Botryoid growth pattern (BGP) is a polypoid mass growing into the renal pelvis, rarely seen in bilateral Wilms tumors (BWT) where it represents a surgical challenge. We report our experience of nephron sparing surgery (NSS) in three patients with BGP in BWT. Surgical en-bloc removal was performed after calyx opening with no complications. The histology of the BGP was Intra Lobar Nephrogenic Rest in all cases while all Wilms tumors were of intermediate risk. One patient early recurred. At a follow-up of 9 months, 22 and 23 years, all patients were alive with a moderate renal insufficiency and hypertension.

The emergence of intracellular calcification among marine unicellular eukaryotes in the Late Triassic (237-201 Ma) had profound consequences for the carbonate buffering capacity of the ocean. Research on the appearance of calcification typically focuses on the reasons that made this process successful on a global scale. The underlying environmental and physiological conditions that led to its appearance, therefore, are still obscure. Using gene tree analysis, we show that the physiological machinery for calcification was already present in non-calcifying ancestor cells. Additionally, by modelling the energy demands for calcium transport in calcifying and non-calcifying cells, we demonstrate that intracellular calcification does not require additional energy investments. Since all eukaryotic cells export calcium across the plasma membrane, our findings indicate that the onset of intracellular calcification in Earth history only required the activation of calcium transport proteins during their passage to the plasma membrane. Our work sheds new light on the physiological and biogeochemical conditions that led to one of the most important evolutionary innovations of the Mesozoic era.

Anticipation is the act of using information about the past and present to make predictions about future scenarios. As a concept, it is predominantly associated with the psychology of the human mind; however, there is accumulating evidence that diverse taxa without complex neural systems, and even biochemical networks themselves, can respond to perceived future conditions. Although predictive biological responses, such as circadian rhythms and stress preconditioning, have been extensively studied over the last century, newer research on predictive genetic networks in microbes have highlighted the existence of anticipatory processes in older, more primitive taxa. When taken together, these seemingly disparate processes can be connected based on a shared anticipatory design. This review discusses the important and often overlooked role of anticipation in the evolution of biological designs, and advocates for establishing a fundamental distinction between anticipatory and reactive processes as an effort to advance our understanding of complex biological processes.

Background: Vascular endothelial growth factor (VEGF) functions are different in different tissues and organs and different functional states. VEGF is highly expressed in early stage diabetic nephropathy (DN) and in turn, lowly expressed in late stage DN. However, their roles in renal progression in advanced diabetes remain unclear. The purpose of this study was to determine the relationship between low VEGF expression and the pathogenesis and prognosis of advanced DN. Methods: Our study found significant differences in VEGF gene expression using data from the Gene Expression Omnibus (GEO) database based on renal tissue samples of DN and normal people. Then, we performed several bioinformatics analyses to determine differentially expressed genes, Gene Ontology (GO), Kyoto Encyclopedia of Genes and Genomes (KEGG) enrichment, Gene-Set Enrichment Analysis (GSEA), and immune infiltration analysis on DN samples to obtain information on VEGF genes. Finally, we constructed protein-protein interaction networks, and screened hub-genes to refine our results further. Results: We found 180 differentially expressed genes through our bioinformatics analysis. They were also enriched in inflammatory response, cell differentiation, cell chemotaxis, proliferation, and apoptosis pathways. We found eight hub-genes by PPI network analysis. Together with VEGF, they may play a key role in regulating the development of DN. Conclusion: Our study revealed the molecular mechanism of DN pathogenesis and provides evidence that a decrease in VEGF expression in moderate-to-late DN could be related to its clinical prognosis. VEGF may be expected to become a new target for DN therapy based on this research.

