const pptxgen = require("pptxgenjs");
const fs = require("fs");

// Load pre-fetched images
const img0 = fs.readFileSync("/home/daytona/workspace/aortic-stenosis-ppt/img0.txt", "utf8"); // valve types
const img1 = fs.readFileSync("/home/daytona/workspace/aortic-stenosis-ppt/img1.txt", "utf8"); // natural history flowchart
const img2 = fs.readFileSync("/home/daytona/workspace/aortic-stenosis-ppt/img2.txt", "utf8"); // CW Doppler
const img3 = fs.readFileSync("/home/daytona/workspace/aortic-stenosis-ppt/img3.txt", "utf8"); // gross pathology

let pres = new pptxgen();
pres.layout = "LAYOUT_16x9";
pres.author = "MCh Cardiac Surgery Teaching";
pres.title = "Aortic Stenosis – MCh Cardiology Teaching Rounds";

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  gray:     "95A5A6",
  grayLt:   "BDC3C7",
};

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// ═══════════════════════════════════════════════════════════════════
// SLIDE 1 – TITLE SLIDE
// ═══════════════════════════════════════════════════════════════════
{
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  // Subtitle
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    fontSize: 18, color: C.grayLt, fontFace: "Calibri", italic: true
  });

  // Topic tags
  const tags = ["Rheumatic Heart Disease", "Pathophysiology", "Echocardiography", "Surgical Management", "TAVI"];
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    s.addShape(pres.shapes.RECTANGLE, {
      x: 0.4 + i * 1.92, y: 2.82, w: 1.78, h: 0.3,
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  s.addText("KEY EPIDEMIOLOGY", {
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    { text: "• 2-5% of adults >65 years have significant AS\n", options: {} },
    { text: "• Most common valvular heart disease in developed world\n", options: {} },
    { text: "• 50% mortality at 2-3 years once symptomatic\n", options: {} },
    { text: "• 100,000+ AVR procedures performed annually in USA", options: {} },
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  s.addText("SOURCES", {
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    fontSize: 9, bold: true, color: C.gold, fontFace: "Calibri",
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    { text: "• Braunwald's Heart Disease, 10th Ed.\n", options: {} },
    { text: "• Schwartz's Principles of Surgery, 11th Ed.\n", options: {} },
    { text: "• Sabiston Textbook of Surgery, 21st Ed.\n", options: {} },
    { text: "• Fuster & Hurst's The Heart, 15th Ed.\n", options: {} },
    { text: "• Otto: Textbook of Clinical Echocardiography", options: {} },
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  s.addText("MCh Cardiology Teaching Rounds  |  Aortic Stenosis", {
    x: 0.2, y: 5.37, w: 9.6, h: 0.255,
    fontSize: 8, color: C.gray, fontFace: "Calibri", valign: "middle"
  });
}


// ═══════════════════════════════════════════════════════════════════
// SLIDE 2 – OUTLINE / TABLE OF CONTENTS
// ═══════════════════════════════════════════════════════════════════
{
  let s = pres.addSlide();
  s.background = { color: C.navy };
  addHeader(s, "Lecture Outline", "MCh Cardiology Teaching Rounds");

  const sections = [
    { num: "01", title: "Rheumatic Heart Disease", sub: "ARF → Molecular mimicry → Chronic RHD → Valve pathology", color: C.crimson },
    { num: "02", title: "Etiology & Classification", sub: "Calcific · Bicuspid · Rheumatic – comparative features", color: C.crimsonLt },
    { num: "03", title: "Pathophysiology", sub: "Pressure overload · LV hypertrophy · Laplace law · Symptom triad", color: C.gold },
    { num: "04", title: "Clinical Features & Investigations", sub: "Examination findings · ECG · CXR · Cardiac catheterization", color: C.teal },
    { num: "05", title: "Echocardiography", sub: "Quantitation · Continuity equation · Low-flow low-gradient AS", color: "#3498DB" },
    { num: "06", title: "Staging & Indications for Intervention", sub: "2021 ACC/AHA Guidelines · Stage A–D3", color: "#9B59B6" },
    { num: "07", title: "Surgical Management", sub: "SAVR · Prosthetic valves · Root enlargement · TAVI · Ross", color: "#27AE60" },
    { num: "08", title: "Outcomes & Follow-up", sub: "Mortality data · Anticoagulation · SVD · Key trials", color: "#E67E22" },
  ];

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    const col = i < 4 ? 0 : 1;
    const row = i % 4;
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    const y = 0.95 + row * 1.15;

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      fontSize: 26, bold: true, color: sec.color,
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      x: x + 0.72, y: y + 0.22, w: 0.02, h: 0.56,
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      fontFace: "Calibri", valign: "top", margin: 0
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}


// ═══════════════════════════════════════════════════════════════════
// SLIDE 3 – RHEUMATIC HEART DISEASE
// ═══════════════════════════════════════════════════════════════════
{
  let s = pres.addSlide();
  s.background = { color: C.navy };
  addHeader(s, "Rheumatic Heart Disease", "Sabiston Surgery 21e · Braunwald's 10e");

  // Left panel – cascade
  addCard(s, 0.18, 0.95, 4.6, 4.5, { fill: C.navyMid, border: C.navyLt, accent: C.crimson, shadow: true });
  s.addText("THE RHEUMATIC CASCADE", {
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    fontSize: 9, bold: true, color: C.crimson, fontFace: "Calibri",
    valign: "middle", margin: 0, charSpacing: 1
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    { step: "01", text: "Group A β-hemolytic Streptococcal pharyngitis (GAS)", color: C.crimson },
    { step: "02", text: "Genetically susceptible host (HLA-DR2, DR4)", color: C.crimsonLt },
    { step: "03", text: "Molecular mimicry — M-protein vs. cardiac laminin", color: C.gold },
    { step: "04", text: "Cross-reactive T-cells & antibodies attack endocardium", color: C.gold },
    { step: "05", text: "Acute Rheumatic Valvulitis (2-6 wks post-infection)", color: C.teal },
    { step: "06", text: "Repeated strep exposures → cumulative valve damage", color: C.teal },
    { step: "07", text: "Commissural fusion + fibrosis → CHRONIC RHD", color: "#3498DB" },
  ];

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    const y = 1.4 + i * 0.55;
    s.addShape(pres.shapes.RECTANGLE, {
      x: 0.3, y, w: 0.42, h: 0.37,
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        fill: { color: C.gray }, line: { color: C.gray }
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  // Right panel – pathology details
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  s.addText("ASCHOFF BODY — PATHOGNOMONIC LESION", {
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    { text: "• Central fibrinoid necrosis\n", options: {} },
    { text: "• Anitschkow (caterpillar) cells — activated macrophages\n", options: {} },
    { text: "• Aschoff giant cells (multinucleated)\n", options: {} },
    { text: "• Verrucous endocarditis — 1-2 mm sterile vegetations at valve closure line\n", options: {} },
    { text: "• Pancarditis: endocardium + myocardium + pericardium", options: {} },
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    fontSize: 10, color: C.offWhite, fontFace: "Calibri", valign: "top"
  });

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  s.addImage({ data: img3, x: 5.0, y: 3.22, w: 2.2, h: 1.85 });
  s.addText("Rheumatic MV — 'fish-mouth' orifice", {
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    fontSize: 7.5, color: C.gray, fontFace: "Calibri", align: "center", italic: true, margin: 0
  });

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  s.addText("RHEUMATIC AV — KEY FEATURES", {
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    { text: "✦ Commissural fusion\n", options: { color: C.teal } },
    { text: "✦ Triangular orifice in systole\n", options: { color: C.teal } },
    { text: "✦ Mitral valve always involved\n", options: { color: C.offWhite } },
    { text: "✦ Mixed lesion: stenosis + regurgitation\n", options: { color: C.offWhite } },
    { text: "✦ Presents 4th–6th decade", options: { color: C.offWhite } },
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    fontSize: 9.5, fontFace: "Calibri", valign: "top"
  });
}


// ═══════════════════════════════════════════════════════════════════
// SLIDE 4 – ETIOLOGY & MORPHOLOGY (with image)
// ═══════════════════════════════════════════════════════════════════
{
  let s = pres.addSlide();
  s.background = { color: C.navy };
  addHeader(s, "Etiology & Valve Morphology", "Textbook of Clinical Echocardiography · Braunwald's");

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  s.addImage({ data: img0, x: 0.25, y: 1.0, w: 5.36, h: 4.0 });
  s.addText("Fig 11.5 — Textbook of Clinical Echocardiography: Aortic valve viewed from above. Top row: diastole. Bottom row: systole.", {
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    fontSize: 7.5, color: C.gray, fontFace: "Calibri", italic: true, align: "center"
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        "Most common in developed world",
        "Fibrocalcification at leaflet bases, aortic side",
        "NO commissural fusion (key!)",
        "Stellate-shaped orifice in systole",
        "Shared risk factors with atherosclerosis",
        "25% adults >65y have aortic sclerosis",
      ]
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    {
      title: "BICUSPID AORTIC VALVE", color: C.teal, age: "50s–60s",
      items: [
        "2/3 of severe AS in adults <70 y",
        "Prevalence ~1-2%, M:F = 3:1",
        "Accelerated calcification of congenital valve",
        "Elliptical orifice; diastolic sagging/systolic doming",
        "50% have associated aortopathy",
        "Right-left cusp fusion most common (~75%)",
      ]
    },
    {
      title: "RHEUMATIC", color: C.crimson, age: "40s–60s",
      items: [
        "Commissural fusion — pathognomonic",
        "Triangular orifice in systole",
        "Mitral valve ALWAYS involved",
        "Common in developing world",
        "Decreasing incidence with GAS treatment",
        "Mixed stenosis + regurgitation typical",
      ]
    },
  ];

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      x: 6.05, y: y + 0.36, w: 3.65, h: 1.0,
      fontSize: 9, color: C.offWhite, fontFace: "Calibri", valign: "top", margin: 0
    });
  });
}


// ═══════════════════════════════════════════════════════════════════
// SLIDE 5 – PATHOPHYSIOLOGY
// ═══════════════════════════════════════════════════════════════════
{
  let s = pres.addSlide();
  s.background = { color: C.navy };
  addHeader(s, "Pathophysiology", "Sabiston · Schwartz Principles of Surgery");

