Synthesis of Hydrophilic Poly(vinylpyrrolidone)/CuS Free-Standing Thin Films Exhibiting Photothermal Conversion.

Free-standing films without the need for any support materials attract attention because of their excellent flexibility in use and ability to be transferred to various substrates. However, free-standing films containing large amounts of inorganic crystalline particles are hard to achieve due to their low strength. In this study, we found the possibility of preparing a free-standing composite film of CuS/polyvinylpyrrolidone (PVP) at a large loading of CuS (>50%) from a concentrated colloidal dispersion of CuS nanoparticles modified with PVP. Despite the large amount of inorganic crystals contained in the free-standing film, the film was strong enough to be handled without any support materials. As a proof-of-concept application of the free-standing film, a solar water evaporation experiment was performed. The CuS/PVP free-standing film exhibited photothermal conversion under light illumination to generate heat and accelerate water evaporation, achieving an evaporation rate of 4.35 kg·m-2 h-1 and an evaporation efficiency of 96.3% at a power density of 3 suns. In addition, thanks to the free-standing feature, one side of the CuS/PVP film could be hydrophobized with polydimethylsiloxane to form a Janus thin film, allowing for floating on the water surface. As a result, effective water evaporation was achieved because of the selective evaporation of water from the air/water interface.

Medical student medium-term skill retention following cardiac point-of-care ultrasound training based on the American Society of Echocardiography curriculum framework.

BACKGROUND: No studies have demonstrated medium- or long-term skill retention of cardiac point-of-care ultrasound (POCUS) curriculum for medical student. Based on the American Society of Echocardiography (ASE) curriculum framework, we developed a blended-learning cardiac POCUS curriculum with competency evaluation. The objective of this study was to investigate the curriculum impact on image acquisition skill retention 8 weeks after initial training. METHODS: This study was a prospective, pre-post education intervention study for first- and second-year medical students, with blinded outcome assessment. The curriculum included a pre-training ASE online module and healthy volunteer hands-on training to obtain 5 views: parasternal long-axis (PLAX), parasternal short-axis (PSAX), apical 4-chamber (A4C), subcostal 4-chamber (S4C), and subcostal inferior vena cava (SIVC) views. Students took 5-view image acquisition skill tests at pre-, immediate post-, and 8-week post-training, using a healthy volunteer. Three blinded assessors rated the image quality using a validated 10-point maximum scoring system. Students used a hand-held ultrasound probe (Butterfly iQ). RESULTS: Fifty-four students completed hands-on training, and pre- and immediate post-training skill tests. Twenty-seven students completed 8-week post-training skill tests. Skill test score improvement between pre- and 8-week post-training was 2.11 points (95% CI, 1.22-3.00; effect size, 1.13). CONCLUSION: The cardiac POCUS curriculum demonstrated medium-term skill retention. The curriculum was sufficient for S4C and SIVC skill retention, but inadequate for PLAX, PSAX, and A4C. Therefore, instructional design modifications or re-training for PLAX, PSAX, and A4C are needed to make the curriculum more effective for clinically relevant skill retention.

Pre-clinical medical student cardiac point-of-care ultrasound curriculum based on the American Society of Echocardiography recommendations: a pilot and feasibility study.

BACKGROUND: Cardiac point-of-care ultrasound (POCUS) training has been integrated into medical school curricula. However, there is no standardized cardiac POCUS training method for medical students. To address this issue, the American Society of Echocardiography (ASE) proposed a framework for medical student cardiac POCUS training. The objective of this pilot study was to develop a medical student cardiac POCUS curriculum with test scoring systems and test the curriculum feasibility for a future definitive study. METHODS: Based on the ASE-recommended framework, we developed a cardiac POCUS curriculum consisting of a pre-training online module and hands-on training with a hand-held ultrasound (Butterfly iQ, Butterfly Network Inc., Guilford, CT, USA). The curriculum learning effects were assessed with a 10-point maximum skill test and a 40-point maximum knowledge test at pre-, immediate post-, and 8-week post-training. To determine the curriculum feasibility, we planned to recruit 6 pre-clinical medical students. We semi-quantitatively evaluated the curriculum feasibility in terms of recruitment rate, follow-up rate 8 weeks after training, instructional design of the curriculum, the effect size (ES) of the test score improvements, and participant satisfaction. To gather validity evidence of the skill test, interrater and test-retest reliability of 3 blinded raters were assessed. RESULTS: Six pre-clinical medical students participated in the curriculum. The recruitment rate was 100% (6/6 students) and the follow-up rate 8 weeks after training was 100% (6/6). ESs of skill and knowledge test score differences between pre- and immediate post-, and between pre- and 8-week post-training were large. The students reported high satisfaction with the curriculum. Both interrater and test-retest reliability of the skill test were excellent. CONCLUSIONS: This pilot study confirmed the curriculum design as feasible with instructional design modifications including the hands-on training group size, content of the cardiac POCUS lecture, hands-on teaching instructions, and hand-held ultrasound usage. Based on the pilot study findings, we plan to conduct the definitive study with the primary outcome of long-term skill retention 8 weeks after initial training. The definitive study has been registered in ClinicalTrials.gov (Identifier: NCT04083924).

