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Abstract Introduction: Transcatheter aortic valve-in-valve implantation (TAVI-ViV) can be associated with unfavorable hemodynamic outcomes. This study aimed to estimate the prevalence, identify the risk factors, and evaluate the outcomes and survival of patients with high residual gradients after TAVI-ViV. Methods: A total of 85 patients were included in the study. The cohort was divided into group A, with postprocedural mean pressure gradient (PG) ≥ 20 mmHg, and group B, with mean PG < 20 mmHg. Results: Postprocedural PG ≥ 20 mmHg was observed in 24.7% of the patients. In a univariate analysis, preoperative gradient, pre-existing patient-prosthesis mismatch (PPM), deep valve implantation, small degenerated valves, and an older generation of transcatheter aortic valves were found to be risk factors for high residual gradient. Multivariate analysis showed that preexisting maxPG > 60 mmHg, implantation level of 4 mm below neo-annulus, and degenerated valve size ≤ 23 mm were independent predictors of high residual gradient. There were no differences in early morbidity (myocardial infarction, pacemaker implantation, stroke, acute renal insufficiency) between groups. Kaplan-Meier estimated that the survival rate was comparable at one and five years regardless of postoperative gradient. Survivors with high residual mean gradient were significantly affected by a high New York Heart Association (NYHA) class. Conclusion: High residual transvalvular gradient after TAVI-ViV is not rare, but it does not significantly affect mortality. High residual mean gradient has a negative impact on NYHA functional class improvement after the procedure. High preoperative gradient, implantation level, and small failed bioprosthesis may predispose to increased residual gradient.

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Abstract Introduction: The objective of this study was to identify risk factors for deep sternal wound infection (DSWI) after off-pump coronary artery bypass (OPCAB) grafting surgery. Methods: A total of 8,442 patients undergoing OPCAB from April 1, 2009 to December 31, 2018 were retrospectively analyzed. A total of 956 were eventually enrolled on this study based on our exclusion criteria. All subjects were divided into two groups: group 1 (n=63) - DSWI; group 2 (n=893) - without DSWI. Patients were excluded if they had one of the following: acute coronary syndrome, conversion to OPCAB grafting surgery, redo procedure, concomitant cardiac surgery procedures. Results: The prevalence of body mass index (BMI) ≥40 kg/m2 (7.9% vs. 1.9%, respectively; P=0.01), lower extremity atherosclerotic artery disease (23.8% vs. 7.2%, respectively; P=0.001) and use of bilateral internal thoracic artery (19.5% vs. 2.5%, respectively; P=0.008) was significantly higher in patients with DSWI. The incidence of morbidities, including reoperation for bleeding (26.4% vs. 2.1%, respectively; P<0.001), stroke (4.8% vs. 0.8%, respectively; P=0.02), acute renal failure (7.9% vs. 0.8%, respectively; P=0.001), delirium (7.9% vs. 1.7%, respectively; P=0.008) and blood transfusion (30.6% vs. 9.8%, respectively; P<0.001) was significantly higher in patients with DSWI. Conclusions: A BMI of >40 kg/m2, lower extremity artery disease, use of bilateral internal thoracic artery (BITA) graft, postoperative stroke, sepsis, reoperation due to postoperative complications and blood product requirement significantly increased the risk of sternal infection after OPCAB.

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INTRODUCTION: Transcatheter aortic valve-in-valve implantation (TAVI-ViV) can be associated with unfavorable hemodynamic outcomes. This study aimed to estimate the prevalence, identify the risk factors, and evaluate the outcomes and survival of patients with high residual gradients after TAVI-ViV. METHODS: A total of 85 patients were included in the study. The cohort was divided into group A, with postprocedural mean pressure gradient (PG) ≥ 20 mmHg, and group B, with mean PG < 20 mmHg. RESULTS: Postprocedural PG ≥ 20 mmHg was observed in 24.7% of the patients. In a univariate analysis, preoperative gradient, pre-existing patient-prosthesis mismatch (PPM), deep valve implantation, small degenerated valves, and an older generation of transcatheter aortic valves were found to be risk factors for high residual gradient. Multivariate analysis showed that preexisting maxPG > 60 mmHg, implantation level of 4 mm below neo-annulus, and degenerated valve size ≤ 23 mm were independent predictors of high residual gradient. There were no differences in early morbidity (myocardial infarction, pacemaker implantation, stroke, acute renal insufficiency) between groups. Kaplan-Meier estimated that the survival rate was comparable at one and five years regardless of postoperative gradient. Survivors with high residual mean gradient were significantly affected by a high New York Heart Association (NYHA) class. CONCLUSION: High residual transvalvular gradient after TAVI-ViV is not rare, but it does not significantly affect mortality. High residual mean gradient has a negative impact on NYHA functional class improvement after the procedure. High preoperative gradient, implantation level, and small failed bioprosthesis may predispose to increased residual gradient.