  // Top: Core mechanism
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  s.addText("CORE MECHANISM: Fixed outflow obstruction → ↑LV systolic pressure → Concentric LV Hypertrophy (Laplace Law: Wall Stress ∝ P × r / 2h)", {
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    fontSize: 11.5, bold: true, color: C.white, fontFace: "Calibri", valign: "middle", margin: 0
  });

  // LV response stages
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  s.addText("LV RESPONSE STAGES", {
    x: 0.35, y: 1.91, w: 5.8, h: 0.28,
    fontSize: 9, bold: true, color: C.teal, fontFace: "Calibri", valign: "middle", margin: 0, charSpacing: 1
  });

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    { stage: "Early decompensation", lv: "Diastolic dysfunction", hemo: "↑LVEDP, ↓compliance", col: C.gold },
    { stage: "Late decompensation", lv: "Systolic dysfunction", hemo: "Low CO, pulm. congestion", col: C.crimsonLt },
    { stage: "End-stage", lv: "Dilated LV, ↓EF", hemo: "Low-flow, low-gradient", col: C.crimson },
  ];

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    stageHeaders.map(h => ({ text: h, options: { bold: true, color: C.navy, fill: { color: C.navyLt }, fontSize: 8 } })),
    ...stages.map(st => [
      { text: st.stage, options: { bold: true, color: st.col, fontSize: 8.5 } },
      { text: st.lv, options: { color: C.offWhite, fontSize: 8.5 } },
      { text: st.hemo, options: { color: C.offWhite, fontSize: 8.5 } }
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    colW: [1.6, 2.3, 2.0],
    border: { pt: 0.5, color: C.navyLt },
    fill: { color: C.navyMid }
  });

  // Symptom triad
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  s.addText("CLASSIC SYMPTOM TRIAD", {
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    fontSize: 9, bold: true, color: C.crimson, fontFace: "Calibri", valign: "middle", margin: 0, charSpacing: 1
  });
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    { s: "Angina", y: "5-yr survival", col: C.gold },
    { s: "Syncope", y: "3-yr survival", col: C.crimsonLt },
    { s: "Heart Failure", y: "<2-yr survival", col: C.crimson },
  ];
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    s.addShape(pres.shapes.RECTANGLE, {
      x: 6.55 + i * 1.1, y: 2.28, w: 1.0, h: 0.82,
      fill: { color: C.navyLt }, line: { color: t.col, pt: 1.5 }
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    s.addText(t.s, {
      x: 6.55 + i * 1.1, y: 2.32, w: 1.0, h: 0.35,
      fontSize: 9, bold: true, color: t.col,
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    s.addText(t.y, {
      x: 6.55 + i * 1.1, y: 2.68, w: 1.0, h: 0.35,
      fontSize: 7.5, color: C.offWhite,
      fontFace: "Calibri", align: "center", margin: 0
    });
  });

  // Progression rates
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  s.addText("AVERAGE ANNUAL PROGRESSION (Schwartz)", {
    x: 0.35, y: 3.31, w: 4.3, h: 0.28,
    fontSize: 9, bold: true, color: C.gold, fontFace: "Calibri", valign: "middle", margin: 0, charSpacing: 1
  });
  const prog = [
    { label: "Peak Jet Velocity", val: "+0.3 m/s / yr" },
    { label: "Mean Gradient", val: "+7 mmHg / yr" },
    { label: "Valve Area", val: "−0.1 cm² / yr" },
  ];
  prog.forEach((p, i) => {
    s.addText(`${p.label}:`, {
      x: 0.32 + i * 1.52, y: 3.65, w: 1.1, h: 0.55,
      fontSize: 8.5, color: C.gray, fontFace: "Calibri", valign: "top", margin: 0
    });
    s.addText(p.val, {
      x: 0.32 + i * 1.52, y: 3.98, w: 1.45, h: 0.25,
      fontSize: 10, bold: true, color: C.gold, fontFace: "Calibri", valign: "middle", margin: 0
    });
  });

  // Natural history flowchart image (bottom half)
  addCard(s, 4.92, 3.28, 5.0, 2.1, { fill: C.navyMid, border: C.navyLt, shadow: true });
  s.addImage({ data: img1, x: 4.97, y: 3.32, w: 4.9, h: 1.9 });
  s.addText("Natural History & Management Overview (Fuster & Hurst, Ch. 28)", {
    x: 4.92, y: 5.25, w: 5.0, h: 0.2,
    fontSize: 7, color: C.gray, fontFace: "Calibri", italic: true, align: "center"
  });

  // Medical Rx note
  addCard(s, 0.18, 4.32, 4.6, 1.0, { fill: C.navyMid, border: C.navyLt, accent: C.crimson, shadow: true });
  s.addText("MEDICAL MANAGEMENT — KEY POINT", {
    x: 0.35, y: 4.35, w: 4.3, h: 0.28,
    fontSize: 9, bold: true, color: C.crimson, fontFace: "Calibri", valign: "middle", margin: 0, charSpacing: 1
  });
  s.addText("NO proven medical therapy modifies the natural history or slows progression of AS. Statins (SEAS/ASTRONOMER trials) showed no benefit. Medical Rx = bridge to surgery only.", {
    x: 0.32, y: 4.66, w: 4.35, h: 0.6,
    fontSize: 9, color: C.offWhite, fontFace: "Calibri", valign: "top", margin: 0
  });
}


// ═══════════════════════════════════════════════════════════════════
// SLIDE 6 – CLINICAL FEATURES & EXAMINATION
// ═══════════════════════════════════════════════════════════════════
{
  let s = pres.addSlide();
  s.background = { color: C.navy };
  addHeader(s, "Clinical Features & Physical Examination", "Braunwald's Heart Disease 10e");

  // Examination findings table
  addCard(s, 0.18, 0.95, 9.65, 0.35, { fill: C.navyLt, border: C.navyLt });
  s.addText("PHYSICAL EXAMINATION FINDINGS", {
    x: 0.25, y: 0.95, w: 9.5, h: 0.35,
    fontSize: 9, bold: true, color: C.white, fontFace: "Calibri",
    valign: "middle", margin: 0, charSpacing: 1
  });

  const examData = [
    [
      { text: "Finding", options: { bold: true, color: C.navy, fill: { color: C.navyLt } } },
      { text: "Sign", options: { bold: true, color: C.navy, fill: { color: C.navyLt } } },
      { text: "Mechanism", options: { bold: true, color: C.navy, fill: { color: C.navyLt } } }
    ],
    [
      { text: "Pulse", options: { bold: true, color: C.gold } },
      { text: "Pulsus parvus et tardus", options: { bold: true, color: C.offWhite } },
      { text: "Fixed reduced CO and delayed ejection", options: { color: C.grayLt } }
    ],
    [
      { text: "Apex Beat", options: { bold: true, color: C.gold } },
      { text: "Sustained, forceful, non-displaced", options: { bold: true, color: C.offWhite } },
      { text: "Concentric hypertrophy (thick walls, no dilation)", options: { color: C.grayLt } }
    ],
    [
      { text: "Murmur", options: { bold: true, color: C.crimson } },
      { text: "Harsh crescendo-decrescendo SEM, 2nd RICS → carotids", options: { bold: true, color: C.offWhite } },
      { text: "Turbulent flow through stenotic valve; late-peaking = more severe", options: { color: C.grayLt } }
    ],
    [
      { text: "S2", options: { bold: true, color: C.gold } },
      { text: "Absent A2 or single / paradoxically split S2", options: { bold: true, color: C.offWhite } },
      { text: "Calcified immobile leaflets; reduced aortic valve closure sound", options: { color: C.grayLt } }
    ],
    [
      { text: "S4 Gallop", options: { bold: true, color: C.gold } },
      { text: "Prominent S4", options: { bold: true, color: C.offWhite } },
      { text: "Forceful atrial kick into stiff non-compliant LV", options: { color: C.grayLt } }
    ],
    [
      { text: "Ejection Click", options: { bold: true, color: C.teal } },
      { text: "Early systolic click", options: { bold: true, color: C.offWhite } },
      { text: "Abrupt halt of mobile valve at max opening (bicuspid/early calcific)", options: { color: C.grayLt } }
    ],
    [
      { text: "Gallavardin Phenomenon", options: { bold: true, color: C.teal } },
      { text: "Musical component at apex (mimics MR)", options: { bold: true, color: C.offWhite } },
      { text: "High-frequency component of AS murmur radiates to apex", options: { color: C.grayLt } }
    ],
  ];

  s.addTable(examData, {
    x: 0.18, y: 1.33, w: 9.65, h: 3.2,
    colW: [1.8, 2.95, 4.9],
    border: { pt: 0.5, color: C.navyLt },
    fill: { color: C.navyMid }
  });

  // Pitfall box
  addCard(s, 0.18, 4.6, 9.65, 0.78, { fill: C.navyMid, border: C.crimson, accent: C.crimson, shadow: true });
  s.addText("⚠  CLINICAL PITFALL:", {
    x: 0.32, y: 4.63, w: 1.5, h: 0.72,
    fontSize: 10, bold: true, color: C.crimson, fontFace: "Calibri", valign: "middle", margin: 0
  });
  s.addText("Pulsus parvus et tardus may be ABSENT in elderly patients due to large artery stiffening — a common false-reassurance trap. Always confirm with Doppler echocardiography. The murmur intensity does NOT correlate with stenosis severity. (Braunwald's Heart Disease, Ch. 83)", {
    x: 1.85, y: 4.63, w: 7.9, h: 0.72,
    fontSize: 9.5, color: C.offWhite, fontFace: "Calibri", valign: "middle", margin: 0
  });
}


// ═══════════════════════════════════════════════════════════════════
// SLIDE 7 – ECHOCARDIOGRAPHY
// ═══════════════════════════════════════════════════════════════════
{
  let s = pres.addSlide();
  s.background = { color: C.navy };
  addHeader(s, "Echocardiographic Assessment", "Textbook of Clinical Echocardiography (Otto)");