In this study, we aim to find out maternal and fetal outcomes in women with PH resulting from different causes and try to determine the risk factors related to adverse maternal and fetal outcomes. 684 women were included in the final analysis, who were mainly had pulmonary hypertension secondary to congenital heart disease (65.4%). Patients with idiopathic PH have the highest mortality (35.3%) and the lowest live birth rate (82.4%). Mortality is similar between moderate and severe PH women(5.3% vs 9.7%, P=0.17), but live birth rate is much lower in severe PH women (78.6% vs 89.9%, P＜0.01). The overall mortality was 2.8%, decreasing from 6.6% (4/61) in 2001~2005 to 1.7% (4/235) in 2016~2020 (P=0.10). Hypoxemia and vaginal birth are risk factors of maternal death both in the univariate analysis [OR 13.49(5.15-35.31), OR 4.16(1.52-11.42), respectively] and multivariate analysis [35.28 (1.42-878.75), 850.86 (5.67-127606.74), respectively]. General anesthesia is a risk factor in the univariate analysis [OR 12.07(3.72-39.15)] but with no significance in the multivariate analysis (P=0.16). We demonstrate a lower mortality rate than previously reported, although of no statistical difference among years in our center. In PH secondary to connective tissue disease and idiopathic PH, maternal mortality remains high. Maternal and fetal outcome are related to the etiology and the severity of PASP. Hypoxemia is a risk factor of maternal death while cesarean section seems to be a protective factor. The ideal choice of anesthesia remains uncertain. PH-targeted drugs cannot effectively decrease mortality rate. Thus, pregnancies remain challengeable in PH women.

INTRODUCTION: Immunosuppressed Renal transplant patients are often susceptible to upper airway infections, especially those of the paranasal sinuses. The increasing number of cases of rhinosinusitis by opportunistic organisms in post-renal transplant (PRT) patients has spawned our interest to analyze this subset of patients. MATERIAL & METHOD: A Retrospective observational Study was done on all PRT patients who presented to the Dept. of Otorhinolaryngology, MGH, Jaipur, with symptoms of rhinosinusitis and required hospitalization. The following variables were studied: age at time of transplantation, gender, cause of CRF, Pre-transplant co-morbidities, Post-transplant immunosuppressant medications, time-interval between transplant and development of symptoms of rhinosinusitis, presenting complaints, radiological presentation, treatment approaches and surgical challenges experienced. RESULT: Out of 11 patients, 8 were males (72.7%) and 3 females (27.3%). All the patients (100%) of the study group presented with unilateral facial pain and/or headache in about 6-12 months post-renal transplant. The most consistent CT finding was involvement of the Maxillary sinuses. All the cases worsened rapidly and required immediate treatment and 9(81.8%) of these patients required Endoscopic surgical debridement, of which 3 (27%) cases required revision surgery within 2 weeks. CONCLUSION: In the immunocompromised host, the initial presentation of rhinosinusitis may be subtle, but the subsequent clinical course is usually fulminant or even fatal. Therefore, their pre-transplant ENT evaluation, a high index of suspicion in the post-transplant period and timely management is vital to avoiding fatal outcomes in these patients. Keywords: Rhinosinusitis, Fungal infections, Invasive Fungal Sinusitis, Immunocompromised states, Post-renal transplant infections. Succinct Keywords: Fungal Rhinosinusitis, Opportunistic infections, Post-transplant Sinusitis, Chronic Rhinosinusitis, Mucormycosis.

Infectious diseases of livestock are a significant burden on animal and human health, particularly in Low and Middle-Income Countries. To prevent and control these diseases, an appropriate surveillance system based on suitable up-to-date epidemiological data is required. This systematic review looks at the available data on infectious diseases of livestock in Cameroon from 2000-2020 gives an epidemiological contribution for effective control strategies and initial step for disease prioritization approach. The systematic review protocol was designed according to the PRISMA statement. Data was searched through online databases. Grey literature comprised of dissertations and thesis from veterinary higher education institutions in Cameroon. A random-effects model was used to calculate pooled prevalence using Comprehensive Meta-analysis software. Major infectious diseases of livestock in Cameroon based on prevalence were gastrointestinal parasitosis (57.4% in cattle, 67.2% in poultry, 88% in pigs), hemoparasites (21.6% in small ruminants, 19.7% in cattle), bovine pasteurellosis (55.5%), fowl salmonellosis (48.2%), SRP (39.7%), FMD (39.4% in cattle) and ASF (18.9%). Furthermore, other important endemic zoonoses in the country included: bovine tuberculosis (3.3% in cattle), brucellosis (7% in cattle, 8% in pigs), bovine leptospirosis (2.5%), RVF (10.9% in cattle, 3.7% in small ruminants) and hepatitis E virus (8.4% in pigs). Most of the retrieved research were carried out in the Adamawa, North-West and West regions. The high-pooled prevalence of various livestock infectious diseases and evidence for the endemicity of major zoonotic infections in Cameroon warrants for enhanced public health interventions strategically targeting prioritized animal diseases for surveillance and control by making sure all diseases that result in production losses, negative economic impacts and public health threats are epidemiologicaly appropriately characterised in all production systems. The evaluation of existing data, albeit publication-specific, is an important step in the process of prioritising animal diseases, including zoonosis.