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INTRODUCTION: The objective of this study was to identify risk factors for deep sternal wound infection (DSWI) after off-pump coronary artery bypass (OPCAB) grafting surgery. METHODS: A total of 8,442 patients undergoing OPCAB from April 1, 2009 to December 31, 2018 were retrospectively analyzed. A total of 956 were eventually enrolled on this study based on our exclusion criteria. All subjects were divided into two groups: group 1 (n=63) - DSWI; group 2 (n=893) - without DSWI. Patients were excluded if they had one of the following: acute coronary syndrome, conversion to OPCAB grafting surgery, redo procedure, concomitant cardiac surgery procedures. RESULTS: The prevalence of body mass index (BMI) ≥40 kg/m2 (7.9% vs. 1.9%, respectively; P=0.01), lower extremity atherosclerotic artery disease (23.8% vs. 7.2%, respectively; P=0.001) and use of bilateral internal thoracic artery (19.5% vs. 2.5%, respectively; P=0.008) was significantly higher in patients with DSWI. The incidence of morbidities, including reoperation for bleeding (26.4% vs. 2.1%, respectively; P<0.001), stroke (4.8% vs. 0.8%, respectively; P=0.02), acute renal failure (7.9% vs. 0.8%, respectively; P=0.001), delirium (7.9% vs. 1.7%, respectively; P=0.008) and blood transfusion (30.6% vs. 9.8%, respectively; P<0.001) was significantly higher in patients with DSWI. CONCLUSIONS: A BMI of >40 kg/m2, lower extremity artery disease, use of bilateral internal thoracic artery (BITA) graft, postoperative stroke, sepsis, reoperation due to postoperative complications and blood product requirement significantly increased the risk of sternal infection after OPCAB.

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INTRODUCTION: Open access (OA) publishing often requires article processing charges (APCs). While OA provides opportunities for broader readership, authors able to afford APCs are more commonly associated with well-funded, high-income country institutions, skewing knowledge dissemination. Here, we evaluate publishing models, OA practices, and APCs in cardiology and cardiac surgery. METHODS: The InCites Journal Citation Reports 2019 directory by Clarivate Analytics was searched for "Cardiac and Cardiovascular Systems" journals. Sister journals of included journals were identified. All journals were categorized as predominantly cardiology or cardiac surgery. Publishing models, APCs, and APC waivers were defined for all journals. RESULTS: One hundred sixty-one journals were identified (139 cardiology, 22 cardiac surgery). APCs ranged from $244 to $5,000 ($244-5,000 cardiology; $383-3,300 cardiac surgery), with mean $2,911±891 and median $3,000 (interquartile range [IQR]: $2,500-3,425) across 139 journals with non-zero available APCs ($2,970±890, median $3,000, IQR: $2,573-3,450, cardiology; $2,491±799, median $2,740, IQR: $2,300-3,000, cardiac surgery). Average APCs were $3,307±566 and median $3,250 (IQR: $3,000-3,500) for hybrid journals ($3,344±583, median $3,260, IQR: $3,000-3,690, cardiology; $2,983±221, median $2,975, IQR: $2,780-3,149, cardiac surgery) and $1,997±832 and median $2,100 (IQR: $1,404-2,538) for fully OA journals ($2,039±843, median $2,100, IQR: $1,419-2,604, cardiology; $1,788±805, median $2,000, IQR: $1,475-2,345, cardiac surgery). Waivers were available for 51 (86.4%) fully OA and 37 (37.4%) hybrid journals. Seventeen journals were fully OA without APCs, one journal did not yet release APCs, and four journals were subscription-only. CONCLUSION: OA publishing is common in cardiology and cardiac surgery with substantial APCs. Waivers remain limited, posing barriers for unfunded and lesser-funded researchers.