  // Left: Severity grading table
  addCard(s, 0.18, 0.95, 4.5, 3.0, { fill: C.navyMid, border: C.navyLt, accent: C.teal, shadow: true });
  s.addText("ACC / AHA SEVERITY GRADING", {
    x: 0.35, y: 0.98, w: 4.2, h: 0.28,
    fontSize: 9, bold: true, color: C.teal, fontFace: "Calibri",
    valign: "middle", margin: 0, charSpacing: 1
  });

  const gradeData = [
    [
      { text: "Parameter", options: { bold: true, color: C.navy, fill: { color: C.navyLt }, fontSize: 8.5 } },
      { text: "Mild", options: { bold: true, color: C.navy, fill: { color: C.navyLt }, fontSize: 8.5 } },
      { text: "Moderate", options: { bold: true, color: C.navy, fill: { color: C.navyLt }, fontSize: 8.5 } },
      { text: "Severe", options: { bold: true, color: C.navy, fill: { color: C.navyLt }, fontSize: 8.5 } }
    ],
    [
      { text: "Peak Jet Velocity (m/s)", options: { color: C.offWhite, fontSize: 9 } },
      { text: "< 3.0", options: { color: C.teal, fontSize: 9 } },
      { text: "3.0–4.0", options: { color: C.gold, fontSize: 9 } },
      { text: "> 4.0", options: { bold: true, color: C.crimson, fontSize: 10 } }
    ],
    [
      { text: "Mean Gradient (mmHg)", options: { color: C.offWhite, fontSize: 9 } },
      { text: "< 25", options: { color: C.teal, fontSize: 9 } },
      { text: "25–40", options: { color: C.gold, fontSize: 9 } },
      { text: "> 40", options: { bold: true, color: C.crimson, fontSize: 10 } }
    ],
    [
      { text: "Valve Area (cm²)", options: { color: C.offWhite, fontSize: 9 } },
      { text: "> 1.5", options: { color: C.teal, fontSize: 9 } },
      { text: "1.0–1.5", options: { color: C.gold, fontSize: 9 } },
      { text: "< 1.0", options: { bold: true, color: C.crimson, fontSize: 10 } }
    ],
    [
      { text: "AVA Index (cm²/m²)", options: { color: C.offWhite, fontSize: 9 } },
      { text: "—", options: { color: C.gray, fontSize: 9 } },
      { text: "—", options: { color: C.gray, fontSize: 9 } },
      { text: "< 0.6", options: { bold: true, color: C.crimson, fontSize: 10 } }
    ],
    [
      { text: "DVI (velocity ratio)", options: { color: C.offWhite, fontSize: 9 } },
      { text: "> 0.50", options: { color: C.teal, fontSize: 9 } },
      { text: "0.25–0.50", options: { color: C.gold, fontSize: 9 } },
      { text: "< 0.25", options: { bold: true, color: C.crimson, fontSize: 10 } }
    ],
  ];

  s.addTable(gradeData, {
    x: 0.25, y: 1.3, w: 4.35, h: 2.55,
    colW: [1.75, 0.7, 0.85, 1.05],
    border: { pt: 0.5, color: C.navyLt },
    fill: { color: C.navyMid }
  });

  // Continuity equation
  addCard(s, 0.18, 4.02, 4.5, 1.37, { fill: C.navyMid, border: C.navyLt, accent: C.gold, shadow: true });
  s.addText("CONTINUITY EQUATION (Most Accurate)", {
    x: 0.35, y: 4.05, w: 4.2, h: 0.28,
    fontSize: 9, bold: true, color: C.gold, fontFace: "Calibri",
    valign: "middle", margin: 0, charSpacing: 1
  });
  s.addText("AVA = (CSA_LVOT × VTI_LVOT) / VTI_AV\n= 0.785 × D_LVOT² × VTI_LVOT / VTI_AV", {
    x: 0.32, y: 4.35, w: 4.25, h: 0.55,
    fontSize: 11, bold: true, color: C.white, fontFace: "Courier New", valign: "top", margin: 0
  });
  s.addText("Based on conservation of mass: flow through LVOT = flow through stenotic valve", {
    x: 0.32, y: 4.92, w: 4.25, h: 0.4,
    fontSize: 8.5, color: C.gray, fontFace: "Calibri", valign: "top", margin: 0
  });

  // Right: CW Doppler image
  addCard(s, 4.85, 0.95, 2.35, 4.44, { fill: C.navyMid, border: C.navyLt, shadow: true });
  s.addImage({ data: img2, x: 4.9, y: 1.0, w: 2.25, h: 3.85 });
  s.addText("CW Doppler: valvular AS vs. subaortic membrane vs. HCM (Otto)", {
    x: 4.85, y: 4.88, w: 2.35, h: 0.45,
    fontSize: 7, color: C.gray, fontFace: "Calibri", italic: true, align: "center"
  });

  // Low-flow low-gradient
  addCard(s, 7.32, 0.95, 2.52, 4.44, { fill: C.navyMid, border: C.navyLt, accent: C.crimson, shadow: true });
  s.addText("LOW-FLOW, LOW-GRADIENT AS", {
    x: 7.48, y: 0.98, w: 2.25, h: 0.3,
    fontSize: 8.5, bold: true, color: C.crimson, fontFace: "Calibri",
    valign: "middle", margin: 0, charSpacing: 0.5
  });

  s.addText("TYPE 1 — Reduced EF (<50%)", {
    x: 7.48, y: 1.32, w: 2.25, h: 0.25,
    fontSize: 8.5, bold: true, color: C.gold, fontFace: "Calibri", valign: "middle", margin: 0
  });
  s.addText([
    { text: "• AVA <1.0 cm², mean grad <40 mmHg, EF <50%\n", options: {} },
    { text: "• 'Pseudo-severe' vs true severe AS\n", options: {} },
    { text: "• Dobutamine stress echo: true severe → AVA stays <1.0, gradient rises\n", options: {} },
    { text: "• False severe → AVA opens >1.0 cm²", options: {} },
  ], {
    x: 7.48, y: 1.6, w: 2.25, h: 1.2,
    fontSize: 8.5, color: C.offWhite, fontFace: "Calibri", valign: "top", margin: 0
  });

  s.addShape(pres.shapes.RECTANGLE, {
    x: 7.4, y: 2.85, w: 2.4, h: 0.02,
    fill: { color: C.navyLt }, line: { color: C.navyLt }
  });

  s.addText("TYPE 2 — Preserved EF ≥50% (Paradoxical)", {
    x: 7.48, y: 2.9, w: 2.25, h: 0.3,
    fontSize: 8.5, bold: true, color: C.teal, fontFace: "Calibri", valign: "middle", margin: 0
  });
  s.addText([
    { text: "• AVA <1.0, grad <40, EF ≥50%, SVi <35 mL/m²\n", options: {} },
    { text: "• Small hypertrophied LV with ↓SV\n", options: {} },
    { text: "• More common in women/elderly/hypertensive\n", options: {} },
    { text: "• CT Ca score confirms: >2000 AU (men), >1200 AU (women)\n", options: {} },
    { text: "• Prognosis same as high-gradient AS; AVR beneficial", options: {} },
  ], {
    x: 7.48, y: 3.22, w: 2.25, h: 2.1,
    fontSize: 8.5, color: C.offWhite, fontFace: "Calibri", valign: "top", margin: 0
  });
}


// ═══════════════════════════════════════════════════════════════════
// SLIDE 8 – STAGING & INDICATIONS
// ═══════════════════════════════════════════════════════════════════
{
  let s = pres.addSlide();
  s.background = { color: C.navy };
  addHeader(s, "Staging & Indications for Intervention", "2021 ACC/AHA Valvular Heart Disease Guidelines");

  // Staging table
  addCard(s, 0.18, 0.95, 9.65, 0.28, { fill: C.navyLt, border: C.navyLt });
  s.addText("2021 ACC/AHA STAGING OF AORTIC STENOSIS", {
    x: 0.25, y: 0.95, w: 9.5, h: 0.28,
    fontSize: 8.5, bold: true, color: C.white, fontFace: "Calibri",
    valign: "middle", margin: 0, charSpacing: 1
  });

  const stageData2 = [
    ["Stage", "Definition", "Hemodynamics", "Symptoms", "LV Function"].map(h => ({
      text: h, options: { bold: true, color: C.navy, fill: { color: C.navyLt }, fontSize: 8 }
    })),
    [
      { text: "A — At Risk", options: { bold: true, color: C.teal, fontSize: 8.5 } },
      { text: "Risk factors for AS", options: { color: C.offWhite, fontSize: 8.5 } },
      { text: "None", options: { color: C.gray, fontSize: 8.5 } },
      { text: "None", options: { color: C.gray, fontSize: 8.5 } },
      { text: "Normal", options: { color: C.teal, fontSize: 8.5 } }
    ],
    [
      { text: "B — Progressive", options: { bold: true, color: C.teal, fontSize: 8.5 } },
      { text: "Mild–moderate AS", options: { color: C.offWhite, fontSize: 8.5 } },
      { text: "Vmax 2–3.9 m/s; mean grad <40; AVA >1.0", options: { color: C.offWhite, fontSize: 8.5 } },
      { text: "None", options: { color: C.gray, fontSize: 8.5 } },
      { text: "Normal or early remodeling", options: { color: C.teal, fontSize: 8.5 } }
    ],
    [
      { text: "C1 — Severe Asymptomatic EF≥50%", options: { bold: true, color: C.gold, fontSize: 8.5 } },
      { text: "Severe AS", options: { color: C.offWhite, fontSize: 8.5 } },
      { text: "Vmax ≥4 m/s; mean grad ≥40; AVA ≤1.0 cm²", options: { color: C.offWhite, fontSize: 8.5 } },
      { text: "None", options: { color: C.gray, fontSize: 8.5 } },
      { text: "LVEF ≥50%", options: { color: C.gold, fontSize: 8.5 } }
    ],
    [
      { text: "C2 — Severe Asymptomatic EF<50%", options: { bold: true, color: C.gold, fontSize: 8.5 } },
      { text: "Severe AS", options: { color: C.offWhite, fontSize: 8.5 } },
      { text: "As above", options: { color: C.offWhite, fontSize: 8.5 } },
      { text: "None", options: { color: C.gray, fontSize: 8.5 } },
      { text: "LVEF <50%", options: { bold: true, color: C.crimson, fontSize: 8.5 } }
    ],
    [
      { text: "D1 — Severe Symptomatic High-Gradient", options: { bold: true, color: C.crimson, fontSize: 8.5 } },
      { text: "Severe AS", options: { color: C.offWhite, fontSize: 8.5 } },
      { text: "Vmax ≥4 m/s; mean grad ≥40", options: { color: C.offWhite, fontSize: 8.5 } },
      { text: "Angina / Syncope / HF", options: { bold: true, color: C.crimson, fontSize: 8.5 } },
      { text: "Usually preserved EF", options: { color: C.offWhite, fontSize: 8.5 } }
    ],
    [
      { text: "D2 — Low-Flow, Low-Gradient, Low EF", options: { bold: true, color: C.crimson, fontSize: 8.5 } },
      { text: "Severe AS", options: { color: C.offWhite, fontSize: 8.5 } },
      { text: "AVA <1.0, grad <40", options: { color: C.offWhite, fontSize: 8.5 } },
      { text: "Symptoms present", options: { bold: true, color: C.crimson, fontSize: 8.5 } },
      { text: "LVEF <50%", options: { bold: true, color: C.crimson, fontSize: 8.5 } }
    ],
    [
      { text: "D3 — Paradoxical Low-Flow, Low-Gradient, EF≥50%", options: { bold: true, color: C.crimsonLt, fontSize: 8.5 } },
      { text: "Severe AS", options: { color: C.offWhite, fontSize: 8.5 } },
      { text: "AVA <1.0, grad <40, SVi <35 mL/m²", options: { color: C.offWhite, fontSize: 8.5 } },
      { text: "Symptoms present", options: { bold: true, color: C.crimson, fontSize: 8.5 } },
      { text: "LVEF ≥50%", options: { color: C.gold, fontSize: 8.5 } }
    ],
  ];