Transesophageal Echocardiography Simulator Training: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

SUMMARY STATEMENT: We aimed to assess the learning effects of novice transesophageal echocardiography (TEE) simulator training and to identify gaps in existing studies. We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing the learning effects of novice TEE training with versus without simulators, searching published articles and proceedings in 6 major databases in June 2019. We included 9 RCTs (268 participants). Compared with nonsimulator training, TEE simulator training resulted in higher skill and knowledge posttraining test scores with large effect sizes (standardized mean difference = 0.81 for skill, 1.61 for knowledge; low-certainty evidence) and higher training satisfaction with a small effect size (standardized mean difference = 0.36; very low-certainty evidence). No RCTs reported training budget or patient outcomes. Additional well-designed studies with low risk of bias and large sample sizes are needed to provide reliable and robust findings and develop more effective TEE simulation-based training curricula.

Synthesis of a Crystalline and Transparent Aerogel Composed of Ni-Al Layered Double Hydroxide Nanoparticles through Crystallization from Amorphous Hydrogel.

Enormous efforts have been devoted to the development of crystalline aerogels toward heterogeneous catalysis, energy storage, ion/molecular absorption, and luminescence. However, properties of aerogels are not fully exploited due to their low content of functional moieties embedded in their solid networks, low crystallinity, and limited chemical compositions. Herein, we develop a one-pot approach based on crystallization from amorphous metal hydroxides modified with a ß-diketone ligand, toward crystalline transition-metal hydroxide aerogels. Synthesis of monolithic and crystalline aerogels of layered double hydroxide (LDH) was performed in a Ni-Al system starting from aqueous ethanol solutions of NiCl2·6H2O and AlCl3·6H2O with acetylacetone (acac) as an organic ligand. Propylene oxide (PO) as an alkalization reagent was added into precursory solutions to yield monolithic wet gels. The successive pH increase induces the formation of a three-dimensional (3-D) solid framework composed of amorphous Al(OH)3. Then, amphoteric Al(OH)3 undergoes crystallization into Ni-Al LDH via an acetylacetone-driven dissolution-crystallization of metal hydroxides without destroying the preformed 3-D solid framework. The process allows us to obtain crystalline aerogel monoliths with high porosity and high transparency after supercritical CO2 drying of wet gels. The present scheme can be expected to synthesize functionalized aerogel composed of crystalline transition-metal oxide/hydroxide nanobuilding blocks (NBBs).

Imparting CO2 reduction selectivity to ZnGa2O4 photocatalysts by crystallization from hetero nano assembly of amorphous-like metal hydroxides.

Imparting an enhanced CO2 reduction selectivity to ZnGa2O4 photocatalysts has been demonstrated by controlled crystallization from interdispersed nanoparticles of zinc and gallium hydroxides. The hydroxide precursor in which Zn(ii) and Ga(iii) are homogeneously interdispersed was prepared through an epoxide-driven sol-gel reaction. ZnGa2O4 obtained by a heat-treatment exhibits a higher surface basicity and an enhanced affinity for CO2 molecules than previously-reported standard ZnGa2O4. The enhanced affinity for CO2 molecules of the resultant ZnGa2O4 leads to highly-selective CO evolution in CO2 photo-reduction with H2O reductants. The present scheme is promising to achieve desirable surface chemistry on metal oxide photocatalysts.

Dendrigraft polylysine coated-poly(glycolic acid) fibrous scaffolds for hippocampal neurons.

