We present a novel approach for managing severe symptomatic aortic valve stenosis, in a patient at high risk for left main coronary artery obstruction with transcatheter aortic valve implantation (TAVR) and also significant bilateral iliofemoral peripheral artery disease limiting traditional transfemoral access. The patient underwent TAVR using transcaval access, and subsequent left aortic leaflet laceration (bioprosthetic aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction [BASILICA]) to reduce the risk of coronary obstruction. A self-expanding TAVR valve was deployed safely, with a good hemodynamic result. This case demonstrates the innovative use of alternative access and native aortic leaflet modification with transcatheter electrosurgery to support TAVR in high-risk aortic stenosis patients.

BACKGROUND:Next-day discharge (NDD) after transcatheter aortic valve replacement (TAVR) has been shown to be safe in appropriately selected patients and has been implemented into clinical practice. As the demand for TAVR grows, improving its accessibility is crucial. Several studies have trialled same-day discharge (SDD) after TAVR, but a review has not been performed. METHODS:Five databases were searched. Baseline demographics, study characteristics and the assessment criteria used to determine eligibility for SDD were extracted and compared. Proportional meta-analysis was used to compare post-TAVI outcomes between SDD and NDD patients. RESULTS:Six studies were included from 1734 screened articles. Of 3519 patients, 318 (9.0%) underwent SDD (mean age 78.2 ± 8.7 years, 59.3% male). Balloon-expandable valves were used in 91.6% of cases, and self-expanding valves in the remaining 8.4%. Patients that underwent SDD experienced lower rates of mortality (OR 0.104, 95% CI 0.015-0.998), all-cause readmission (OR 0.194, 95% CI 0.052-0.717), cardiovascular readmissions (OR 0.155, 95% CI 0.026-0.971), and new pacemaker requirement (OR 0.167, 95% CI 0.028-0.995) at 30 days after TAVR compared with patients that underwent NDD. There was no difference in rates of stroke (OR 0.407, 95% CI 0.015-16.694) or major vascular complications (0.0% vs 0.0%). CONCLUSIONS:Current evidence supports the safety and feasibility of SDD after elective transfemoral TAVR in appropriately selected patients. Heterogeneity between eligibility criteria used to select patients for SDD, especially related to conduction disease, poses a barrier to implementation. Further research on self-expanding valves is needed.

Permanent pacemaker implantation (PPMI) is an important complication following transcatheter aortic valve replacement (TAVR). The influence of valvular and subvalvular calcium and its distribution between aortic leaflets on the risk of PPMI following TAVR remains unclear. We performed a systematic review of the aortic valve complex (AVC) calcium by leaflet, left ventricular outflow tract (LVOT) calcium by leaflet, total AVC calcium, total LVOT calcium, and mitral annular calcium and its association with post-TAVR atrioventricular block, left bundle branch block, and new PPMI. The search strategy included five databases identifying 893 articles. A total of 34 studies with 11,528 patients were included for qualitative analysis, and seven studies totaling 1056 patients were suitable for quantitative analysis. On meta-analysis, left coronary cusp calcium and right coronary cusp calcium were significant predictors of PPMI, while noncoronary cusp (NCC) calcium was not predictive (left coronary cusp: mean difference: 21.05 mm3, 95% CI: 5.92-36.19, p ​< ​0.001; right coronary cusp: mean difference: 46.02 mm3, 95% CI: 1.84-90.21, p ​= ​0.04, and NCC: mean difference: 0.19 mm3, 95% CI: −0.32 to 0.50, p ​= ​0.10). On qualitative review, LVOT calcium in the NCC region was the leaflet most commonly predictive of post-TAVR conduction outcomes. Total AVC, total LVOT calcium, and mitral annular calcium had no convincing association with post-TAVR conduction outcomes. The distribution of calcium rather than its total volume was associated with post-TAVR conduction abnormalities. Heterogeneity in methodology and implantation techniques between studies limits the clinical significance of these findings.