The interest of this article is to show the relevance of the non-linear geometric model to estimate and to simulate numerically the critical wooden beams buckling load. Base on the kinematic hypotheses of the Vlassov's theory, the consideration of the kinematic relationships associated with warping are presented in a coherent and unified geometric form. The virtual work principal in updated lagrangian description allowed us to determine the incremental equations of equilibrium. Polynomial interpolation helps us to reconstruct the main matrices of the problem of nonlinear geometry. The size of the rigidity matrices obtained takes into account the warping phenomenon. In a numerical plan, the resolution of the equations established allows us to appreciate relevance of the seventh degree of freedom on predicting the critical buckling load.

The trials testing the efficacy of tocilizumab in patients with Covid-19 pneumonia: are we missing something? The new coronavirus infection (COVID19) is affecting societies and economies globally. Developing therapies for hospitalized patients is a global urgency to optimize the care and outcomes. . Investigators identify molecular targets with a potential role in the development and outcome of adult respiratory distress syndrome (ARDS) in Covid19, argue that a pragmatic, novel and rational target that should be seriously considered in efforts to mitigate the effects of COVID-19 infection. This is followed by rapidly designed randomized clinical trials (RCT) in patients with confirmed COVID-19 infection with subsequent plan to develop populational recomendations. The common end points are preventing intubation or death in hospitalized patients with COVID-19.In this context, the efficacy of tocilizumab in patients with Covid-19 has been examined in several randomized trials (1-6). The trials differ significantly in the inclusion and exclusion criteria. The trials enrolled patients with a different disease severity at baseline. As evidence build up gradually in the current ecological crisis, the use of concomitant glucocorticoid or antiviral agents did not display most up-to-date standard of care in the trials. Commonly, the researchers report that the confidence intervals (CI) for efficacy comparisons are wide, so some benefit or harm is uncertain.The trials did not show difference in mortality between the tocilizumab and control groups, but the other efficacy end point of survival without invasive or noninvasive mechanical ventilation by day 14 was acchieved in the CORIMUNO-TOCI-1 trial (3), without a mortality benefit at day 28. The results of the trials suggest that patient enrollment criteria determine the benefit from tocilizumab. Due to wide CIs, the conclusion is made in these trials that tocilizumab ‘does not show efficacy’ . CIs are helpful in determining not only statistical significance but also the clinical relevance of the findings. Hospitalized patients with Covid19 display wide physiological and biological heterogeneity (7). Wide CIs suggest how large the effect of a treatment could plausibly be. Thus, we can not rule out the possibility that tocilizimab would help in certain groups of patients. In fact, a systematic review and meta-analysis reports that addition of tocilizumab to the standard of care reduces mortality in severe COVID-19 (8).The conventional RCT paradigm can test new therapeutic candidates in limited number of patients. For conditions with wide heterogeneity. the need exists to understand the mechanisms of vast heterogeneity in drug-related outcomes. Without further understanding the basis individual differences in drug safety and efficacy, we face the risk of early removal of a potentially useful companions from further development. As with any maturing field, conflicting observations should be expected. Global efforts are needed to inform the health care professionals about the interpretation of conflicting results and messages.We wish to emphasize, however, avoiding premature clinical decisions in today’s difficult conditions should be a centerpiece concept in clinical pharmacology and population health. With growing technological advances, effective drugs are being developed and used in Covid19. Timely detection of population signals pertaining to efficacy and toxicity can be problematic.The new coronavirus infection (COVID19) is a current and urgent matter globally. The medical communities could not anticipate the severity of the situation we are facing today. In the midst of pandemic we take the risks of visualizing the real effects of therapies either far too late and premature decisions about the safety. Exercising pharmacovigilance and the novel concept of pharmacogenovigilance thorough global centers can offer a mechanistic insight and firm causality assessment of Covid19 therapies (9,10).In conclusion, Covid19 trials are in need of anticipatory systems that can detect early signals of safety and efficacy in the transition of health interventions to population scale applications. Early removal of a potentially useful therapies from further development can be a premature decision in today’s difficult conditions.