Poly(glycolic acid) (PGA) fibers are a good candidate material for nerve cell scaffolds, which is applicable to the treatment of peripheral nerve injuries. Polylysine is widely used as a coating material for cell substrates to promote nerve cell adhesion. In this study, linear and dendrigraft polylysines were used to coat PGA fibers. The association of large dendrigraft polylysines with PGA fibers was lower and unstable, compared with linear polylysine. However, more hippocampal neurons adhered to PGA fibers coated with large dendrigraft polylysine than linear polylysine. Enhanced cell adhesion was observed, even when the dendrigraft polylysine was coated on the PGA fibers at a low concentration (0.05 µg/mL) or when it was coated in water instead of alkaline buffer. Differences in cell adhesion properties were seen between the dendrigraft polylysine coating and a laminin coating. Thus, large dendrigraft polylysines are a useful coating material for nerve cell scaffolds. © 2016 Wiley Periodicals, Inc. J Biomed Mater Res Part A: 104A: 2744-2750, 2016.

Efficacy and Safety Evaluation of Tolvaptan on Management of Fluid Balance after Cardiovascular Surgery Using Cardiopulmonary Bypass.

Background: Tolvaptan is an orally administered selective vasopressin 2 receptor antagonist that promotes aquaresis. This study aimed to evaluate the efficacy and safety of tolvaptan on management of systemic fluid balance after cardiovascular surgery using cardiopulmonary bypass. . Methods: Sixty-four patients who underwent cardiovascular surgery using cardiopulmonary bypass in our hospital were enrolled for this prospective, randomized study. These patients were divided into three groups: tolvaptan 15 mg+furosemide 20 mg (TH group), tolvaptan 7.5 mg+furosemide 20 mg (TI group), and furosemide 40 mg+spironolactone 50 mg (C group). The endpoint was safety management of systemic fluid balance using tolvaptan without renal dysfunction and electrolyte imbalance. Results: The mean daily urine output in the TH and TL groups (2656±767 and 2505 ±684 mL) was significantly higher than that in the C group (1956±494 mL, TH vs C: p<0.01 and TL vs C: p=0.03). The lowest serum sodium level during medication in the TH group (139.3 ±2.3 mEq/L) was significantly higher than that in the C group (137.1±2.9 mEq/L, p=0.03) The lowest serum osmolality during medication in the TH group was significantly higher than that in the C group (284.8 ±4.3 vs 279.5± 6.3 mOsm/kg, p<0.01). None had critical hypernatremia, hyperosm6lality, or renal dysfunction in any. of the groups. Conclusions: Tolvaptan exerts, a strong diuretic effect compared with conventional diuretics (furosemide and spironolactone) during the postoperative period after an operation using cardiopulmonary bypass without adverse effects on electrolyte balance and renal function.

[Surgical treatment for pseudoaneurysm of the sinus of valsalva ruptured into the right atrium after mycotic right coronary artery aneurysm repair;report of a case].

A 67-year-old man was admitted to our hospital by ambulance after syncope due to complete A-V block. He had received surgical treatment for mycotic aneurysm of the right coronary artery 3 months before, with patch plasty of the right sinus of Valsalva and bypass grafting to the right coronary artery (RCA) as well as the left anterior descending branch. Computed tomography revealed pseudoaneurysm of the right Valsalva sinus of about 8 cm in diameter and a shunt flow to the right atrium. The previous bypass graft to RCA had been occluded due to compression by the aneurysm. As he was in a shock state, emergency operation was performed. Cardiopulmonary bypass was first established, and after the rectal temperature reached to 26 degrees centigrade, the chest was opened. The pseudoaneurysm burst out when the sternum was re-opened. Under circulatory arrest, the ascending aorta was clamped, and then the circulation was resumed. The previous bovine pericardium patch repairing the Valsalva sinus was detached due to infection, and mural thrombus and pus were observed in the aneurysm. At the bottom of the aneurysm, a fistula connected to the right atrium was found. Debridement around the aneurysm was performed as much as possible. The defect of the Valsalva sinus was repaired with a Dacron patch immersed in gentian violet. The postoperative course was uneventful without any recurrence of infection.

X-ray phase-contrast computed tomography visualizes the microstructure and degradation profile of implanted biodegradable scaffolds after spinal cord injury.