BACKGROUND:Landmark trials showed that invasive pressure measurement (Fractional Flow Reserve, FFR) was a better guide to coronary stenting than visual assessment. However, present-day interventionists have benefited from extensive research and personal experience of mapping anatomy to hemodynamics. AIMS:To determine if visual assessment of the angiogram performs as well as invasive measurement of coronary physiology. METHODS:25 interventional cardiologists independently visually assessed the single vessel coronary disease of 200 randomized participants in The Objective Randomized Blinded Investigation with optimal medical Therapy of Angioplasty in stable angina trial (ORBITA). They gave a visual prediction of the FFR and Instantaneous Wave-free Ratio (iFR), denoted vFFR and viFR respectively. Each judged each lesion on 2 occasions, so that every lesion had 50 vFFR, and 50 viFR assessments. The group consensus visual estimates (vFFR-group and viFR-group) and individual cardiologists' visual estimates (vFFR-individual and viFR-individual) were tested alongside invasively measured FFR and iFR for their ability to predict the placebo-controlled reduction in stress echo ischemia with stenting. RESULTS:Placebo-controlled ischemia improvement with stenting was predicted by vFFR-group (p < 0.0001) and viFR-group (p < 0.0001), vFFR-individual (p < 0.0001) and viFR-individual (p < 0.0001). There were no significant differences between the predictive performance of the group visual estimates and their invasive counterparts: p = 0.53 for vFFR vs FFR and p = 0.56 for viFR vs iFR. CONCLUSION:Visual assessment of the angiogram by contemporary experts, provides significant additional information on the amount of ischaemia which can be relieved by placebo-controlled stenting in single vessel coronary artery disease.

Chronic tricuspid regurgitation (TR) results in progressive right ventricular (RV) volume overload, followed by right-sided chamber dilatation, RV systolic dysfunction, and eventual low-output cardiac failure. Severe TR is associated with considerable morbidity and mortality, and yet until recently, patients in the late stage of their disease course had limited treatment options. Cognizant of the high mortality rates associated with surgical intervention, tricuspid valve (TV) transcatheter edge-to-edge repair (TEER) has emerged as a promising solution for patients with severe TR. As has been learned from the transcatheter mitral valve TEER experience, detailed morphological and mechanistic assessment of the TV with transthoracic and transesophageal imaging is essential to optimal patient selection and procedural success. The current review will provide a comprehensive overview of TV anatomy, the updated mechanistic classification of TR, and key echocardiographic considerations in the evaluation, management, and follow-up of patients undergoing TV TEER.

Aortic stenosis (AS) once was conceptualized as a mechanical problem with a fixed left ventricular (LV) afterload because of an obstructive valve. With time, there has been growing recognition that AS functions more like a series circuit, with important contributions from the ventricle through to the vasculature. Emerging evidence suggests that higher blood pressure and increased arterial stiffness, synonymous with vascular aging, increases global LV afterload in patients with AS. This in turn, has adverse consequences on quality-of-life measures and survival. Although traditional methods have emphasized measurement of the transvalvular pressure gradient, focusing on valvular hemodynamics alone may be inadequate. By definition, total vascular load of the human circulation includes both steady and pulsatile components. Steady load is best represented by the systemic vascular resistance whereas pulsatile load occurs because of wave reflections and vascular stiffness, and is often referred to as the valvulo-arterial impedance. In the following Review, we evaluate existing and upcoming methods to assess vascular load in patients with AS in order to better understand the effects of vascular aging on this insidious disease process.

Background: Treating known risk factors for coronary artery disease (CAD) has substantially reduced CAD morbidity and mortality. However, a significant burden of CAD remains unexplained. Immunoglobulin E sensitization to mammalian oligosaccharide galactose-α-1,3-galactose (α-Gal) was recently associated with CAD in a small observational study. We sought to confirm that α-Gal sensitization is associated with CAD burden, in particular noncalcified plaque. Additionally, we sort to assess whether that α-Gal sensitization is associated with ST-segment–elevated myocardial infarction (STEMI) Methods: We performed a cross-sectional analysis of participants enrolled in the BioHEART cohort study. We measured α-Gal specific-immunoglobulin E antibodies in serum of 1056 patients referred for CT coronary angiography for suspected CAD and 100 selected patients presenting with STEMI, enriched for patients without standard modifiable risk factors. CT coronary angiograms were assessed using coronary artery calcium scores and segmental plaque scores. Results: α-Gal sensitization was associated with presence of noncalcified plaque (odds ratio, 1.62 [95% CI, 1.04–2.53], P =0.03) and obstructive CAD (odds ratio, 2.05 [95% CI, 1.29-3.25], P =0.002), independent of age, sex, and traditional risk factors. The α-Gal sensitization rate was 12.8-fold higher in patients with STEMI compared with matched healthy controls and 2.2-fold higher in the patients with STEMI compared with matched stable CAD patients (17% versus 1.3%, P =0.01 and 20% versus 9%, P =0.03, respectively). Conclusions: α-Gal sensitization is independently associated with noncalcified plaque burden and obstructive CAD and occurs at higher frequency in patients with STEMI than those with stable or no CAD. These findings may have implications for individuals exposed to ticks, as well as public health policy. Registration: URL: https://www.anzctr.org.au ; Unique identifier: ACTRN12618001322224.