  s.addTable(stageData2, {
    x: 0.18, y: 1.26, w: 9.65, h: 2.55,
    colW: [2.3, 1.0, 2.4, 1.55, 2.4],
    border: { pt: 0.5, color: C.navyLt },
    fill: { color: C.navyMid }
  });

  // Indications
  const indBoxes = [
    {
      label: "CLASS I  (MUST DO)", color: C.teal, items: [
        "Symptomatic severe AS (Stage D1) → AVR",
        "Severe AS (any stage) undergoing other cardiac surgery",
        "Asymptomatic severe AS with LVEF <50% (Stage C2)",
      ]
    },
    {
      label: "CLASS IIa  (SHOULD DO)", color: C.gold, items: [
        "Asymptomatic very severe AS: Vmax ≥5 m/s or mean grad ≥60 mmHg (Stage C1)",
        "Asymptomatic severe AS undergoing non-cardiac surgery",
        "Low-flow, low-gradient AS with reduced EF confirmed by dobutamine stress echo (D2)",
      ]
    },
    {
      label: "CLASS IIb  (CONSIDER)", color: C.crimsonLt, items: [
        "Asymptomatic severe AS with rapid progression (+0.3 m/s/yr) or high institutional TAVI expertise",
        "Moderate AS undergoing cardiac surgery for other indications",
      ]
    },
  ];

  indBoxes.forEach((box, i) => {
    const x = 0.18 + i * 3.27;
    addCard(s, x, 3.88, 3.15, 1.5, { fill: C.navyMid, border: box.color, accent: box.color, shadow: true });
    s.addText(box.label, {
      x: x + 0.15, y: 3.91, w: 2.95, h: 0.28,
      fontSize: 8.5, bold: true, color: box.color, fontFace: "Calibri",
      valign: "middle", margin: 0, charSpacing: 0.5
    });
    s.addText(box.items.map(it => `• ${it}`).join("\n"), {
      x: x + 0.15, y: 4.22, w: 2.95, h: 1.1,
      fontSize: 8.5, color: C.offWhite, fontFace: "Calibri", valign: "top", margin: 0
    });
  });
}


// ═══════════════════════════════════════════════════════════════════
// SLIDE 9 – SURGICAL MANAGEMENT: SAVR
// ═══════════════════════════════════════════════════════════════════
{
  let s = pres.addSlide();
  s.background = { color: C.navy };
  addHeader(s, "Surgical Aortic Valve Replacement (SAVR)", "Schwartz's Principles of Surgery 11e · Sabiston 21e");

  // Left: Step-by-step
  addCard(s, 0.18, 0.95, 4.6, 4.5, { fill: C.navyMid, border: C.navyLt, accent: C.teal, shadow: true });
  s.addText("OPERATIVE STEPS", {
    x: 0.35, y: 0.98, w: 4.3, h: 0.28,
    fontSize: 9, bold: true, color: C.teal, fontFace: "Calibri",
    valign: "middle", margin: 0, charSpacing: 1
  });

  const steps = [
    "Median sternotomy — pericardial suspension",
    "Heparin 300–400 IU/kg (ACT >400 s)",
    "Aortic cannulation (distal ascending aorta)",
    "Venous cannulation (RA single stage or bicaval)",
    "CPB established — mild hypothermia 28–32°C",
    "Aortic cross-clamp applied",
    "Antegrade ± retrograde cold blood cardioplegia",
    "Transverse/oblique aortotomy 1.5-2 cm above RCA ostium",
    "Valve excision + meticulous annular decalcification",
    "Annular sizing — avoid patient-prosthesis mismatch",
    "Prosthesis implanted (interrupted pledgeted sutures)",
    "Aortotomy closed (two-layer felt-reinforced suture)",
    "De-airing maneuvers",
    "Aortic cross-clamp release; wean from CPB",
    "TEE assessment: gradient, paravalvular leak, LV function",
    "Protamine reversal; hemostasis; sternal closure",
  ];

  steps.forEach((step, i) => {
    const y = 1.33 + i * 0.26;
    s.addText(`${i + 1}.`, {
      x: 0.28, y, w: 0.28, h: 0.25,
      fontSize: 8.5, bold: true, color: C.teal,
      fontFace: "Calibri", valign: "middle", margin: 0
    });
    s.addText(step, {
      x: 0.55, y, w: 4.08, h: 0.25,
      fontSize: 8.5, color: C.offWhite,
      fontFace: "Calibri", valign: "middle", margin: 0
    });
  });

  // Top right: Prosthesis types
  addCard(s, 4.95, 0.95, 4.87, 2.25, { fill: C.navyMid, border: C.navyLt, accent: C.gold, shadow: true });
  s.addText("PROSTHETIC VALVE SELECTION", {
    x: 5.12, y: 0.98, w: 4.6, h: 0.28,
    fontSize: 9, bold: true, color: C.gold, fontFace: "Calibri",
    valign: "middle", margin: 0, charSpacing: 1
  });

  const prosthData = [
    ["", "Mechanical", "Bioprosthetic"].map(h => ({
      text: h, options: { bold: true, color: C.navy, fill: { color: C.navyLt }, fontSize: 8.5 }
    })),
    [
      { text: "Durability", options: { color: C.offWhite, fontSize: 8.5 } },
      { text: "30+ years (indefinite)", options: { color: C.teal, fontSize: 8.5, bold: true } },
      { text: "10–20 years (SVD risk)", options: { color: C.gold, fontSize: 8.5 } }
    ],
    [
      { text: "Anticoagulation", options: { color: C.offWhite, fontSize: 8.5 } },
      { text: "LIFELONG warfarin (INR 2.0–3.0)", options: { color: C.crimson, fontSize: 8.5 } },
      { text: "Aspirin only after 3–6 months", options: { color: C.teal, fontSize: 8.5, bold: true } }
    ],
    [
      { text: "Thromboembolism", options: { color: C.offWhite, fontSize: 8.5 } },
      { text: "~1–2%/year (with anticoag)", options: { color: C.gold, fontSize: 8.5 } },
      { text: "Lower", options: { color: C.teal, fontSize: 8.5 } }
    ],
    [
      { text: "Best for", options: { color: C.offWhite, fontSize: 8.5 } },
      { text: "Age <60 y, can tolerate anticoag", options: { color: C.offWhite, fontSize: 8.5 } },
      { text: "Age >65 y; sedentary; anticoag risk", options: { color: C.offWhite, fontSize: 8.5 } }
    ],
    [
      { text: "Types", options: { color: C.offWhite, fontSize: 8.5 } },
      { text: "Bileaflet (St Jude, CarboMedics)", options: { color: C.grayLt, fontSize: 8.5 } },
      { text: "Porcine, Bovine pericardial, Homograft", options: { color: C.grayLt, fontSize: 8.5 } }
    ],
  ];

  s.addTable(prosthData, {
    x: 5.05, y: 1.3, w: 4.7, h: 1.85,
    colW: [1.35, 1.7, 1.65],
    border: { pt: 0.5, color: C.navyLt },
    fill: { color: C.navyMid }
  });

  // Mid right: Root enlargement
  addCard(s, 4.95, 3.28, 4.87, 1.3, { fill: C.navyMid, border: C.navyLt, accent: C.crimsonLt, shadow: true });
  s.addText("AORTIC ROOT ENLARGEMENT (for small annuli / PPM prevention)", {
    x: 5.12, y: 3.31, w: 4.6, h: 0.28,
    fontSize: 9, bold: true, color: C.crimsonLt, fontFace: "Calibri",
    valign: "middle", margin: 0, charSpacing: 0.5
  });
  const rootPros = [
    { name: "Nicks", desc: "Incise non-coronary sinus into ant. MV leaflet → +1-2 sizes" },
    { name: "Manougian", desc: "NC/LC commissure through ant. MV leaflet → larger enlargement" },
    { name: "Konno-Rastan", desc: "Through RCA/RVOT into septum → maximal enlargement; risk: VSD, CHB" },
  ];
  rootPros.forEach((p, i) => {
    s.addText(`${p.name}:`, { x: 5.08, y: 3.62 + i * 0.3, w: 1.0, h: 0.28, fontSize: 9, bold: true, color: C.crimsonLt, fontFace: "Calibri", valign: "middle", margin: 0 });
    s.addText(p.desc, { x: 6.1, y: 3.62 + i * 0.3, w: 3.65, h: 0.28, fontSize: 9, color: C.offWhite, fontFace: "Calibri", valign: "middle", margin: 0 });
  });

  // PPM definition
  addCard(s, 4.95, 4.63, 4.87, 0.78, { fill: C.navyMid, border: C.navyLt, accent: C.gold, shadow: true });
  s.addText("PATIENT-PROSTHESIS MISMATCH (PPM):", {
    x: 5.12, y: 4.65, w: 4.6, h: 0.28,
    fontSize: 9, bold: true, color: C.gold, fontFace: "Calibri", valign: "middle", margin: 0
  });
  s.addText("Moderate PPM: indexed EOA <0.85 cm²/m² | Severe PPM: <0.65 cm²/m². Prevent with oversizing or root enlargement. Surgical mortality 1–3% (isolated AVR at experienced centres).", {
    x: 5.12, y: 4.95, w: 4.6, h: 0.43,
    fontSize: 9, color: C.offWhite, fontFace: "Calibri", valign: "top", margin: 0
  });
}