Tissue engineering strategies for spinal cord repair are a primary focus of translational medicine after spinal cord injury (SCI). Many tissue engineering strategies employ three-dimensional scaffolds, which are made of biodegradable materials and have microstructure incorporated with viable cells and bioactive molecules to promote new tissue generation and functional recovery after SCI. It is therefore important to develop an imaging system that visualizes both the microstructure of three-dimensional scaffolds and their degradation process after SCI. Here, X-ray phase-contrast computed tomography imaging based on the Talbot grating interferometer is described and it is shown how it can visualize the polyglycolic acid scaffold, including its microfibres, after implantation into the injured spinal cord. Furthermore, X-ray phase-contrast computed tomography images revealed that degradation occurred from the end to the centre of the braided scaffold in the 28 days after implantation into the injured spinal cord. The present report provides the first demonstration of an imaging technique that visualizes both the microstructure and degradation of biodegradable scaffolds in SCI research. X-ray phase-contrast imaging based on the Talbot grating interferometer is a versatile technique that can be used for a broad range of preclinical applications in tissue engineering strategies.

Successful surgical treatment of traumatic transection of the innominate artery: a case report.

Blunt traumatic injury to the innominate artery is relatively rare. We present the case of a 40-year-old woman who fell from a fourth-floor window and was transferred to our hospital with multiple injuries, hemodynamic shock, and disturbance of consciousness. Computed tomography with image reconstruction revealed transection of the innominate artery near its origin. Emergent surgery required establishment of cardiopulmonary bypass before sternotomy in preparation for uncontrollable hemorrhage. Proximal aortic arch replacement with a branch to the right axillary artery was successfully performed using circulatory arrest and selective cerebral perfusion.

Atomic sites and stability of Cs+ captured within zeolitic nanocavities.

Zeolites have potential application as ion-exchangers, catalysts and molecular sieves. Zeolites are once again drawing attention in Japan as stable adsorbents and solidification materials of fission products, such as (137)Cs(+) from damaged nuclear-power plants. Although there is a long history of scientific studies on the crystal structures and ion-exchange properties of zeolites for practical application, there are still open questions, at the atomic-level, on the physical and chemical origins of selective ion-exchange abilities of different cations and detailed atomic structures of exchanged cations inside the nanoscale cavities of zeolites. Here, the precise locations of Cs(+) ions captured within A-type zeolite were analyzed using high-resolution electron microscopy. Together with theoretical calculations, the stable positions of absorbed Cs(+) ions in the nanocavities are identified, and the bonding environment within the zeolitic framework is revealed to be a key factor that influences the locations of absorbed cations.

Does rich coronary collateral circulation distal to chronically occluded left anterior descending artery compete with graft flow?

OBJECTIVES: In coronary artery bypass grafting (CABG), graft flow distal to a mild stenosis can compete with relatively preserved native flow through the stenosis and the competition can result in graft stenosis. In chronic total occlusion (CTO), coronary collateral circulation, which is essential to maintain myocardial viability distal to CTO, varies in extent among patients and the extent can be scored by Rentrop grade in coronary angiography. We investigated whether rich collateral circulation distal to CTO competes with distally anastomosed graft flow in association with Rentrop grade. METHODS: Of 666 patients who underwent CABG from January 2001 to December 2012, 70 patients whose left internal thoracic artery (ITA) was grafted distal to CTO in the left anterior descending artery (LAD) were divided into three groups: Poor collaterals (Rentrop grades 0 and 1, Group P, n = 22), Moderate collaterals (grade 2, Group M, n = 23) and Rich collaterals (grade 3, Group R, n = 25). The intraoperative measurements of mean graft flow (MGF) and pulsatility index (PI) of left ITA grafts, early graft patency and long-term clinical outcomes were compared. RESULTS: The MGF and PI of left ITA grafts differed significantly among the three groups (P = 0.025 and P = 0.046, respectively). Lower Rentrop grade was associated with preferable results of higher MGF and lower PI. The graft flow pattern in Group P showed a significantly higher MGF (P = 0.020) and lower PI (P = 0.041) than those in Group R. All early postoperative coronary angiograms showed patent left ITA grafts. Serial echocardiographic evaluations, survival rates and cardiac event-free rates were comparable with the follow-up of 5.00 ± 3.11 years. CONCLUSIONS: Rich collateral circulation distal to CTO in LADs can potentially compete with graft flow, although the competition seems not to affect clinical outcomes probably due to the regression of collaterals surmounted by the graft flow. Rentrop grade is shown to certainly reflect the degree of collateral haemodynamic circulation distal to CTO and especially important to evaluate intraoperative graft flow appropriately, considering the possible phenomenon of graft flow competition.

