PURPOSE: A method and system controlling user's experience of application in a client device ... more PURPOSE: A method and system controlling user's experience of application in a client device are provided to perform customization of the application by making resident client entities negotiate with client execution entities or servers. CONSTITUTION: Operation of application according to defined regulation is modified in a client device by negotiation between resident entities. The application performs rendering(508) in the client device based on the defined regulations by using the resident client entities. At least one of the resident client entities is a client execution entity. The client execution entity is a browser engine. [Reference numerals] (501) Monitoring application/data flow from user interface; (502) Acquiring application trigger; (503) Triggering negotiation by resident client entity; (504) Negotiation between resident client entity and remote host for controlling application/data being rendered; (505) Application is not customized?; (506) Transmitting application to resident client entity for customization; (507) Transmitting application to client executing entity; (508) Rendering application
Continuous flow left ventricular assist devices (LVAD) are emerging to become the standard of car... more Continuous flow left ventricular assist devices (LVAD) are emerging to become the standard of care for the treatment of advanced heart failure. However, knowledge of normal values for transthoracic echocardiographic (TTE) examination and measurements in these patients are lacking. Methods: We retrospectively analyzed all TTE examinations in 63 consecutive patients, performed at 90 and 180 days after surgery with implantation of a HeartMate II continuous flow LVAD between February 2007 and January 2010. All patients had to be considered stable on LVAD therapy, without the need for inotropic support at the time of examination. Results: End diastolic and end systolic diameters, and left ventricle mass decreased considerably. Mitral inflow deceleration time prolonged, left atrial volume and E/e' ratio decreased, all consistent with decreased left ventricular filling pressure. Estimated right ventricular (RV), and right atrial pressure decreased significantly. Quantitatively estimated RV function and the right...
Left ventricular assist devices (LVADs) have been used to treat advanced heart failure refractory... more Left ventricular assist devices (LVADs) have been used to treat advanced heart failure refractory to medical management, as bridge therapy to myocardial recovery, as bridge therapy to cardiac transplantation, or as destination therapy for patients with unfavorable transplant candidacy. Neurologic complications are some of the most common and devastating complications in these patients. Preoperative carotid ultrasound is, therefore, a standard evaluation in patients at risk for cerebrovascular disease. Postoperative carotid artery Doppler sonography is performed in those patients with neurologic symptoms. It is likely, therefore, that sonographers, radiologists, and other physicians working in a center where LVADs are implanted will likely encounter a carotid artery Doppler study in this patient group. To our knowledge, the carotid Doppler findings in these patients have never been published. We review the Doppler ultrasound findings in 6 patients after LVAD insertion.
Journal of the American Society of Echocardiography, 2011
Background: Continuous-flow left ventricular assist devices (LVADs) have become part of the stand... more Background: Continuous-flow left ventricular assist devices (LVADs) have become part of the standard of care for the treatment of advanced heart failure. However, knowledge of normal values for transthoracic echocardiographic examination and measurements in these patients are lacking. Methods: All transthoracic echocardiographic examinations in 63 consecutive patients, performed 90 and 180 days after surgery with the implantation of a HeartMate II continuous-flow LVAD between February 2007 and January 2010, were retrospectively analyzed. All patients had to be outpatients at 3 and 6 months after surgery and considered stable on LVAD therapy (New York Heart Association class I or II and no need for inotropes, intravenous furosemide, or hospitalization). Results: End-diastolic and end-systolic diameters and left ventricular mass decreased considerably compared with baseline measurements before LVAD implantation. Mitral inflow deceleration time increased (188 6 70 vs 132.5 6 27 msec, P = .009) and left atrial volume (84.1 6 33 vs 141.7 6 62 mL, P = .003) and E/e 0 ratio decreased (20.3 6 9 vs 26 6 11, P = .01), all consistent with decreased left ventricular filling pressure. Estimated right ventricular (RV) and right atrial pressure decreased significantly (34.1 6 10 vs 51.7 6 14 mm Hg and 9.5 6 5 vs 14.4 6 5 mm Hg, respectively, P < .0001 for both). Quantitatively estimated RV function (P = .02), RV fractional area change (27.9 6 10% vs 37.4 6 10.9%, P < .0001), and the RV index of myocardial performance (0.32 6 0.1 vs 0.65 6 0.2 vs 0.32 6 .01, P < .0001) improved, suggesting improved RV efficiency. LVAD therapy resulted in significant decreases in the severity of mitral regurgitation. Tricuspid regurgitation improved in patients who had concurrent tricuspid surgical correction and was unchanged otherwise. Aortic regurgitation severity increased 3 months after LVAD implantation. There were no significant differences in any of the echocardiographic parameters in the 6-month evaluation compared with the 3-month evaluation. Conclusions: This is the first report of selected typical echocardiographic values in a group of stable patients with normally functioning HeartMate II continuous-flow LVADs. A stable functioning continuous LVAD is associated with evidence of efficient unloading of the left ventricle, improved RV function, significant improvement in mitral regurgitation, improvement in tricuspid regurgitation only in patients undergoing repair, and increased aortic regurgitation. These normal data provide a basis for future echocardiographic studies after LVAD implantation.