// ═══════════════════════════════════════════════════════════════════
// SLIDE 10 – TAVI
// ═══════════════════════════════════════════════════════════════════
{
  let s = pres.addSlide();
  s.background = { color: C.navy };
  addHeader(s, "Transcatheter Aortic Valve Implantation (TAVI/TAVR)", "Schwartz 11e · Braunwald's 10e · PARTNER / Evolut Trials");

  // Valve types side by side
  addCard(s, 0.18, 0.95, 4.6, 1.65, { fill: C.navyMid, border: C.navyLt, accent: C.teal, shadow: true });
  s.addText("TRANSCATHETER VALVE TYPES", {
    x: 0.35, y: 0.98, w: 4.3, h: 0.28,
    fontSize: 9, bold: true, color: C.teal, fontFace: "Calibri",
    valign: "middle", margin: 0, charSpacing: 1
  });

  // Balloon-expandable
  s.addShape(pres.shapes.RECTANGLE, { x: 0.25, y: 1.3, w: 2.15, h: 1.22, fill: { color: C.navyLt }, line: { color: C.navyLt } });
  s.addText("BALLOON-EXPANDABLE\n(Edwards SAPIEN 3/Ultra)", {
    x: 0.28, y: 1.32, w: 2.1, h: 0.38,
    fontSize: 8.5, bold: true, color: "#3498DB", fontFace: "Calibri", align: "center", margin: 0
  });
  s.addText("• Co-Cr stent + bovine pericardial leaflets\n• Rapid ventricular pacing during deployment\n• Precise annular positioning\n• PPM: 5–10%", {
    x: 0.28, y: 1.72, w: 2.1, h: 0.78,
    fontSize: 8.5, color: C.offWhite, fontFace: "Calibri", valign: "top", margin: 0
  });

  // Self-expanding
  s.addShape(pres.shapes.RECTANGLE, { x: 2.55, y: 1.3, w: 2.12, h: 1.22, fill: { color: C.navyLt }, line: { color: C.navyLt } });
  s.addText("SELF-EXPANDING\n(Medtronic CoreValve / Evolut)", {
    x: 2.58, y: 1.32, w: 2.09, h: 0.38,
    fontSize: 8.5, bold: true, color: C.teal, fontFace: "Calibri", align: "center", margin: 0
  });
  s.addText("• Nitinol frame + porcine pericardial\n• No rapid pacing; repositionable (Evolut R)\n• Supra-annular leaflets → better hemodynamics\n• PPM: 15–25% (AV node compression)", {
    x: 2.58, y: 1.72, w: 2.09, h: 0.78,
    fontSize: 8.5, color: C.offWhite, fontFace: "Calibri", valign: "top", margin: 0
  });

  // Access routes
  addCard(s, 0.18, 2.68, 4.6, 1.35, { fill: C.navyMid, border: C.navyLt, accent: C.gold, shadow: true });
  s.addText("ACCESS ROUTES", {
    x: 0.35, y: 2.71, w: 4.3, h: 0.28,
    fontSize: 9, bold: true, color: C.gold, fontFace: "Calibri",
    valign: "middle", margin: 0, charSpacing: 1
  });
  const routes = [
    { r: "Transfemoral (TF)", note: "~90% of cases — gold standard; ≥5.5 mm artery required", col: C.teal },
    { r: "Transaortic (TAo)", note: "Upper J ministernotomy; for severe PVD", col: C.gold },
    { r: "Transapical (TA)", note: "Anterolateral thoracotomy; LV apex antegrade", col: C.crimsonLt },
    { r: "Transaxillary/Subclavian", note: "Alternative when femoral unsuitable; ≥5.5 mm artery", col: "#9B59B6" },
  ];
  routes.forEach((r, i) => {
    s.addText(`${r.r}:`, { x: 0.32, y: 3.02 + i * 0.24, w: 1.75, h: 0.22, fontSize: 8.5, bold: true, color: r.col, fontFace: "Calibri", valign: "middle", margin: 0 });
    s.addText(r.note, { x: 2.1, y: 3.02 + i * 0.24, w: 2.55, h: 0.22, fontSize: 8.5, color: C.offWhite, fontFace: "Calibri", valign: "middle", margin: 0 });
  });

  // Key Trials table
  addCard(s, 0.18, 4.1, 4.6, 1.3, { fill: C.navyMid, border: C.navyLt, accent: C.crimson, shadow: true });
  s.addText("KEY LANDMARK TRIALS", {
    x: 0.35, y: 4.13, w: 4.3, h: 0.28,
    fontSize: 9, bold: true, color: C.crimson, fontFace: "Calibri",
    valign: "middle", margin: 0, charSpacing: 1
  });
  const trialsData = [
    ["Trial (Year)", "Population", "Key Finding"].map(h => ({
      text: h, options: { bold: true, color: C.navy, fill: { color: C.navyLt }, fontSize: 7.5 }
    })),
    [
      { text: "PARTNER B (2010)", options: { color: C.teal, fontSize: 8 } },
      { text: "Inoperable", options: { color: C.offWhite, fontSize: 8 } },
      { text: "TAVI: 50% RRR all-cause mortality vs. medical Rx", options: { color: C.offWhite, fontSize: 8 } }
    ],
    [
      { text: "PARTNER A (2011)", options: { color: C.teal, fontSize: 8 } },
      { text: "High risk", options: { color: C.offWhite, fontSize: 8 } },
      { text: "TAVI non-inferior to SAVR at 1 year", options: { color: C.offWhite, fontSize: 8 } }
    ],
    [
      { text: "PARTNER 2 (2016)", options: { color: C.gold, fontSize: 8 } },
      { text: "Intermediate risk", options: { color: C.offWhite, fontSize: 8 } },
      { text: "TAVI non-inferior; TF subgroup superior", options: { color: C.offWhite, fontSize: 8 } }
    ],
    [
      { text: "PARTNER 3 (2019)", options: { bold: true, color: C.crimson, fontSize: 8 } },
      { text: "Low risk", options: { color: C.offWhite, fontSize: 8 } },
      { text: "TAVI SUPERIOR to SAVR (composite endpoint at 1 yr)", options: { bold: true, color: C.crimson, fontSize: 8 } }
    ],
  ];
  s.addTable(trialsData, {
    x: 0.25, y: 4.44, w: 4.45, h: 0.9,
    colW: [1.3, 0.95, 2.2],
    border: { pt: 0.5, color: C.navyLt },
    fill: { color: C.navyMid }
  });

  // Right: Complications + SAVR vs TAVI guidance
  addCard(s, 4.95, 0.95, 4.87, 2.38, { fill: C.navyMid, border: C.navyLt, accent: C.crimson, shadow: true });
  s.addText("TAVI COMPLICATIONS", {
    x: 5.12, y: 0.98, w: 4.6, h: 0.28,
    fontSize: 9, bold: true, color: C.crimson, fontFace: "Calibri",
    valign: "middle", margin: 0, charSpacing: 1
  });

  const compsData = [
    ["Complication", "Rate", "Management"].map(h => ({
      text: h, options: { bold: true, color: C.navy, fill: { color: C.navyLt }, fontSize: 8 }
    })),
    [{ text: "Stroke", options: { color: C.offWhite, fontSize: 8 } }, { text: "2–5%", options: { color: C.crimson, fontSize: 8, bold: true } }, { text: "Cerebral embolic protection (Sentinel)", options: { color: C.grayLt, fontSize: 8 } }],
    [{ text: "Paravalvular leak", options: { color: C.offWhite, fontSize: 8 } }, { text: "5–15% trace-mild", options: { color: C.gold, fontSize: 8 } }, { text: "Post-dilatation; valve-in-valve if severe", options: { color: C.grayLt, fontSize: 8 } }],
    [{ text: "Permanent pacemaker", options: { color: C.offWhite, fontSize: 8 } }, { text: "SE 15–25%; BE 5–10%", options: { color: C.gold, fontSize: 8 } }, { text: "Permanent pacemaker implant", options: { color: C.grayLt, fontSize: 8 } }],
    [{ text: "Vascular access complications", options: { color: C.offWhite, fontSize: 8 } }, { text: "5–10%", options: { color: C.gold, fontSize: 8 } }, { text: "Surgical repair / covered stent", options: { color: C.grayLt, fontSize: 8 } }],
    [{ text: "Annular rupture", options: { color: C.offWhite, fontSize: 8 } }, { text: "<1%", options: { color: C.crimson, fontSize: 8, bold: true } }, { text: "Emergency surgery; often fatal", options: { color: C.crimson, fontSize: 8 } }],
    [{ text: "Coronary occlusion", options: { color: C.offWhite, fontSize: 8 } }, { text: "<1%", options: { color: C.crimson, fontSize: 8, bold: true } }, { text: "Emergency PCI/CABG; coronary protection wire", options: { color: C.grayLt, fontSize: 8 } }],
  ];

  s.addTable(compsData, {
    x: 5.05, y: 1.3, w: 4.7, h: 1.96,
    colW: [1.7, 1.2, 1.8],
    border: { pt: 0.5, color: C.navyLt },
    fill: { color: C.navyMid }
  });

  // SAVR vs TAVI decision
  addCard(s, 4.95, 3.42, 4.87, 1.98, { fill: C.navyMid, border: C.navyLt, accent: C.gold, shadow: true });
  s.addText("TAVI vs. SAVR — 2021 ACC/AHA DECISION GUIDE", {
    x: 5.12, y: 3.45, w: 4.6, h: 0.28,
    fontSize: 9, bold: true, color: C.gold, fontFace: "Calibri",
    valign: "middle", margin: 0, charSpacing: 0.5
  });

  const decData = [
    ["Age / Risk", "Preferred Approach"].map(h => ({
      text: h, options: { bold: true, color: C.navy, fill: { color: C.navyLt }, fontSize: 8.5 }
    })),
    [{ text: "< 65 years", options: { bold: true, color: C.teal, fontSize: 9 } }, { text: "SAVR preferred (better long-term data; TAVI durability uncertain)", options: { color: C.offWhite, fontSize: 8.5 } }],
    [{ text: "65–80 years", options: { bold: true, color: C.gold, fontSize: 9 } }, { text: "Shared decision — TAVI or SAVR (heart valve team)", options: { color: C.offWhite, fontSize: 8.5 } }],
    [{ text: "> 80 years / Prohibitive risk", options: { bold: true, color: C.crimson, fontSize: 9 } }, { text: "TAVI preferred", options: { bold: true, color: C.crimson, fontSize: 9 } }],
    [{ text: "Redo surgery / degenerated bioprosthesis", options: { color: C.offWhite, fontSize: 8.5 } }, { text: "Valve-in-Valve TAVI (avoids redo sternotomy)", options: { color: C.teal, fontSize: 8.5 } }],
  ];

  s.addTable(decData, {
    x: 5.05, y: 3.77, w: 4.7, h: 1.56,
    colW: [1.75, 2.95],
    border: { pt: 0.5, color: C.navyLt },
    fill: { color: C.navyMid }
  });
}