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Abstract Introduction: Destructive aortic root endocarditis is associated with high mortality rates. The objective of this article was to characterize the clinical and microbiological profiles of these patients, especially concerning an already implanted aortic valve prosthesis. We also focused on prognostic factors. Methods: Eighty patients underwent aortic root replacement due to destructive endocarditis from 1999 to 2018 in our institution. We analyzed their pre, intra, and postoperative data, outcomes, and predictors of mortality. Results: Thirty-one patients had native valve endocarditis (NVE), eight patients had early-onset prosthetic valve endocarditis (PVE), and 41 patients had late-onset PVE. Streptococcus was found in 19.4% of NVE cases and no PVE case. Coagulase-negative Staphylococcus was responsible for 62.5% of the cases of early-onset PVE. Thirty-four (42.5%) patients had received inappropriate antibiotics before admission. No microorganism was associated with higher risk of mortality. Aortoventricular dehiscence was identified as an independent risk factor of mortality along with PVE, concomitant bypass surgery, and delayed diagnosis. The incidence of postoperative complications was similar in all three groups. Rates of long-term survival (P=0.044) and freedom from the composite endpoint (P=0.024) defined as death, stroke, aortic valve reinfection, and aortic valve reoperation were the lowest within the NVE group and the highest among the PVE patients. Conclusion: In endocarditis, prolonged diagnostics, inadequate antimicrobial treatment, and late surgery led to destructive local complications and worsened the prognosis. PVE is associated with higher mortality than NVE.

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INTRODUCTION: This study aims to test the effect of phenytoin as an inhibitor of the process of dystrophic calcification in bovine pericardium and porcine leaflets implanted in the subcutaneous tissue of rats. METHODS: Isolated segments of biomaterials were implanted subcutaneously in young rats. The study groups received 500 mg phenytoin per kilogram of diet per day. After 90 days, samples were collected and quantitative calcification assessment by optical microscopy, radiological studies with mammography, and atomic emission spectrometry were performed. RESULTS: Inflammatory reaction was a frequent finding in all groups when analyzed by optical microscopy. The calcium level assessed by atomic absorption spectrophotometry was significantly lower in the study groups using phenytoin compared to the control groups (control bovine pericardium group X=0.254±0.280 µg/mg; study bovine pericardium group X=0.063±0.025 µg/mg; control porcine aortic leaflets group X=0.640±0.226 µg/mg; study porcine aortic leaflets group X=0.056±0.021 µg/mg; P<0.05). Radiologic studies revealed a statistically significant difference between the groups treated with and without phenytoin (not only regarding the bovine pericardium but also the porcine leaflets). CONCLUSION: The results obtained suggest that phenytoin reduces the calcification process of bovine pericardium segments and porcine aortic leaflets in subdermal implants in rats; also, the incidence of calcification in bovine pericardium grafts was similar to that of porcine aortic leaflets.

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Abstract Introduction: Open access (OA) publishing often requires article processing charges (APCs). While OA provides opportunities for broader readership, authors able to afford APCs are more commonly associated with well-funded, high-income country institutions, skewing knowledge dissemination. Here, we evaluate publishing models, OA practices, and APCs in cardiology and cardiac surgery. Methods: The InCites Journal Citation Reports 2019 directory by Clarivate Analytics was searched for "Cardiac and Cardiovascular Systems" journals. Sister journals of included journals were identified. All journals were categorized as predominantly cardiology or cardiac surgery. Publishing models, APCs, and APC waivers were defined for all journals. Results: One hundred sixty-one journals were identified (139 cardiology, 22 cardiac surgery). APCs ranged from $244 to $5,000 ($244-5,000 cardiology; $383-3,300 cardiac surgery), with mean $2,911±891 and median $3,000 (interquartile range [IQR]: $2,500-3,425) across 139 journals with non-zero available APCs ($2,970±890, median $3,000, IQR: $2,573-3,450, cardiology; $2,491±799, median $2,740, IQR: $2,300-3,000, cardiac surgery). Average APCs were $3,307±566 and median $3,250 (IQR: $3,000-3,500) for hybrid journals ($3,344±583, median $3,260, IQR: $3,000-3,690, cardiology; $2,983±221, median $2,975, IQR: $2,780-3,149, cardiac surgery) and $1,997±832 and median $2,100 (IQR: $1,404-2,538) for fully OA journals ($2,039±843, median $2,100, IQR: $1,419-2,604, cardiology; $1,788±805, median $2,000, IQR: $1,475-2,345, cardiac surgery). Waivers were available for 51 (86.4%) fully OA and 37 (37.4%) hybrid journals. Seventeen journals were fully OA without APCs, one journal did not yet release APCs, and four journals were subscription-only. Conclusion: OA publishing is common in cardiology and cardiac surgery with substantial APCs. Waivers remain limited, posing barriers for unfunded and lesser-funded researchers.