Background: Electrocardiogram (ECG) measured QRS duration has been shown to influence cardiovascular outcomes. However, there is paucity of data on whether ECG QRS duration is influenced by obesity and sex in large populations. Methods: All ECGs performed by a pathology provider over a 2-year period were included. ECGs with confounding factors and those not in sinus rhythm were excluded from the primary analysis. Results: Of the 76,220 who met the inclusion criteria, 41,685 (55%) were females. The median age of the study cohort was 61 years (interquartile [IQR] range 48-71 years). The median QRS duration was 86 ms (IQR 80-94 ms). The median BMI was 27.6 kg/m(2) (IQR 24.2-31.8 kg/m(2)). When stratified according to the World Health Organization classification of BMI < 18.50 kg/m(2), 18.50-24.99 kg/m(2), 25.00-29.99 kg/m(2), and >= 30.00 kg/m(2), the median QRS durations were 82 ms (IQR 76-88 ms), 86 ms (IQR 80-92 ms), 88 ms (IQR 80-94 ms) and 88 ms (IQR 82-94 ms), respectively (p < 0.001 for linear trend). Median QRS duration for females was 84 ms (IQR 78-88 ms); for males, it was 92 ms (IQR 86-98 ms), p < 0.001. Compared to males, females had narrower QRS complexes at similar age and similar BMI. In multiple linear regression analysis, BMI correlated positively with QRS duration (standardized beta 0.095, p < 0.001) independent of age, sex, and heart rate. Conclusions: In this large cohort there was a positive association between increasing BMI and QRS duration. Females had narrower QRS duration than males at similar age and similar BMI.

This case study is a rare example of cardiac hydatidosis in a high-income country, where a middle-aged man presented with a ruptured right ventricular cyst causing anaphylaxis, pulmonary emboli and dissemination of Echinococcus throughout the lung. He survived the cyst rupture and underwent cardiac surgery but had incomplete resection and experienced progressive cardiopulmonary hydatidosis despite antihelminthic therapy. As a result, he experienced an array of cardiopulmonary sequelae over his lifespan. This case report highlights rare clinical manifestations of hydatid disease and potential complications of its treatment.

Background There is increasing recognition that heavy exertion can occasionally trigger an acute myocardial infarction (MI), although some uncertainties exist regarding the link. The primary aim of this study was to compare the relative risk (RR) of MI following vigorous exertion between those with confirmed coronary occlusion and those with a non-occluded culprit artery on acute angiography. Secondary aims were to determine if the risk of coronary occlusion is modified by the type of exercise (dynamic or isometric resistance), the frequency of regular exertion or whether the exertion was emotionally charged. Methods Seven hundred sixty-two (762) participants with MI (410 with coronary occlusion TIMI 0,1), and 352 (46%) with a non-occluded culprit artery (TIMI 2,3) completed a questionnaire within 4 days of admission, detailing episodes of physical exertion in the 28 hours prior to symptom onset and the usual frequency of such exertion. Exertion exposures within 1 hour prior to symptom onset were compared to subjects' usual yearly exposure, with case-crossover methodology. Results The RR of symptom onset following heavy physical exertion level >= 6 (exertion scale 1-8), was higher in those with TIMI 0,1 compared to those with TIMI 2,3 flow (RR 6.30, 95% CI 4.70-8.50 vs 3.93, 2.89-5.30). The increased risk of coronary occlusion following vigorous exertion was observed following both dynamic exertion and isometric resistance, and did not differ between exertion types. The highest risk of coronary occlusion following exertion was observed in those who were sedentary (regular vigorous exertion <1 day weekly) (RR = 77, 95% CI 46-132), whereas in those who frequently perform regular vigorous physical exertion (>4 days weekly), the RR of symptom onset during exertion was significantly lower, RR 2.3 (95% CI 1.5-3.6). There was no significant difference in relative risk based on whether the exertion was reported as emotionally charged. Conclusions The relative risk that heavy exertion will trigger a non-fatal MI with an occluded artery is greater than for a non-occluded culprit artery. Both dynamic and isometric exertion increase the relative risk of event, while exposure to regular vigorous exertion reduces the relative risk.