// ═══════════════════════════════════════════════════════════════════
// SLIDE 11 – SPECIAL PROCEDURES & OUTCOMES
// ═══════════════════════════════════════════════════════════════════
{
  let s = pres.addSlide();
  s.background = { color: C.navy };
  addHeader(s, "Special Procedures, Outcomes & Follow-up", "Schwartz 11e · Sabiston · Braunwald's");

  // Ross procedure
  addCard(s, 0.18, 0.95, 3.1, 2.68, { fill: C.navyMid, border: C.navyLt, accent: "#9B59B6", shadow: true });
  s.addText("ROSS PROCEDURE", {
    x: 0.35, y: 0.98, w: 2.85, h: 0.28,
    fontSize: 9, bold: true, color: "#9B59B6", fontFace: "Calibri",
    valign: "middle", margin: 0, charSpacing: 1
  });
  s.addText([
    { text: "Concept:\n", options: { bold: true, color: "#9B59B6" } },
    { text: "Native pulmonary valve → aortic position (autograft)\nHomograft → pulmonary position\n\n", options: { color: C.offWhite } },
    { text: "Advantages:\n", options: { bold: true, color: C.teal } },
    { text: "• Living autograft — grows with patient\n• No anticoagulation\n• Best hemodynamics\n• Endocarditis-resistant\n\n", options: { color: C.offWhite } },
    { text: "Best for:\n", options: { bold: true, color: C.gold } },
    { text: "Children, young adults, women of childbearing age, athletes\n\n", options: { color: C.offWhite } },
    { text: "Outcomes:\n", options: { bold: true, color: C.gray } },
    { text: "10-yr survival 90%; freedom from reoperation 75-80% at 15-20 yrs\nRisk: autograft dilatation; pulmonary homograft calcification", options: { color: C.offWhite } },
  ], {
    x: 0.32, y: 1.3, w: 2.9, h: 2.28,
    fontSize: 8.5, fontFace: "Calibri", valign: "top", margin: 0
  });

  // Bentall procedure
  addCard(s, 3.42, 0.95, 3.1, 2.68, { fill: C.navyMid, border: C.navyLt, accent: C.gold, shadow: true });
  s.addText("BENTALL PROCEDURE (Composite Root Replacement)", {
    x: 3.58, y: 0.98, w: 2.85, h: 0.36,
    fontSize: 9, bold: true, color: C.gold, fontFace: "Calibri",
    valign: "middle", margin: 0
  });
  s.addText([
    { text: "Indication:\n", options: { bold: true, color: C.gold } },
    { text: "AS + ascending aortic aneurysm OR bicuspid AS with aortopathy (≥4.5-5.0 cm)\n\n", options: { color: C.offWhite } },
    { text: "Classic Bentall:\n", options: { bold: true, color: C.crimsonLt } },
    { text: "Mechanical valve + Dacron graft — composite conduit; coronary reimplantation as buttons\n\n", options: { color: C.offWhite } },
    { text: "Tissue Bentall:\n", options: { bold: true, color: C.crimsonLt } },
    { text: "Bioprosthetic valve + Dacron graft (BioValsalva) — avoids anticoagulation\n\n", options: { color: C.offWhite } },
    { text: "David Procedure (Valve-Sparing):\n", options: { bold: true, color: C.teal } },
    { text: "Native valve reimplanted into Dacron tube. Ideal when valve morphology is good (no calcification). Avoids prosthesis entirely.", options: { color: C.offWhite } },
  ], {
    x: 3.58, y: 1.38, w: 2.88, h: 2.2,
    fontSize: 8.5, fontFace: "Calibri", valign: "top", margin: 0
  });

  // Redo AVR
  addCard(s, 6.66, 0.95, 3.17, 2.68, { fill: C.navyMid, border: C.navyLt, accent: C.crimson, shadow: true });
  s.addText("REDO AVR — SPECIAL CONSIDERATIONS", {
    x: 6.82, y: 0.98, w: 2.92, h: 0.36,
    fontSize: 9, bold: true, color: C.crimson, fontFace: "Calibri",
    valign: "middle", margin: 0
  });
  s.addText([
    { text: "Redo sternotomy risks:\n", options: { bold: true, color: C.crimson } },
    { text: "• Adhesions → injury to patent grafts (RIMA, SVG)\n• Higher morbidity and mortality (5–10%)\n• Cannulation: femoral or axillary first\n\n", options: { color: C.offWhite } },
    { text: "Valve-in-Valve TAVI:\n", options: { bold: true, color: C.teal } },
    { text: "• TAVI inside degenerated bioprosthesis\n• Avoids redo sternotomy entirely\n• VIVID registry: good outcomes\n• Risk: coronary obstruction if tall leaflets → coronary protection wire mandatory\n• Ideal for high-risk redo patients", options: { color: C.offWhite } },
  ], {
    x: 6.82, y: 1.38, w: 2.94, h: 2.2,
    fontSize: 8.5, fontFace: "Calibri", valign: "top", margin: 0
  });

  // Outcomes
  addCard(s, 0.18, 3.72, 9.65, 0.35, { fill: C.navyLt, border: C.navyLt });
  s.addText("OUTCOMES & POST-OPERATIVE MANAGEMENT", {
    x: 0.25, y: 3.72, w: 9.5, h: 0.35,
    fontSize: 9, bold: true, color: C.white, fontFace: "Calibri",
    valign: "middle", margin: 0, charSpacing: 1
  });

  const outData = [
    [
      { text: "Procedure", options: { bold: true, color: C.navy, fill: { color: C.navyLt }, fontSize: 8.5 } },
      { text: "30-day Mortality", options: { bold: true, color: C.navy, fill: { color: C.navyLt }, fontSize: 8.5 } },
      { text: "5-yr Survival", options: { bold: true, color: C.navy, fill: { color: C.navyLt }, fontSize: 8.5 } },
      { text: "Anticoagulation", options: { bold: true, color: C.navy, fill: { color: C.navyLt }, fontSize: 8.5 } },
      { text: "Follow-up Echo", options: { bold: true, color: C.navy, fill: { color: C.navyLt }, fontSize: 8.5 } },
    ],
    [
      { text: "Isolated SAVR (elective)", options: { color: C.offWhite, fontSize: 8.5 } },
      { text: "1–3%", options: { color: C.teal, bold: true, fontSize: 9 } },
      { text: "~80%", options: { color: C.teal, fontSize: 8.5 } },
      { text: "Tissue: Aspirin ± warfarin 3-6 mo; Mechanical: Warfarin lifelong (INR 2.0–3.0)", options: { color: C.offWhite, fontSize: 8.5 } },
      { text: "Every 3–5 years (stable bioprosthesis)", options: { color: C.offWhite, fontSize: 8.5 } }
    ],
    [
      { text: "SAVR + CABG", options: { color: C.offWhite, fontSize: 8.5 } },
      { text: "3–5%", options: { color: C.gold, bold: true, fontSize: 9 } },
      { text: "~70%", options: { color: C.gold, fontSize: 8.5 } },
      { text: "As per prosthesis type + DAPT post-CABG", options: { color: C.offWhite, fontSize: 8.5 } },
      { text: "Every 3–5 years", options: { color: C.offWhite, fontSize: 8.5 } }
    ],
    [
      { text: "TAVI (transfemoral, low risk)", options: { color: C.offWhite, fontSize: 8.5 } },
      { text: "<2%", options: { color: C.teal, bold: true, fontSize: 9 } },
      { text: "~85%", options: { color: C.teal, fontSize: 8.5 } },
      { text: "DAPT 3–6 months → aspirin alone; warfarin if AF", options: { color: C.offWhite, fontSize: 8.5 } },
      { text: "Annual (assess SVD, thrombosis, PVL)", options: { color: C.offWhite, fontSize: 8.5 } }
    ],
    [
      { text: "Redo Sternotomy AVR", options: { color: C.offWhite, fontSize: 8.5 } },
      { text: "5–10%", options: { color: C.crimsonLt, bold: true, fontSize: 9 } },
      { text: "~65%", options: { color: C.gold, fontSize: 8.5 } },
      { text: "As per new prosthesis type", options: { color: C.offWhite, fontSize: 8.5 } },
      { text: "Every 3–5 years", options: { color: C.offWhite, fontSize: 8.5 } }
    ],
  ];

  s.addTable(outData, {
    x: 0.18, y: 4.1, w: 9.65, h: 1.3,
    colW: [1.9, 1.1, 1.0, 3.5, 2.15],
    border: { pt: 0.5, color: C.navyLt },
    fill: { color: C.navyMid }
  });
}


// ═══════════════════════════════════════════════════════════════════
// SLIDE 12 – SUMMARY / TAKE-HOME
// ═══════════════════════════════════════════════════════════════════
{
  let s = pres.addSlide();
  s.background = { color: C.navy };