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INTRODUCTION: Destructive aortic root endocarditis is associated with high mortality rates. The objective of this article was to characterize the clinical and microbiological profiles of these patients, especially concerning an already implanted aortic valve prosthesis. We also focused on prognostic factors. METHODS: Eighty patients underwent aortic root replacement due to destructive endocarditis from 1999 to 2018 in our institution. We analyzed their pre, intra, and postoperative data, outcomes, and predictors of mortality. RESULTS: Thirty-one patients had native valve endocarditis (NVE), eight patients had early-onset prosthetic valve endocarditis (PVE), and 41 patients had late-onset PVE. Streptococcus was found in 19.4% of NVE cases and no PVE case. Coagulase-negative Staphylococcus was responsible for 62.5% of the cases of early-onset PVE. Thirty-four (42.5%) patients had received inappropriate antibiotics before admission. No microorganism was associated with higher risk of mortality. Aortoventricular dehiscence was identified as an independent risk factor of mortality along with PVE, concomitant bypass surgery, and delayed diagnosis. The incidence of postoperative complications was similar in all three groups. Rates of long-term survival (P=0.044) and freedom from the composite endpoint (P=0.024) defined as death, stroke, aortic valve reinfection, and aortic valve reoperation were the lowest within the NVE group and the highest among the PVE patients. CONCLUSION: In endocarditis, prolonged diagnostics, inadequate antimicrobial treatment, and late surgery led to destructive local complications and worsened the prognosis. PVE is associated with higher mortality than NVE.

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INTRODUCTION: The coronavirus disease 2019 (COVID-19) pandemic has been a worldwide challenge, and efforts to "flatten the curve," including restrictions imposed by policymakers and medical societies, have forced a reduction in the number of procedures performed in the Brazilian Health Care System. The aim of this study is to evaluate the outcomes of coronary artery bypass graft (CABG) from 2008 to 2020 in the SUS and to assess the impacts of the COVID-19 pandemic in the number of procedures and death rate of CABG performed in 2020 through the database DATASUS. METHODS: This study is based on publicly available material obtained from DATASUS, the Brazilian Ministry of Health's data processing system, on numbers of surgical procedures and death rates. Only isolated CABG procedures were included in our study. We used the TabNet software from the DATASUS website to generate reports. RESULTS: We identified 281,760 CABG procedures performed from January 2008 to December 2020. The average number of procedures until the end of 2019 was of 22,104. During 2020 there was a 25% reduction CABG procedures, to 16,501. There was an increase in the national death rate caused by a statistical significant increase in death rates in Brazil's Southeast and Central-west regions. CONCLUSION: The COVID-19 pandemic remains a global challenge for Brazil's health care system. During the year of 2020 there was a reduction in access to CABG related to an increase in the number of COVID-19 cases. There was also an increase in the national CABG death rate.