IntroductionSupraventricular ectopic complexes (SVEC) are known risk factors of recurrent atrial fibrillation (AF). However, the impact of SVEC in different age groups is unknown. We aimed to investigate the risk of AF recurrence with higher SVEC burden in patients ±57years, respectively, after treatment with antiarrhythmic medication (AAD) or catheter ablation (CA).MethodsIn total, 260 patients with LVEF >40% and age ≤70 years were randomized to AAD (N=132) or CA (N=128) as first-line treatment for paroxysmal AF. All patients underwent 7-day Holter monitoring at baseline, and after 3, 6, 12, 18 and 24months and were categorized according to median age ±57years. We used multivariate Cox regression analyses and we defined high SVEC burden at 3months of follow-up as the upper 75th percentile >195SVEC/day. AF recurrence was defined as AF ≥1min, AF-related cardioversion or hospitalization.ResultsAge >57years were significantly associated with higher AF recurrence rate after CA (58% vs 36%, p=0.02). After CA, we observed a higher SVEC burden during follow-up in patients >57years which was not observed in the younger age group treated with CA (p=0.006). High SVEC burden at 3months after CA was associated with AF recurrence in older patients but not in younger patients (>57years: HR 3.4 [1.4–7.9], p=0.005). We did not find any age-related differences after AAD.ConclusionWe found that younger and older patients respond differently to CA and that SVEC burden was only associated with AF recurrence in older patients.

Aims Early identification of patients who could benefit from early re-intervention after catheter ablation is highly warranted. Our aim was to investigate the association between post-procedural burden of supraventricular ectopic complexes (SVEC) and the risk of long-term atrial fibrillation (AF) recurrence. Methods and results A total of 125 patients undergoing catheter ablation for AF were included. Patients underwent 7-day Holter recordings immediately post-procedural. The number of SVEC in post-procedural Holter recordings was categorized into quartiles: 0-72, 73-212, 213-782 and ≥ 783 SVEC/day. Long-term AF recurrence was defined as a combined endpoint of AF ≥ 1 min during follow-up Holter recordings, cardioversion or hospitalization for AF after a 3-month blanking period and within 24 months of follow-up. High post-procedural supraventricular ectopy burden was associated with an increased risk of long-term AF recurrence in a dose-dependent manner (≥ 783 SVEC: HR 4.6 [1.9-11.5], P < 0.001) irrespective of AF recurrence during the blanking period or other risk factors. In patients with early AF recurrence < 90 days after catheter ablation ectopy burden was also highly predictive of long-term AF recurrence (SVEC ≥ 213: HR 3.0 [1.3-6.7], P = 0.007). Correspondingly, patients with early AF recurrence but low ectopy burden remained at low risk of long-term AF recurrence after the blanking period. Conclusion Our results indicate that post-procedural ectopy burden is highly associated with long-term AF recurrence and could be a potent risk marker for selection of patients for early re-ablation. Development of future ablation risk stratification and strategies should include focus on post-procedural ectopy burden.

BackgroundSupraventricular ectopic complexes (SVEC) originating in the pulmonary veins are known triggers of atrial fibrillation (AF) which led to the development of pulmonary vein isolation for AF. However, the long-term prevalence of SVEC after catheter ablation (CA) as compared to antiarrhythmic medication (AAD) is unknown. Our aims were to compare the prevalence of SVEC after AAD and CA and to estimate the association between baseline SVEC burden and AF burden during 24months of follow-up.MethodsPatients with paroxysmal AF (N=260) enrolled in the MANTRA PAF trial were treated with AAD (N=132) or CA (N=128). At baseline and 3, 6, 12, 18 and 24months follow-up patients underwent 7-day Holter monitoring to assess SVEC and AF burden. We compared SVEC burden between treatments with Wilcoxon sum rank test.ResultsPatients treated with AAD had significantly lower daily SVEC burden during follow-up as compared to CA (AAD: 19 [6–58] versus CA: 39 [14–125], p=0.003). SVEC burden increased post-procedurally followed by a decrease after CA whereas after AAD SVEC burden decreased and stabilized after 3months of follow-up. Patients with low SVEC burden had low AF burden after both treatments albeit this was more pronounced after CA at 24months of follow-up.ConclusionAAD was superior to CA in suppressing SVEC burden after treatment of paroxysmal AF. After CA SVEC burden increased immediately post-procedural followed by a decrease whereas after AAD an early decrease was observed. Lower SVEC burden was highly associated with lower AF burden during follow-up especially after CA.