Objective: To determine the anatomy knowledge in postgraduate obstetrics and gynaecology trainees. Our hypothesis was that trainees possess a good knowledge of anatomy and, on average, would correctly answer at least 80% of questions on core anatomy knowledge. Design: A 10-year longitudinal study. Setting: This study included the results from annual progress tests over 10 years (2010–2019) that were completed by Dutch obstetrics and gynaecology postgraduates. Population: Dutch trainees in the field of obstetrics and gynaecology. Methods: Anatomy questions included in a yearly progress test were assessed for their relevance. Relevance was determined according to a previous Delphi study, which identified 86 structures that are essential for the safe and competent practice of general gynaecologists. Scores on relevant anatomy questions were calculated. Main Outcome Measures: The mean percentage correct answers. Results: Of all 1637 questions of the yearly progress test, 54 were anatomy-related questions (3.3%). Of these 54 questions, 38 (70%) were considered as relevant questions. The mean 10-year correct response rate on relevant questions was 64.5%. Conclusions: The anatomy knowledge of obstetrics and gynaecology trainees is insufficient. Our results highlight the need to test and improve anatomy knowledge during postgraduate obstetrics and gynaecology training. Funding: None. Keywords: anatomy knowledge, progress testing, obstetrics and gynaecology, postgraduate training

Abstract Objective: To assess the difference in the trajectories of soluble HLA-G in maternal sera during pregnancy between women delivering small for gestational age (SGA) and appropriate for gestational age (AGA) neonates. Design and Settings: Pilot case-control study nested within a cohort study - Garbh-Ini. Population: North-Indian pregnant females delivering SGA (N=23) or AGA (N=17) neonates. Method: Soluble HLA-G1/G5 was estimated in the maternal sera at different time points in pregnancy using sandwich ELISA. Linear mixed models were built and compared to study the association between sHLA-G levels during pregnancy and SGA births. Main Outcome Measure:Birth of SGA or AGA neonates. Results: No significant difference was observed in the sHLA-G trajectories during pregnancy in mothers delivering SGA as compared to those delivering AGA (p-value = 0.5677). A trend towards higher sHLA-G levels at the first trimester of pregnancy (<14weeks of gestation) was observed in mothers delivering SGA neonates (Median= 41.71, IQR= 21.31 to 71.38) as compared to those delivering AGA neonates (Median=37.58, IQR=19.05 to 73.57). Conclusion: The trajectory of sHLA-G during the course of pregnancy is not different between mothers delivering SGA and those delivering AGA. However, a trend towards higher sHLA-G levels at the first trimester was observed in mothers delivering SGA, which could be explored further in studies with larger sample sizes. Funding: “Department of Biotechnology, Ministry of Science and Technology, Government of India (BT/07/IYBA/2013-12), (grant BT/PR9983/MED/97/194/2013)” and “Grand Challenges India–All Children Thriving Program, Biotechnology Industry Research Assistance Council (grant BIRAC/GCI/0114/03/14-ACT)”. Keywords: India, SGA, pregnancy, sHLA-G

Commentary:

Acute uterine prolapse in third trimester of pregnancy: a case report

In this paper, the aim is to identify uncertain topological structures of stochastic multi-weighted complex networks (SMWCN), in which both time-varying delayed coupling and non-delayed coupling are considered. Distinguished from the previous work, graph theory and Lyapunov method are combined to research topology identification of SMWCN. Combining LaSalle-type invariance principle for stochastic differential equations and some strategies of inequalities, theoretical results about topology identification and partial topology identification of SMWCN are obtained under adaptive control and adaptive pinning control, respectively. Furthermore, by using the drive-response concept, response network can reach synchronization with drive network. In the end, two numerical simulations are provided to demonstrate the effectiveness and correctness of theoretical results, in which typical L\”{u} chaotic system is used to describe the vertex’s dynamical behavior.