Diagnosing a paradoxical embolism is challenging, and it can be proven only if the thrombus is id... more Diagnosing a paradoxical embolism is challenging, and it can be proven only if the thrombus is identified across the intracardiac defect. Very few cases have been diagnosed as an impending paradoxical embolism. Recently, the diagnosis and management of these entities have greatly improved with the advent of transesophageal echocardiography (compared with transthoracic echocardiography). Pulmonary hypertension may cause right-to-left shunting across a patent foramen ovale and predispose development of a paradoxical embolism. We report a patient with an impending paradoxical embolism that was caught in transit across the patent foramen ovale. The patient was treated successfully with emergent surgery.
Background. We sought to evaluate freedom from reinfection after surgery for infected aortic root... more Background. We sought to evaluate freedom from reinfection after surgery for infected aortic root replacement (ARR) and the impact of use of synthetic material at reoperation. Methods. Adult patients (aged more than 18 years) undergoing surgery for infected composite aortic root prosthesis at our institution were identified and their perioperative outcomes and late survival evaluated. Results. Between January 1, 1993, and December 31, 2009, 15 patients (male, 87%; mean [SD] age, 57 [16] years) underwent surgery. All but 1 patient (6.7%) underwent reconstruction with a homograft. Eight patients (53.3%) required synthetic material to complete the repair, including 4 patients who underwent hemiarch reconstruction. Ten patients (66.7%) had circulatory arrest (mean [SD] time, 23.3 [11.0] minutes) and 3 (20.0%) underwent concomitant coronary artery bypass grafting. The 30-day mortality rate was 13.3% (n ؍ 2). Three patients (20.0%)-2 of whom had positive blood cultures in hospital after redo ARR-had reinfection, for which 2 underwent re-replacement of the aortic root. Survival was 86.7%, 65.0%, and 50.6%, and freedom from reinfection was 90.9%, 79.5%, and 79.5% at 3, 6, and 12 months, respectively. Freedom from reinfection was less for the patients who had positive blood cultures within 2 weeks of redo ARR (p < 0.03) and for patients who had multiple previous sternotomies (p ؍ 0.006). Use of synthetic graft material had no adverse impact. Conclusions. Infected ARR prostheses can be replaced with a homograft with favorable outcomes. Use of synthetic material to complete the repair does not adversely impact outcome.
PURPOSE: A method and system controlling user's experience of application in a client device ... more PURPOSE: A method and system controlling user's experience of application in a client device are provided to perform customization of the application by making resident client entities negotiate with client execution entities or servers. CONSTITUTION: Operation of application according to defined regulation is modified in a client device by negotiation between resident entities. The application performs rendering(508) in the client device based on the defined regulations by using the resident client entities. At least one of the resident client entities is a client execution entity. The client execution entity is a browser engine. [Reference numerals] (501) Monitoring application/data flow from user interface; (502) Acquiring application trigger; (503) Triggering negotiation by resident client entity; (504) Negotiation between resident client entity and remote host for controlling application/data being rendered; (505) Application is not customized?; (506) Transmitting application to resident client entity for customization; (507) Transmitting application to client executing entity; (508) Rendering application
Continuous flow left ventricular assist devices (LVAD) are emerging to become the standard of car... more Continuous flow left ventricular assist devices (LVAD) are emerging to become the standard of care for the treatment of advanced heart failure. However, knowledge of normal values for transthoracic echocardiographic (TTE) examination and measurements in these patients are lacking. Methods: We retrospectively analyzed all TTE examinations in 63 consecutive patients, performed at 90 and 180 days after surgery with implantation of a HeartMate II continuous flow LVAD between February 2007 and January 2010. All patients had to be considered stable on LVAD therapy, without the need for inotropic support at the time of examination. Results: End diastolic and end systolic diameters, and left ventricle mass decreased considerably. Mitral inflow deceleration time prolonged, left atrial volume and E/e' ratio decreased, all consistent with decreased left ventricular filling pressure. Estimated right ventricular (RV), and right atrial pressure decreased significantly. Quantitatively estimated RV function and the right...
Left ventricular assist devices (LVADs) have been used to treat advanced heart failure refractory... more Left ventricular assist devices (LVADs) have been used to treat advanced heart failure refractory to medical management, as bridge therapy to myocardial recovery, as bridge therapy to cardiac transplantation, or as destination therapy for patients with unfavorable transplant candidacy. Neurologic complications are some of the most common and devastating complications in these patients. Preoperative carotid ultrasound is, therefore, a standard evaluation in patients at risk for cerebrovascular disease. Postoperative carotid artery Doppler sonography is performed in those patients with neurologic symptoms. It is likely, therefore, that sonographers, radiologists, and other physicians working in a center where LVADs are implanted will likely encounter a carotid artery Doppler study in this patient group. To our knowledge, the carotid Doppler findings in these patients have never been published. We review the Doppler ultrasound findings in 6 patients after LVAD insertion.