Aims Identification and management of the Standard Modifiable Cardiovascular Risk Factors (SMuRFs; hypercholesterolaemia, hypertension, diabetes and smoking) has substantially improved cardiovascular disease outcomes. However, cardiovascular disease remains the leading cause of death worldwide. Suspecting an evolving pattern of risk factor profiles in the ST elevation myocardial infarction (STEMI) population with the improvements in primary care, we hypothesized that the proportion of 'SMuRFless' STEMI patients may have increased. Methods/results We performed a single centre retrospective study of consecutive STEMI patients presenting from January 2006 to December 2014. Over the study period 132/695 (25%) STEMI patients had 0 SMuRFs, a proportion that did not significantly change with age, gender or family history. The proportion of STEMI patients who were SMuRFless in 2006 was 11%, which increased to 27% by 2014 (odds ratio 1.12 per year, 95% confidence interval: 1.04-1.22). The proportion of patients with hypercholesterolaemia decreased (odds ratio 0.92, 95% confidence interval 0.86-0.98), as did the proportion of current smokers (odds ratio 0.93, 95% confidence interval 0.86-0.99), with no significant change in the proportion of patients with diabetes and hypertension. SMuRF status was not associated with extent of coronary disease; in-hospital outcomes, or discharge prescribing patterns. Conclusion The proportion of STEMI patients with STEMI poorly explained by SMuRFs is high, and is significantly increasing. This highlights the need for bold approaches to discover new mechanisms and markers for early identification of these patients, as well as to understand the outcomes and develop new targeted therapies.

Introduction: This single-subject case report aims to describe and discuss a case of a patient with established C5 tetraplegia with acute coronary syndrome presenting with left upper quadrant pain and tenderness. Case presentation: A 65-year-old male with chronic C5 American Spinal Injury Association Impairment Scale (AIS) A tetraplegia presented to the emergency department with severe left upper quadrant pain radiating across the chest to the right upper limb with associated dyspnoea and diaphoresis. Prior to his emergency department admission, he had experienced progressive worsening of left upper quadrant pain and tenderness over several months. He was a non-smoker and swam regularly. He underwent coronary angiography and was found to have significant coronary artery disease. Drug-eluting stents were placed to critical coronary artery lesions followed by an uneventful hospital course with complete symptom resolution and discharge home. Discussion: Patients with tetraplegia are known to have higher rates of cardiovascular disease compared to ambulatory patients. Their cardiovascular risk profile may include atypical risk factors, for example, sleep disordered breathing, relative immobility and autonomic dysfunction. A high index of suspicion for cardiac pathology is warranted in those with cervical tetraplegia with persistent ‘atypical’ symptoms, including within the abdomen (especially when no specific abdominal organ dysfunction is evident). Sleep apnoea and significantly impaired mobility are potential cardiac risk factors in this patient group and should alert the emergency physician to cardiac disease (as in this case) irrespective of their complex past medical history and symptomatology.

BACKGROUND:Respiratory infection has been associated with an increased short-term risk of myocardial infarction (MI). However, previous studies have predominantly been conducted without angiographic confirmation of MI. The possibility can therefore not be excluded that raised troponin levels or electrocardiogram abnormalities that may be seen with respiratory infections are due to non-ischaemic causes.AIMS:To investigate the association between respiratory infection and angiographically confirmed MI.METHODS:Interviews were conducted within 4 days of hospitalisation in 578 patients with angiographically confirmed MI, to assess for recent exposure to respiratory infection symptoms and the usual annual frequency of these symptoms. Using case-crossover methodology, exposure to respiratory infection prior to the onset of MI was compared against the usual frequency of exposure in the past year.RESULTS:Symptoms of respiratory infection were reported by 100 (17%) and 123 (21%) within 7 and 35 days, respectively, prior to MI. The relative risk (RR) for MI occurring within 1-7 days after respiratory infection symptoms was 17.0 (95% confidence interval (CI) 13.2-21.8), and declined with subsequent time periods. In a subgroup analysis, the RR tended to be lower in groups taking regular cardiac medications. For those who reported milder, upper respiratory tract infection symptoms, the RR for the 1-7-day time period was 13.5 (95% CI 10.2-17.7).CONCLUSION:These findings confirm that respiratory infection can trigger MI. Further study is indicated to identify treatment strategies to decrease this risk, particularly in individuals who may have increased susceptibility.