  // Top bar
  s.addShape(pres.shapes.RECTANGLE, {
    x: 0, y: 0, w: 10, h: 1.1,
    fill: { color: C.navyMid }, line: { color: C.navyMid }
  });
  s.addShape(pres.shapes.RECTANGLE, {
    x: 0, y: 0, w: 0.18, h: 1.1,
    fill: { color: C.crimson }, line: { color: C.crimson }
  });
  s.addText("TAKE-HOME MESSAGES", {
    x: 0.3, y: 0, w: 9.5, h: 0.65,
    fontSize: 30, bold: true, color: C.white,
    fontFace: "Calibri", valign: "middle", charSpacing: 2
  });
  s.addText("Aortic Stenosis — MCh Cardiology Teaching Rounds", {
    x: 0.3, y: 0.65, w: 9.5, h: 0.45,
    fontSize: 13, color: C.grayLt, fontFace: "Calibri", italic: true
  });

  const takeHome = [
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    { n: "02", txt: "Calcific AS is most common in developed world; bicuspid AV accounts for 2/3 of AS in adults <70 yrs. Bicuspid carries 50% risk of associated aortopathy — always screen the aorta.", col: C.gold },
    { n: "03", txt: "Symptom onset is the critical inflection point. The '5-3-2 rule': angina (5-yr survival), syncope (3 yr), heart failure (<2 yr). 50% mortality without intervention once symptomatic.", col: C.teal },
    { n: "04", txt: "Echo is definitive: AVA <1.0 cm², mean gradient >40 mmHg, Vmax >4 m/s = severe. The continuity equation (conservation of mass) is the most accurate method for AVA calculation.", col: "#3498DB" },
    { n: "05", txt: "NO medical therapy slows AS progression. BAV is a bridge, not a cure (in calcific AS). AVR is the only definitive treatment with dramatic improvement in survival and quality of life.", col: "#9B59B6" },
    { n: "06", txt: "TAVI has revolutionised management. PARTNER 3 (2019) showed TAVI superior to SAVR in low-risk patients at 1 year. Age <65 → SAVR preferred; 65–80 → shared decision; >80 → TAVI preferred.", col: "#E67E22" },
    { n: "07", txt: "For small annuli — prevent PPM with root enlargement (Nicks/Manougian/Konno). Ross procedure (pulmonary autograft) is best for young patients requiring durable, anticoagulation-free valve.", col: "#27AE60" },
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    fontSize: 7, color: C.gray, fontFace: "Calibri", valign: "middle"
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// ─── WRITE FILE ────────────────────────────────────────────────────
pres.writeFile({ fileName: "/home/daytona/workspace/aortic-stenosis-ppt/Aortic_Stenosis_MCh_Teaching_Rounds.pptx" })
  .then(() => console.log("✅ Presentation written successfully!"))
  .catch(err => { console.error("ERROR:", err); process.exit(1); });

const pptxgen = require("pptxgenjs");
const fs = require("fs");

const img0 = fs.readFileSync("/home/daytona/workspace/aortic-stenosis-ppt/img0.txt","utf8"); // valve types
const img1 = fs.readFileSync("/home/daytona/workspace/aortic-stenosis-ppt/img1.txt","utf8"); // natural history
const img2 = fs.readFileSync("/home/daytona/workspace/aortic-stenosis-ppt/img2.txt","utf8"); // CW Doppler
const img3 = fs.readFileSync("/home/daytona/workspace/aortic-stenosis-ppt/img3.txt","utf8"); // gross path

let pres = new pptxgen();
pres.layout = "LAYOUT_16x9";
pres.title = "Aortic Stenosis — MCh Cardiology Teaching Rounds";

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}


// ════════════════════════════════════════════════════════════════
// SLIDE 1 — TITLE
// ════════════════════════════════════════════════════════════════
{
  let s = pres.addSlide(); bg(s);
  s.addShape(pres.shapes.RECTANGLE,{x:0,y:0,w:0.22,h:H,fill:{color:C.crimson},line:{color:C.crimson}});
  s.addShape(pres.shapes.RECTANGLE,{x:0.22,y:2.5,w:W-0.22,h:0.04,fill:{color:C.panel},line:{color:C.panel}});

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  s.addText("A Comprehensive Review for MCh Cardiology Teaching Rounds",{x:0.42,y:2.0,w:9.3,h:0.55,fontSize:16,color:C.grayLt,fontFace:"Calibri",italic:true});

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    s.addShape(pres.shapes.RECTANGLE,{x:0.42+i*1.37,y:2.7,w:1.28,h:0.28,fill:{color:C.mid},line:{color:C.panel,pt:0.8}});
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  });

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  stats.forEach(([n,l,c],i)=>{ statBox(s,0.42+i*2.38,3.12,2.22,1.92,n,l,c); });
  footer(s,"Sources: Braunwald's Heart Disease 10e · Schwartz's Principles of Surgery 11e · Sabiston Textbook of Surgery 21e · Fuster & Hurst's The Heart 15e · Otto: Textbook of Clinical Echocardiography");
}

// ════════════════════════════════════════════════════════════════
// SLIDE 2 — CONTENTS
// ════════════════════════════════════════════════════════════════
{
  let s = pres.addSlide(); bg(s);
  hdr(s,"Lecture Outline");

  const secs=[
    {n:"01",t:"Rheumatic Heart Disease",d:"ARF · Molecular mimicry · Aschoff body · Chronic RHD",c:C.crimson},
    {n:"02",t:"Etiology & Classification",d:"Calcific · Bicuspid · Rheumatic — comparative morphology",c:C.red2},
    {n:"03",t:"Pathophysiology",d:"Pressure overload · Concentric hypertrophy · Laplace law",c:C.gold},
    {n:"04",t:"Natural History & Symptom Triad",d:"5-3-2 rule · Angina · Syncope · Heart failure",c:C.orange},
    {n:"05",t:"Clinical Features",d:"Examination · Pulsus parvus et tardus · Gallavardin · S2/S4",c:C.teal},
    {n:"06",t:"Investigations",d:"ECG · CXR · Cardiac catheterization · Gorlin formula",c:C.blue},
    {n:"07",t:"Echocardiography",d:"Continuity equation · Grading · Low-flow low-gradient AS",c:C.purple},
    {n:"08",t:"Staging & Indications",d:"2021 ACC/AHA Stages A–D3 · Class I / IIa / IIb",c:C.green},
    {n:"09",t:"Surgical Management (SAVR)",d:"Operative steps · Prosthesis types · Root enlargement",c:C.teal},
    {n:"10",t:"TAVI / Special Procedures",d:"PARTNER trials · Valve types · Ross · Bentall · Redo AVR",c:C.orange},
  ];

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  });
  footer(s);
}

// ════════════════════════════════════════════════════════════════
// SLIDE 3 — SECTION DIVIDER: RHEUMATIC HEART DISEASE
// ════════════════════════════════════════════════════════════════
{ sectionTitle(pres.addSlide(),"01","Rheumatic Heart Disease","From Group A Streptococcal Pharyngitis to Chronic Valve Damage",C.crimson); }

// ════════════════════════════════════════════════════════════════
// SLIDE 4 — ACUTE RHEUMATIC FEVER: MECHANISM
// ════════════════════════════════════════════════════════════════
{
  let s = pres.addSlide(); bg(s);
  hdr(s,"Acute Rheumatic Fever — Pathogenesis","Sabiston Textbook of Surgery 21e");

  // Left flow arrows
  const steps=[
    {t:"Group A β-hemolytic Streptococcal Pharyngitis",c:C.crimson},
    {t:"Genetically susceptible host  (HLA-DR2, DR4 alleles)",c:C.red2},
    {t:"MOLECULAR MIMICRY\nStreptococcal M-protein ↔ Cardiac laminin",c:C.gold},
    {t:"Cross-reactive T-cells & antibodies\nattack the cardiac endocardium",c:C.orange},
    {t:"Acute Rheumatic Valvulitis\n(2–6 weeks post-infection)",c:C.teal},
  ];

  steps.forEach((st,i)=>{
    card(s,0.2,0.93+i*0.86,4.55,0.72,C.mid,st.c);
    s.addText(st.t,{x:0.35,y:0.93+i*0.86,w:4.3,h:0.72,fontSize:11.5,bold:i===2,color:i===2?C.gold:C.off,fontFace:"Calibri",valign:"middle",margin:0});
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    }
  });

  // Right: Jones Criteria
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  pill(s,"REVISED JONES CRITERIA (2015)",4.93,0.93,C.blue);
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  card(s,4.93,3.15,4.9,1.6,C.mid,C.gold);
  pill(s,"MINOR CRITERIA",4.93,3.15,C.gold);
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}

// ════════════════════════════════════════════════════════════════
// SLIDE 5 — ASCHOFF BODY & VALVULAR PATHOLOGY
// ════════════════════════════════════════════════════════════════
{
  let s = pres.addSlide(); bg(s);
  hdr(s,"Rheumatic Carditis — Pathological Features","Braunwald's Heart Disease 10e · Sabiston 21e");

  // Aschoff body
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  pill(s,"ASCHOFF BODY — PATHOGNOMONIC LESION",0.2,0.93,C.gold);
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    "Central area of FIBRINOID NECROSIS",
    "Anitschkow cells (caterpillar cells) — activated macrophages with owl-eye nuclei",
    "Aschoff giant cells — multinucleated",
    "Perivascular granulomatous inflammation",
    "Found in myocardium; heals by fibrosis",
  ],0.32,1.25,4.35,2.2,{fs:11});

  // Valvular pathology
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  pill(s,"ACUTE VALVULAR CHANGES",0.2,3.68,C.crimson);
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    "Verrucous endocarditis: 1–2 mm sterile vegetations along line of valve closure",
    "Mitral valve most affected (65–70%) → combined mitral + aortic (25%)",
    "Chordal involvement: oedema → later fusion and shortening",
    "Pancarditis: endocarditis + myocarditis + pericarditis",
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  s.addImage({data:img3,x:5.0,y:0.98,w:4.75,h:3.35});
  s.addText("Gross specimen: rheumatic valve — fused leaflets forming slit-like orifice (Sabiston, Fig. 112.12)",{x:4.93,y:4.36,w:4.9,h:0.32,fontSize:8,color:C.gray,fontFace:"Calibri",italic:true,align:"center",margin:0});

  // Chronic RHD note
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  s.addText("CHRONIC RHD: Repeated streptococcal exposures → cumulative valve damage → commissural fusion + fibrosis → stenosis. Develops silently over 10–40 years.",{x:5.05,y:4.73,w:4.7,h:0.63,fontSize:9.5,color:C.off,fontFace:"Calibri",valign:"middle",margin:0});
  footer(s);
}

// ════════════════════════════════════════════════════════════════
// SLIDE 6 — SECTION: ETIOLOGY
// ════════════════════════════════════════════════════════════════
{ sectionTitle(pres.addSlide(),"02","Etiology & Classification","Calcific · Bicuspid · Rheumatic — Morphology & Distinguishing Features",C.gold); }