Journal of the American Society of Echocardiography, 2011
Background: Continuous-flow left ventricular assist devices (LVADs) have become part of the stand... more Background: Continuous-flow left ventricular assist devices (LVADs) have become part of the standard of care for the treatment of advanced heart failure. However, knowledge of normal values for transthoracic echocardiographic examination and measurements in these patients are lacking. Methods: All transthoracic echocardiographic examinations in 63 consecutive patients, performed 90 and 180 days after surgery with the implantation of a HeartMate II continuous-flow LVAD between February 2007 and January 2010, were retrospectively analyzed. All patients had to be outpatients at 3 and 6 months after surgery and considered stable on LVAD therapy (New York Heart Association class I or II and no need for inotropes, intravenous furosemide, or hospitalization). Results: End-diastolic and end-systolic diameters and left ventricular mass decreased considerably compared with baseline measurements before LVAD implantation. Mitral inflow deceleration time increased (188 6 70 vs 132.5 6 27 msec, P = .009) and left atrial volume (84.1 6 33 vs 141.7 6 62 mL, P = .003) and E/e 0 ratio decreased (20.3 6 9 vs 26 6 11, P = .01), all consistent with decreased left ventricular filling pressure. Estimated right ventricular (RV) and right atrial pressure decreased significantly (34.1 6 10 vs 51.7 6 14 mm Hg and 9.5 6 5 vs 14.4 6 5 mm Hg, respectively, P < .0001 for both). Quantitatively estimated RV function (P = .02), RV fractional area change (27.9 6 10% vs 37.4 6 10.9%, P < .0001), and the RV index of myocardial performance (0.32 6 0.1 vs 0.65 6 0.2 vs 0.32 6 .01, P < .0001) improved, suggesting improved RV efficiency. LVAD therapy resulted in significant decreases in the severity of mitral regurgitation. Tricuspid regurgitation improved in patients who had concurrent tricuspid surgical correction and was unchanged otherwise. Aortic regurgitation severity increased 3 months after LVAD implantation. There were no significant differences in any of the echocardiographic parameters in the 6-month evaluation compared with the 3-month evaluation. Conclusions: This is the first report of selected typical echocardiographic values in a group of stable patients with normally functioning HeartMate II continuous-flow LVADs. A stable functioning continuous LVAD is associated with evidence of efficient unloading of the left ventricle, improved RV function, significant improvement in mitral regurgitation, improvement in tricuspid regurgitation only in patients undergoing repair, and increased aortic regurgitation. These normal data provide a basis for future echocardiographic studies after LVAD implantation.
Diagnosing a paradoxical embolism is challenging, and it can be proven only if the thrombus is id... more Diagnosing a paradoxical embolism is challenging, and it can be proven only if the thrombus is identified across the intracardiac defect. Very few cases have been diagnosed as an impending paradoxical embolism. Recently, the diagnosis and management of these entities have greatly improved with the advent of transesophageal echocardiography (compared with transthoracic echocardiography). Pulmonary hypertension may cause right-to-left shunting across a patent foramen ovale and predispose development of a paradoxical embolism. We report a patient with an impending paradoxical embolism that was caught in transit across the patent foramen ovale. The patient was treated successfully with emergent surgery.
Background. We sought to evaluate freedom from reinfection after surgery for infected aortic root... more Background. We sought to evaluate freedom from reinfection after surgery for infected aortic root replacement (ARR) and the impact of use of synthetic material at reoperation. Methods. Adult patients (aged more than 18 years) undergoing surgery for infected composite aortic root prosthesis at our institution were identified and their perioperative outcomes and late survival evaluated. Results. Between January 1, 1993, and December 31, 2009, 15 patients (male, 87%; mean [SD] age, 57 [16] years) underwent surgery. All but 1 patient (6.7%) underwent reconstruction with a homograft. Eight patients (53.3%) required synthetic material to complete the repair, including 4 patients who underwent hemiarch reconstruction. Ten patients (66.7%) had circulatory arrest (mean [SD] time, 23.3 [11.0] minutes) and 3 (20.0%) underwent concomitant coronary artery bypass grafting. The 30-day mortality rate was 13.3% (n ؍ 2). Three patients (20.0%)-2 of whom had positive blood cultures in hospital after redo ARR-had reinfection, for which 2 underwent re-replacement of the aortic root. Survival was 86.7%, 65.0%, and 50.6%, and freedom from reinfection was 90.9%, 79.5%, and 79.5% at 3, 6, and 12 months, respectively. Freedom from reinfection was less for the patients who had positive blood cultures within 2 weeks of redo ARR (p < 0.03) and for patients who had multiple previous sternotomies (p ؍ 0.006). Use of synthetic graft material had no adverse impact. Conclusions. Infected ARR prostheses can be replaced with a homograft with favorable outcomes. Use of synthetic material to complete the repair does not adversely impact outcome.
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Papers by DIPESH H. Shah