ABSTRACT INTRODUCTION Nurses are the linchpin of Enhanced Recovery After Surgery (ERAS) program, as they are in direct contact with patients and various caregivers. The aim of the present survey was to assess ERAS key factors and challenges from a nurse perspective. METHODS Qualitative study among ERAS dedicated nurses and ERAS Interactive Audit System (EIAS) administrators using an online questionnaire (Survey Monkey®) yielding 29 questions. The survey focused on challenges and drawbacks encountered during ERAS training, implementation and daily clinical practice. Closed multiple choice- and open-end questions and semantic differential scales (0-10) were used. Panelists received 3 reminders within 4 and 8 weeks after invitation. RESULTS 123 out of 306 invited nurses completed the sur¬vey (response rate 40%). Overall, the success of the institutional ERAS program was rated a 6.9±2/10. Improving both patient outcomes (90%) and satisfaction (69%) were rated as main motivators for ERAS implementation, while time restraints (50%) and logistics (43%) were identified as main barriers. The study revealed a wide heterogeneity in coordination and management strategies (ERAS meetings, work models, teaching strategies). Sustained staff education before (9.1/10 ) and after (9.1/10) implementation, a dedicated ERAS coordinator (8.9/10) and regular meetings (8.3/10 scale) were rated as key factors for a successful program. Difficulty of implementation, maintenance and data acquisition were all rated >5/10. CONCLUSION Despite heterogeneity in coordination and management, ERAS program is evaluated assuccessfully from a nurse perspective. Continuous staff education and coordination beyond the implementation period appear to be of utmost importance for a sustained program.

Conifer forests worldwide are becoming increasingly vulnerable to the effects of climate change. Although phenolic compounds (PCs) have been shown to be modulated by biotic and abiotic stresses, the genetic basis underlying the variation in their basal composition remains poorly documented in conifers. We used QTL mapping and RNA-Seq to explore the complex polygenic network underlying the constitutive production of PCs in white spruce (Picea glauca) progeny for two years. QTL detection was performed for nine PCs and differentially expressed genes (DEGs) were identified between individuals with high and low PC contents for five PCs exhibiting stable QTLs across time. A total of 17 QTLs were detected for eight metabolites, including one major QTL explaining up to 91.3% of the neolignan-2 variance. The RNA-Seq analysis highlighted 50 DEGs associated with phenylpropanoid biosynthesis, several key transcription factors, and a subset of 137 genes showing opposite expression patterns in individuals with high levels of the flavonoids gallocatechin and taxifolin glucoside. A total of 19 DEGs co-localised with QTLs. Our findings represent a promising step towards resolving the genomic architecture of PC production in spruce and facilitate the functional characterization of genes and transcriptional networks responsible for differences in constitutive production of PCs in conifers.

In this study, we will implement new perceptions for the bright and dark soliton solutions to the modified nonlinear Schrödinger equation (MNLSE)or forms of the rogue wave modes for a derivative nonlinear Schrodinger model with positive linear dispersion which describe the propagation of rogue waves in Ocean engineering as well as all similar waves such as dynamics waveguides that have unexpected large displacements, the waves which occur only in the regime of positive cubic nonlinearity, regime that coincides exactly with the existence of instabilities of plane waves , long-wave limit of a breather (a pulsing mode). Two famous different schemas are involved for this purpose. The first schema is the solitary wave ansatze method (SWAM), while the second scheme is the extended simple equation method (ESEM). The two schemas are implemented in the same vein and parallel to construct new perceptions to the soliton solutions of this model. A comparison between the obtained new perceptions with the old perceptions that achieved previously by other authors has been demonstrated.

Background and purpose: Preclinical studies of MR309, a selective sigma1 receptor (σ1R) antagonist, support a potential role in treating neuropathic pain. We report two studies that provide insight into the pharmacokinetics (PK) and brain σ1R binding of MR309. Experimental approach: Steady-state PK of MR309 (400 mg QD and 200 mg BID for 10 days; EudraCT 2015-001818-99 [PK study]) and the relationship between MR309 plasma exposure and brain σ1R occupancy (EudraCT 2017-000670-11 [PET study]) were investigated in healthy volunteers. Positron emission tomography (PET) using the σ1R ligand [11C]SA4503 was conducted at baseline, 2h and 8h after a single dose of MR309 (200–800 mg). The relationship between brain σ1R occupancy and MR309 exposure was explored using data-driven model fitting. Key results: MR309 was well tolerated, brain σ1R occupancy ranged between 30.5% and 74.9% following single-dose MR309 (n=7). MR309 BID provided a plasma PK profile with less fluctuation than QD dosing (n=16). MR309 200 mg BID yielded average steady state plasma concentrations between 2000 and 4000 ng/mL in the PK study, which corresponded to an estimated brain σ1R occupancy of 59–74%. Conclusions and implications: MR309 200 mg BID dose was below the 75% σ1R occupancy threshold expected to elicit maximal antinociceptive effect as observed in neuropathic pain models. Further investigations of MR309 for neuropathic pain will require higher brain σ1R occupancy, and establish the optimal dose by elucidating the clinical impact of a broad range of brain σ1R occupancy across different neuropathic pain indications.