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Abstract Introduction: This study aims to test the effect of phenytoin as an inhibitor of the process of dystrophic calcification in bovine pericardium and porcine leaflets implanted in the subcutaneous tissue of rats. Methods: Isolated segments of biomaterials were implanted subcutaneously in young rats. The study groups received 500 mg phenytoin per kilogram of diet per day. After 90 days, samples were collected and quantitative calcification assessment by optical microscopy, radiological studies with mammography, and atomic emission spectrometry were performed. Results: Inflammatory reaction was a frequent finding in all groups when analyzed by optical microscopy. The calcium level assessed by atomic absorption spectrophotometry was significantly lower in the study groups using phenytoin compared to the control groups (control bovine pericardium group X=0.254±0.280 µg/mg; study bovine pericardium group X=0.063±0.025 µg/mg; control porcine aortic leaflets group X=0.640±0.226 µg/mg; study porcine aortic leaflets group X=0.056±0.021 µg/mg; P<0.05). Radiologic studies revealed a statistically significant difference between the groups treated with and without phenytoin (not only regarding the bovine pericardium but also the porcine leaflets). Conclusion: The results obtained suggest that phenytoin reduces the calcification process of bovine pericardium segments and porcine aortic leaflets in subdermal implants in rats; also, the incidence of calcification in bovine pericardium grafts was similar to that of porcine aortic leaflets.

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Epicardial adipose tissue (EAT) is correlated with endothelial dysfunction, metabolic syndrome, increased mortality and recent studies showed a possible association with the increased risk of stroke. We performed a systematic review of studies evaluating the association between EAT and stroke. Eighty studies met the inclusion criteria and were consequently analyzed. The review had Five main findings. First, the increased epicardial fat thickness (EFT) may be associated with the stroke episode. Second, regardless of the imaging method (echocardiography, MRI, and CT) this association remains. Third, the association of metabolic syndrome and atrial fibrillation seems to increase the risk of stroke. Fourth, this systematic review was considered as low risk of bias. Despite being unable to establish a clear association between EAT and stroke, we have organized and assessed all the research papers on this topic, analyzing their limitations, suggesting improvements in future pieces of research and pointing out gaps in the literature. Furthermore, the mechanistic links between increased EAT and stroke incidence remains unclear, thus, further research is warranted.

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BACKGROUND: There is a rising trend for transcatheter aortic valve implantation (TAVI) in bicuspid aortic stenosis patients. Data on the use of self-expandable (SEV) vs. balloon-expandable (BEV) valves in these patients are scarce. Therefore, we systematically compared clinical outcomes in bicuspid aortic stenosis patients treated with SEV and BEV. METHODS: Data were extracted from PubMed/MEDLINE, EMBASE, CENTRAL/CCTR, ClinicalTrials.gov, SciELO, LILACS, Google Scholar and reference lists of relevant articles. Eight studies published from 2013 to 2020 including a total of 1,080 patients (BEV: n = 620; SEV: n = 460) were selected. Primary endpoints were procedural, 30-day and 1-year mortality. Secondary endpoints were new pacemaker implantation, annular rupture, coronary obstruction, moderate-to-severe paravalvular leak, need of second valve, stroke and acute kidney injury. RESULTS: We found no statistically significant difference in mortality between patients treated with BEV vs. SEV during index procedure, at 30 days and at 1 year. BEVs showed a statistically significant higher risk of annulus rupture (2.5%) in comparison with SEV (0%) (OR 5.81 [95% CI, 3.78-8.92], p < .001). New generation BEVs were also associated with significantly less paravalvular leak when compared to new generation SEVs (OR 0.08 [95% CI, 0.02-0.35], p = .001). CONCLUSIONS: This meta-analysis of observational studies of TAVI for bicuspid valves, showed no difference in short- and mid-term TAVI mortality with BEVs and SEVs. BEVs presented a higher risk of annular rupture in comparison with SEV.

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BACKGROUND: Left ventricular aneurysms (LVA) are serious complications of myocardial infarction, being divided into true and false type. The false one-pseudoaneurysm (PA), is a life-threatening condition that requires urgent treatment due to the high risk of rupture. CASE PRESENTATION: An 84-year-old female presented with progressive heart failure symptoms. Investigation showed a small true LVA and a large PA. Open surgical repair was ruled out as Euroscore and Society of Thoracic Surgeons (STS) score were 42.80% and 39.97%, respectively. After discussion at our Heart Team meeting, percutaneous approach was found to be the best option. Guided by transesophageal echocardiography, we used an interventricular septal defect occluder to close the gap between the LV and the PA. Control ventriculography showed full closure of the gap, with no residual flow to the PA cavity. The patient was discharged from the hospital on the fifth postoperative day and has remained asymptomatic since then. CONCLUSION: Percutaneous approach proved to be a safe and effective modality to treat LV PA. The device implanted achieved the goal of blocking blood flow through the communication between LV and the PA.