Network topology for the formation of solvated electrons in binary CaO-Al2O3 composition glasses.

Glass formation in the CaO-Al2O3 system represents an important phenomenon because it does not contain typical network-forming cations. We have produced structural models of CaO-Al2O3 glasses using combined density functional theory-reverse Monte Carlo simulations and obtained structures that reproduce experiments (X-ray and neutron diffraction, extended X-ray absorption fine structure) and result in cohesive energies close to the crystalline ground states. The O-Ca and O-Al coordination numbers are similar in the eutectic 64 mol % CaO (64CaO) glass [comparable to 12CaO·7Al2O3 (C12A7)], and the glass structure comprises a topologically disordered cage network with large-sized rings. This topologically disordered network is the signature of the high glass-forming ability of 64CaO glass and high viscosity in the melt. Analysis of the electronic structure reveals that the atomic charges for Al are comparable to those for Ca, and the bond strength of Al-O is stronger than that of Ca-O, indicating that oxygen is more weakly bound by cations in CaO-rich glass. The analysis shows that the lowest unoccupied molecular orbitals occurs in cavity sites, suggesting that the C12A7 electride glass [Kim SW, Shimoyama T, Hosono H (2011) Science 333(6038):71-74] synthesized from a strongly reduced high-temperature melt can host solvated electrons and bipolarons. Calculations of 64CaO glass structures with few subtracted oxygen atoms (additional electrons) confirm this observation. The comparable atomic charges and coordination of the cations promote more efficient elemental mixing, and this is the origin of the extended cage structure and hosted solvated (trapped) electrons in the C12A7 glass.

Is elimination of cardiotomy suction preferable in aortic valve replacement? Assessment of perioperative coagulation, fibrinolysis and inflammation.

OBJECTIVES: Guidelines recommend the avoidance of direct return of pericardial blood based on evidence from coronary surgery. A continuous auto-transfusion system (CATS) can be a good alternative to cardiotomy suction by reinfusing aspirated pericardial blood without the necessity of intermittent collection. To clarify the effects of direct return of pericardial blood in aortic valve replacement (AVR), we compared the effects of cardiotomy suction and an alternative CATS on perioperative coagulofibrinolysis and inflammation systems, and clinical outcomes. METHODS: In 40 AVR operations between April 2009 and April 2011, the retransfusion method of pericardial blood during cardiopulmonary bypass (CPB) was allocated to the use of cardiotomy suction (non-Cell-Saver group, n = 20) or CATS (Cell-Saver group, n = 20) under identical protocols of anticoagulation and transfusion. The blood from the left ventricular vent was returned to the venous reservoir. We obtained blood samples at nine points up to the morning after surgery. RESULTS: Perioperative values for coagulofibrinolysis markers, such as thrombin-antithrombin III complex, fibrinogen degeneration products, D-dimer and plasmin-α2 plasmin inhibitor complex, were significantly lower in the Cell-Saver group than those in the non-Cell-Saver group from 1 h after the initiation of cardiopulmonary bypass to 3 or 6 h after termination of cardiopulmonary bypass (P < 0.05 for all markers). A fibrinolysis inhibition marker of plasminogen activator inhibitor-1 and the inflammation markers of interleukin-6, 8 and 10 as well as tumour necrosis factor-α were not significantly different. The amount of packed red blood cells required after the termination of CPB was significantly less in the Cell-Saver group compared with that in the non-Cell-Saver group (P = 0.004). There were no significant differences in the other clinical outcomes between the two groups. CONCLUSIONS: In AVR, the avoidance of direct return of pericardial blood induced considerable suppressions of coagulofibrinolysis responses. A CATS is a favourable alternative for managing pericardial blood during cardiopulmonary bypass. Our results support the published guidelines and could help to establish ideal strategies for eliminating the use of cardiotomy suction, thus facilitating less-invasive valve surgeries with marked suppression of coagulofibrinolysis responses.

[Axillo-axillary bypass for coronary-subclavian steal syndrome].

