadmill tests before and after PCI were analyzed. Patients were classified into functional complete revascularization (CR) group (rFSS=0) and functional incomplete revascularization (IR) group (rFSS≥1). Increase of exercise time after PCI was compared between the 2 groups. Improvement of exercise capacity was defined as ≥10% increase of exercise time after PCI. Results Functional CR was achieved in 79 patients (71.8%), otherwise classified as functional IR in 31 patients (18.2%). There were no significant differences in baseline characteristics including medication profiles. Increase of exercise time was significantly associated with increase of 3-vessel QFR (r=0.198, P=0.038) and rFSS (r=−0.312, P<0.001), but not with decrease of SYNTAX score (r=0.097, P=0.313). The rFSS showed significantly higher c-index to predict the improvement of exercise capacity after PCI than increase of 3-vessel QFR or decrease of SYNTAX score (0.722 vs. 0.627 vs. 0.492, respectively, P<0.001). Patients with functional CR, defined by rFSS, showed significantly higher increase of exercise time than those with functional IR (97.7 sec vs. 12.5 sec, P<0.001). Functional CR was an independent predictor of the improvement of exercise capacity after PCI (adjusted odds ratio 4.656, 95% CI 1.678–12.920, P=0.002). Conclusions Integrated anatomic and functional scoring system (rFSS) was significantly associated with improvement of exercise capacity after PCI. SIHD patients with functional CR, defined by rFSS, showed significantly higher exercise capacity after PCI than those with functional IR. Summarizing Figure Funding Acknowledgement Type of funding source: Private company. Main funding source(s): SaeHan NK & D and Medis Corporation