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INTRODUCTION: The benefit of total arterial revascularization (TAR) in coronary artery bypass grafting (CABG) remains a controversial issue. This study sought to evaluate whether there is any difference on the long-term results of TAR and non-TAR CABG patients. METHODS: The Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica dataBASE (EMBASE), Cochrane Central Register of Controlled Trials (CENTRAL/CCTR), Clinical Trials.gov, Scientific Electronic Library Online (SciELO), Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS), and Google Scholar databases were searched for studies published by October 2020. Randomized clinical trials and observational studies with propensity score matching comparing TAR versus non-TAR CABG were included. Random-effects meta-analysis was performed. The current barriers to implementation of TAR in clinical practice and measures that can be used to optimize outcomes were reviewed. RESULTS: Fourteen publications (from 2012 to 2020) involving a total of 22,746 patients (TAR: 8,941 patients; non-TAR: 13,805 patients) were included. The pooled hazard ratio (HR) for long-term mortality (over 10 years) was lower in the TAR group than in the non-TAR group (random effect model: HR 0.676, 95% confidence interval 0.586-0.779, P<0.001). There was evidence of low heterogeneity of treatment effect among the studies for mortality, and none of the studies had a particular impact on the summary result. The result was not influenced by age, sex, or comorbidities. We identified low risk of publication bias related to this outcome. CONCLUSION: This review found that TAR presents the best long-term results in patients who undergo CABG. Given that many patients are likely to benefit from TAR, its use should be encouraged.

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Abstract Introduction: The benefit of total arterial revascularization (TAR) in coronary artery bypass grafting (CABG) remains a controversial issue. This study sought to evaluate whether there is any difference on the long-term results of TAR and non-TAR CABG patients. Methods: The Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica dataBASE (EMBASE), Cochrane Central Register of Controlled Trials (CENTRAL/CCTR), Clinical Trials.gov, Scientific Electronic Library Online (SciELO), Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS), and Google Scholar databases were searched for studies published by October 2020. Randomized clinical trials and observational studies with propensity score matching comparing TAR versus non-TAR CABG were included. Random-effects meta-analysis was performed. The current barriers to implementation of TAR in clinical practice and measures that can be used to optimize outcomes were reviewed. Results: Fourteen publications (from 2012 to 2020) involving a total of 22,746 patients (TAR: 8,941 patients; non-TAR: 13,805 patients) were included. The pooled hazard ratio (HR) for long-term mortality (over 10 years) was lower in the TAR group than in the non-TAR group (random effect model: HR 0.676, 95% confidence interval 0.586-0.779, P<0.001). There was evidence of low heterogeneity of treatment effect among the studies for mortality, and none of the studies had a particular impact on the summary result. The result was not influenced by age, sex, or comorbidities. We identified low risk of publication bias related to this outcome. Conclusion: This review found that TAR presents the best long-term results in patients who undergo CABG. Given that many patients are likely to benefit from TAR, its use should be encouraged.

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Aortic stenosis (AS) remains one of the most common valvular heart diseases, with enormous impact on patient survival. Over the past years, transcatheter aortic valve implantation (TAVI) has become a reality worldwide, offering a less invasive method to treat AS. Apart from the classical indications for aortic valve disease, recent studies tried to address unanswered questions for TAVI - asymptomatic severe AS, bicuspid aortic valves and moderate AS in patients with heart failure. This review discusses the rationale of those possible indications, pitfalls and current evidence in the medical literature.

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BACKGROUND: The adult type of anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) is characterized by late presentation due to collateral coronary flow. Patients often present with long time recurrent angina or dyspnea. Surgical correction can be a challenge due to the vast collateral coronary circulation. CASE PRESENTATION: A previously healthy 41-year-old male presented in the emergency room referring typical angina and dyspnea. Coronary angiography revealed ALCAPA. Surgical correction was indicated. Under cardiopulmonary bypass, the left main coronary artery ostium was isolated and directly reimplanted in the aorta. The patient was discharged from the hospital without complications and asymptomatic. Control coronary angiography showed enlarged left main coronary artery and regression of the collateral circulation. CONCLUSION: Even with a well-developed collateral circulation, detachment of the left coronary artery and direct implantation in the aorta is feasible, achieving good long-term results.

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