We describe a case of coronary-subclavian steal syndrome in a 77-year-old man who presented with progressive coronary ischemia 8 years after coronary artery bypass grafting with an in-situ left internal thoracic artery graft. Coronary and left subclavian artery angiogram revealed completely patent internal thoracic artery graft and 90% stenosis in the proximal left subclavian artery. We performed axilloaxillary artery bypass using expanded polytetrafluoroethylene (ePTFE)[8 mm] graft. No coronary ischemia was noted postoperatively. Axillo-axillary artery bypass grafting was effective for coronary subclavian steal syndrome.

Adding coronary artery bypass grafting to aortic valve replacement increases operative mortality for elderly (70 years and older) patients with aortic stenosis.

OBJECTIVE: This retrospective study aimed to determine the effect of simultaneous aortic valve replacement (AVR) and coronary artery bypass grafting (CABG) on operative outcomes and long-term survival in elderly patients with a high prevalence of comorbidity. METHODS: One hundred and fifty-seven elderly patients (70 years old or older) undergoing isolated AVR (n = 120) or combined AVR/CABG (n = 37) were evaluated. Operative outcomes were compared between the two surgical groups. Long-term survival was also compared between the groups using the Kaplan-Meier method and long-rank (Mantel-Cox) test. RESULTS: Operative mortality was 0.8 % for the isolated AVR group and 5.4 % for the combined AVR/CABG group (p = 0.076). The length of the intensive care unit stay for the combined AVR/CABG group was significantly longer than that for the isolated AVR group (median: 40 vs. 21 h, p = 0.008). However, the occurrence rate of hospital complications, such as reoperation for bleeding, deep sternal infection, supra-ventricular arrhythmia, and neurological complications, was similar between the two groups. Actuarial survival at 3 and 5 years was 82.3 and 80.9 % for the isolated AVR group, and 88.3 and 73.0 % for the combined AVR/CABG group, respectively (p = 0.637). CONCLUSIONS: The satisfactory operative and long-term results in our study support a more aggressive simultaneous coronary revascularization combined with AVR for aortic valve stenosis in elderly patients.

Paclitaxel-loaded hydroxyapatite/collagen hybrid gels as drug delivery systems for metastatic cancer cells.

Hydroxyapatite (HA) is a biocompatible and porous inorganic material that can behave as an effective drug carrier. In this study, HA nanoparticles were prepared according to the hydrothermal method and used as a drug carrier for a water-insoluble anticancer drug, paclitaxel (Tax). The absorption of Tax onto the HA was dependent on the solvent composition. The Tax-loaded HA (Tax/HA) exhibited a lower level of activity than the free Tax because the HA material was not stably dispersed in aqueous media. The Tax/HA was therefore embedded in a collagen gel to give the Tax/HA-embedded collagen gel (Tax/HA/Col), which exhibited a higher level of activity than the Tax-containing collagen gel (Tax/Col). Interestingly, the highly metastatic MDA-MB-231 cells were more sensitive to the Tax/HA/Col than the poorly metastatic MCF-7 cells. Tax/HA/Col is therefore useful for the drug delivery into metastatic cancer cells.

Risk factors for late valve-related mortality after aortic valve replacement in elderly patients.

PURPOSE: Few recent studies have examined the long-term outcomes after aortic valve replacement (AVR), and independent predictors for long-term survival and valve-related mortality have not been elucidated. METHODS: From January 1993 to December 2009, 132 elderly patients (≥70 years old) with aortic stenosis underwent AVR in our hospital. The patients comprised 61 men and71 women with a mean age of 76.1 ± 3.7 years. Patients with acute or old myocardial infarction, mitral valve disease, and re-do surgery were not included in this study. Risk factors for late valve-related mortality were examined. RESULTS: The 5-year freedom from valve-related mortality rate was 89.6%. The following significant independent risk factors for late valve-related mortality were identified:increase in the preoperative left ventricular mass index (hazard ratio, 1.10 [per 10 g/m(2)];p = 0.040); lack of sinus rhythm (hazard ratio, 7.11; p = 0.005); peak transvalvular pressure gradient of <60 mmHg (hazard ratio, 7.48; p = 0.008). CONCLUSION: In the elderly, AVR should be performed at an early stage of aortic stenosis, before an increase in the left ventricular mass index has occured, and while the heart rhythm is in sinus rhythm and the peak transvalvular pressure gradient is high.