Aims: The Absorb everolimus-eluting bioresorbable vascular scaffold (BVS) represents an important advance in percutaneous coronary intervention (PCI) technology. With increasing use of BVS, it is important to understand its expansion characteristics to ensure optimal scaffold deployment. Optical coherence tomography (OCT) has been shown to improve detection of intraprocedural complications compared with conventional intravascular imaging modalities. This study aimed to determine whether or not OCT, post successful angiographic BVS implantation, influenced decision making with regard to the need for further scaffold optimisation. Methods and results: Consecutive patients undergoing OCT-guided BVS implantation from August 2012 to March 2013 were reviewed to determine if further intervention was required to optimise BVS implantation, based on OCT performed after what was deemed to be an optimal angiographic result. Nineteen patients with 29 scaffolds were analysed. Mean age was 53.7, with 84% male. There was a range of lesion types with 12 (63%) type A and seven (37%) type B or C. Of 29 scaffolds analysed, 28% required further intervention after OCT review, three (37.5%) due to scaffold malapposition and five (62.5%) due to scaffold underexpansion. Conclusions: Despite achieving angiographic success in all BVS implantations, further optimisation was required in over a quarter of patients on the basis of OCT findings. KEYWORDS

Objectives Assess the effect of aspiration thrombectomy on diagnosis and management of embolic acute myocardial infarction. Background Discrimination of embolic acute myocardial infarction from atherosclerotic plaque rupture/erosion prompts oral anticoagulation treatment of source of embolus, as well as avoiding unnecessary stenting and dual antiplatelet therapy. However, detection is difficult without aspiration. Methods We compared rates of diagnosis of embolic infarction for 2.5 years prior to (pre‐RAT) and 2.5 years post routine aspiration thrombectomy (post‐RAT). Baseline demographics, outcomes, and treatment strategies were also compared between the embolic infarction and atherosclerotic infarction. Results Diagnosed embolic infarction rose from 1.2% in the pre‐RAT era to 2.8% in the post‐RAT period ( P < 0.05). In addition, more successful removal of thrombus by aspiration led to less stenting (20% vs. 55% P < 0.05) in the post‐RAT period thus avoiding the hazards of “triple therapy.” Embolic infarction was more frequently associated with atrial fibrillation (55% vs. 8%), had higher mortality (17% vs. 4%), and had higher rates of embolic stroke (13% vs. 0.3%) when compared with atherosclerotic MI (all P < 0.05). Conclusions Routine aspiration thrombectomy more readily identifies embolic infarction allowing more specific therapy and avoidance of stenting and triple anticoagulant therapy. © 2015 Wiley Periodicals, Inc.

Transcatheter aortic valve implantation (TAVI) has been increasingly utilized for the treatment of severe symptomatic aortic stenosis in inoperable and high surgical risk patients. Recent advances in valve technology include repositionable scaffolds and smaller delivery systems, as well as improvement in periprocedural imaging. These advances have resulted in reduction of vascular complications, rates of paravalvular aortic regurgitation and periprocedural stroke and improved overall outcomes. Increasingly, TAVI is the preferred treatment for high-risk surgical patients with severe aortic stenosis. Consequently, there is growing interest for the use of TAVI in lower surgical risk patients. Furthermore, the role of TAVI has expanded to include valve-in-valve procedures for the treatment of degenerative bioprosthetic valves and bicuspid aortic valves. Questions remain in regard to the optimal management of concurrent coronary artery disease, strategies to minimize valve leaflet restriction and treatment of conduction abnormalities as well as identifying newer indications for its use.

The performed investigation focus on a monoblock type design for a water cooled DEMO divertor using Eurofer as structural material. In 2013, a study case of such a concept was presented. It was shown that basic concepts using Eurofer as structural material are limited to an incident heat flux of 8 MW m−2. Since, the EFDA agency issued new specifications. In this study, the conceptual design is reassessed with regard to specifications. Then, steady state thermal analyses and thermo-mechanical elastic analyses have been performed to define an upgrade of the geometry taking into account new specifications, design criteria and the maximum heat flux requirement of 10 MW m−2. An analysis of the influence of each adjustable geometrical parameter on thermo-mechanical design criteria was performed. As a consequence, geometrical parameters were set in order to fit to materials requirements. For defined hydraulic conditions taken in the most favourable configuration, the limit of this design is estimated to an incident heat flux of 10 MW m−2. Margin to critical heat flux and rules against progressive deformation/ratcheting in structural material limit the design.