Immunization has been considered as a successful global health program that saves life of many persons each year. The vaccines reduce the risk of getting the disease by providing immunity in the body. Therefore, the constant availability of essential vaccines is an important factor in the health of the community. One of the most important vaccines worldwide is the diphtheria vaccine, which is usually given multivalent with tetanus and pertussis. It takes about 45 days to produce this vaccine from the time of initial culture to the production of the toxoid. If it is possible to carry out many stages of production under normal conditions and maintain the chemical intermediate, it will be a great help to produce this vaccine. In this study, the method of purification (by washing and chromatography) and storage of toxins for several months is presented. In this method, by concentrating the sample, it can be stored in a smaller space and there will be no problem in providing a suitable space. Another problem with the diphtheria vaccine is that it is reversible after detoxification of the toxin using formaldehyde. In order to solve this problem, it is suggested to use mPEG for detoxification, which will produce more stable covalent bonds between PEG and the first type of amine groups (-NH2) in the toxin chain. Therefore, we will have a stable product that the results of animal tests show that this product caused no wound or necrosis in the tested animals.

Climate change is expected to increase the frequency and severity of abiotic stresses (e.g., hot spell, salinity, drought), which might lead to loss of crop yield. We investigated the effect of salinity (S), short episodes of high temperature (HS) and combination of S+HS at the reproductive phase on seeds and dead pericarps properties of the crop plant Brassica juncea. Three interval exposures to HS resulted in massive seed abortion, and seeds from salt-treated plants germinated poorly. HS significantly reduced metabolites accumulated in dead pericarps, except for upregulation of isomaltose and cellobiose. Salt induced alteration in metabolite levels including increase in proline, reduction in TCA intermediates and changes in phytohormone levels. Proteome analysis revealed hundreds of proteins stored in dead pericarps whose levels and composition were altered under salt stress. The integration of metabolic and proteomic data showed that changes in metabolites were highly correlated with changes in proteins involved in their biosynthetic pathways. Thus, dead pericarps store beneficial substances whose level and composition are altered under stress conditions. The results highlighted the detrimental effect of short episodes of HS during the reproductive phase on crop production, which might have implications for global food security in the face of climate change.

We described three novel avastroviruses identified in dead wild crows by next-generation and Sanger sequencing. They shared 40-50% nucleotide identities to known avastroviruses, and formed a new cluster in the genus Avastrovirus. This study highlighted the continually expanding host range and increasing genetic diversity of avastroviruses.

Transient Myeloproliferative Disorder (TMD) is a rare diagnosis that clinicians should be aware of as early recognition and management is vital. There is little guidance regarding the details of management for TMD, with respect to dosing and duration of chemotherapy. We present our management in two cases of TMD.

Background: Left atrial appendage aneurysm (LAAA) is a rare cardiac disease with potentially life-threatening complications such as systemic thromboembolism, atrial tachyarrhythmia and cardiac dysfunction. Currently, early surgical intervention is recommended as the most suitable treatment to prevent these complications. Case introduction: In this case report, we describe a 58-year-old female patient admitted to the hospital with the main symptoms of active dyspnea and recurrent palpitations for 3 years, which had worsened for a week prior to presentation. The relevant literature was also reviewed to summarize the clinical features of LAAA and physical examination and diagnostic work-ups for patients, including those with no apparent symptoms. These findings will provide valuable information for further treatment options and facilitate necessary intervention measures to prevent serious complications.

With the expanding use of cardiac implantable electronic device (CIEDs) in older populations with more complicated conditions have bring about higher rates of CIED infections. We report four cases of CIED infections from single-center, who were extracted endocardial leads with intra-op transesophageal echocardiography (TEE) monitoring and guidance. Three of them had fatal complications as pulmonary embolism, pericardial tamponade and tricuspid trauma. The other one was found a massive vegetation detected by TEE not by pre-op transthoracic echocardiogram (TTE), which could avoid intra-op embolism. Application of TEE helps improving efficacy and safety by capacitating the operators to perform the procedure, guiding them to better plans and to rapidly recognize and manage relative complications. Thus, continuously intra-op TEE should be one of the routine monitoring methods in this high-risk procedure.