// ════════════════════════════════════════════════════════════════
// SLIDE 7 — THREE CAUSES WITH IMAGE
// ════════════════════════════════════════════════════════════════
{
  let s = pres.addSlide(); bg(s);
  hdr(s,"Causes of Aortic Stenosis — Valve Morphology","Textbook of Clinical Echocardiography (Otto)");

  card(s,0.2,0.93,5.55,4.45,C.mid);
  s.addImage({data:img0,x:0.27,y:0.97,w:5.41,h:4.1});
  s.addText("Fig 11.5 — TTE parasternal short-axis. Top: diastole. Bottom: systole. (Otto: Textbook of Clinical Echocardiography)",{x:0.2,y:5.05,w:5.55,h:0.3,fontSize:7.5,color:C.gray,fontFace:"Calibri",italic:true,align:"center"});

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    {t:"CALCIFIC / DEGENERATIVE",a:"Aortic side calcification at leaflet bases · NO commissural fusion · Stellate orifice · Age 70–80s · Shared risk factors with atherosclerosis",c:C.gold},
    {t:"BICUSPID AORTIC VALVE",a:"2/3 of severe AS in adults <70 y · Prevalence 1–2% (M:F 3:1) · Elliptical orifice · Associated aortopathy in 50% · Accelerated calcification",c:C.teal},
    {t:"RHEUMATIC",a:"Commissural fusion (pathognomonic) · Triangular orifice · Mitral valve ALWAYS involved · Developing world · Age 40–60s",c:C.crimson},
  ];
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  });
  footer(s);
}

// ════════════════════════════════════════════════════════════════
// SLIDE 8 — COMPARATIVE TABLE
// ════════════════════════════════════════════════════════════════
{
  let s = pres.addSlide(); bg(s);
  hdr(s,"Comparative Features of AS Etiology","Braunwald's · Otto · Schwartz");

  const rows=[
    ["Feature","Calcific / Degenerative","Bicuspid AV","Rheumatic"],
    ["Age at presentation","70s–80s","50s–60s","40s–60s"],
    ["Commissural fusion","NO","NO (raphe present)","YES — pathognomonic"],
    ["Orifice shape (systole)","Stellate / irregular","Elliptical","Triangular"],
    ["Calcification site","Base of leaflets (aortic side)","Leaflet body","Leaflet tips + commissures"],
    ["Mitral valve","Separate disease","Independent (possible assoc)","ALMOST ALWAYS involved"],
    ["Regurgitation","Uncommon","Possible (aortopathy/prolapse)","Common — mixed lesion"],
    ["Associated condition","Atherosclerosis","Aortopathy (50%)","Mitral stenosis"],
    ["Prevalence (developed)","Most common","Common in <70 yr","Decreasing"],
    ["Genetic/hereditary factor","Risk factor overlap","Autosomal dominant (fibrillin)","HLA-DR susceptibility"],
  ];

  const colColors=[null,C.gold,C.teal,C.crimson];
  const tableData = rows.map((row,ri)=>
    row.map((cell,ci)=>({
      text: cell,
      options:{
        bold: ri===0 || ci===0,
        fontSize: ri===0?9.5:10,
        color: ri===0?(ci===0?C.navy:C.navy): (ci===0?C.grayLt:(cell.includes("YES")||cell.includes("ALMOST")||cell.includes("pathogno")?C.crimson:C.off)),
        fill:{color: ri===0?(ci===0?C.panel:colColors[ci]||C.panel): (ri%2===0?C.mid:C.panel2)},
        align: ci===0?"left":"left",
        valign:"middle",
      }
    }))
  );

  s.addTable(tableData,{x:0.2,y:0.93,w:9.63,h:4.35,
    colW:[2.2,2.48,2.48,2.47],
    border:{pt:0.5,color:C.panel},
  });
  footer(s);
}

// ════════════════════════════════════════════════════════════════
// SLIDE 9 — SECTION: PATHOPHYSIOLOGY
// ════════════════════════════════════════════════════════════════
{ sectionTitle(pres.addSlide(),"03","Pathophysiology","Pressure Overload · Concentric Hypertrophy · Laplace Law · Frank-Starling",C.teal); }

// ════════════════════════════════════════════════════════════════
// SLIDE 10 — CORE MECHANISM
// ════════════════════════════════════════════════════════════════
{
  let s = pres.addSlide(); bg(s);
  hdr(s,"Pressure Overload — Core Mechanism","Sabiston · Schwartz Principles of Surgery 11e");

  card(s,0.2,0.93,9.63,0.88,C.panel2,C.crimson);
  s.addText("FIXED OUTFLOW OBSTRUCTION → ↑ LV Systolic Pressure → CONCENTRIC LV HYPERTROPHY",{x:0.32,y:0.93,w:9.4,h:0.88,fontSize:14,bold:true,color:C.white,fontFace:"Calibri",valign:"middle",align:"center",margin:0});

  // Laplace law
  card(s,0.2,1.93,4.7,1.6,C.mid,C.gold);
  pill(s,"LAPLACE LAW",0.2,1.93,C.gold);
  s.addText("Wall Stress  ∝  (Pressure × Radius)\n                  2 × Wall Thickness",{x:0.32,y:2.24,w:4.48,h:0.72,fontSize:14,bold:true,color:C.white,fontFace:"Courier New",valign:"middle",margin:0});
  s.addText("As LV pressure ↑, wall thickness ↑ proportionally → wall stress normalised → myocardial work preserved",{x:0.32,y:2.98,w:4.48,h:0.48,fontSize:9.5,color:C.grayLt,fontFace:"Calibri",valign:"top",margin:0});

  // Frank-Starling
  card(s,5.08,1.93,4.75,1.6,C.mid,C.teal);
  pill(s,"FRANK-STARLING MECHANISM",5.08,1.93,C.teal);
  s.addText("As EDV increases → myocardial stretch → ↑ contractile force → maintained stroke volume.",{x:5.22,y:2.24,w:4.5,h:0.55,fontSize:11,color:C.off,fontFace:"Calibri",valign:"top",margin:0});
  s.addText("Once sarcomere length exceeds 2.2 μm (optimal) → contractile function falls → heart failure ensues.",{x:5.22,y:2.82,w:4.5,h:0.65,fontSize:10.5,color:C.grayLt,fontFace:"Calibri",valign:"top",margin:0});

  // 4-stage progression
  const stages=[
    {s:"COMPENSATION",d:"Concentric hypertrophy · EF normal · Preserved SV · ↑ LVESP · Normal CO",c:C.teal},
    {s:"EARLY DECOMP.",d:"Diastolic dysfunction · Impaired relaxation · ↑ LVEDP · Reduced LV compliance",c:C.gold},
    {s:"LATE DECOMP.",d:"Systolic dysfunction · EF begins to fall · Low CO · Pulmonary congestion",c:C.orange},
    {s:"END-STAGE",d:"Dilated LV · Markedly reduced EF · Low-flow, low-gradient pattern",c:C.crimson},
  ];
  stages.forEach((st,i)=>{
    card(s,0.2+i*2.42,3.65,2.28,1.72,C.mid,st.c);
    s.addShape(pres.shapes.RECTANGLE,{x:0.2+i*2.42,y:3.65,w:2.28,h:0.32,fill:{color:st.c},line:{color:st.c}});
    s.addText(st.s,{x:0.2+i*2.42,y:3.65,w:2.28,h:0.32,fontSize:8.5,bold:true,color:C.navy,fontFace:"Calibri",align:"center",valign:"middle",margin:0});
    s.addText(st.d,{x:0.28+i*2.42,y:4.0,w:2.12,h:1.3,fontSize:9.5,color:C.off,fontFace:"Calibri",valign:"top",margin:0});
    if(i<3) s.addText("→",{x:2.34+i*2.42,y:4.3,w:0.22,h:0.4,fontSize:18,color:C.gray,fontFace:"Calibri",align:"center",valign:"middle",margin:0});
  });
  footer(s);
}

// ════════════════════════════════════════════════════════════════
// SLIDE 11 — NATURAL HISTORY & SYMPTOM TRIAD
// ════════════════════════════════════════════════════════════════
{
  let s = pres.addSlide(); bg(s);
  hdr(s,"Natural History & The Classic Symptom Triad","Schwartz · Braunwald · Fuster & Hurst 15e");

  // Natural history image
  card(s,0.2,0.93,6.0,3.35,C.mid);
  s.addImage({data:img1,x:0.27,y:0.97,w:5.86,h:3.05});
  s.addText("Fuster & Hurst Ch. 28: Natural history — long latent period, rapid decline once symptoms develop",{x:0.2,y:4.3,w:6.0,h:0.28,fontSize:7.5,color:C.gray,fontFace:"Calibri",italic:true,align:"center"});

  // Progression rates
  card(s,6.38,0.93,3.45,1.55,C.mid,C.gold);
  pill(s,"ANNUAL PROGRESSION (AVERAGE)",6.38,0.93,C.gold);
  const pr=[["Peak Jet Velocity","+ 0.3 m/s / yr"],["Mean Gradient","+ 7 mmHg / yr"],["Valve Area","− 0.1 cm² / yr"]];
  pr.forEach(([l,v],i)=>{
    s.addText(l+":",{x:6.52,y:1.26+i*0.37,w:2.0,h:0.34,fontSize:10,color:C.grayLt,fontFace:"Calibri",valign:"middle",margin:0});
    s.addText(v,{x:8.55,y:1.26+i*0.37,w:1.2,h:0.34,fontSize:11,bold:true,color:C.gold,fontFace:"Calibri",valign:"middle",align:"right",margin:0});
  });

  // Triad boxes
  const triad=[
    {sym:"ANGINA",surv:"~5 yr survival",mech:"↑O₂ demand (hypertrophy) + ↓supply (subendocardial compression, reduced CPP)",c:C.gold},
    {sym:"SYNCOPE",surv:"~3 yr survival",mech:"Fixed CO → cerebral hypoperfusion on exertion; baroreceptor dysfunction; arrhythmia",c:C.orange},
    {sym:"HEART FAILURE",surv:"< 2 yr survival",mech:"Diastolic dysfunction → ↑LVEDP → pulmonary oedema; late: systolic failure, low output",c:C.crimson},
  ];
  triad.forEach((t,i)=>{
    card(s,6.38,2.6+i*0.98,3.45,0.84,C.mid,t.c);
    s.addText(t.sym,{x:6.52,y:2.62+i*0.98,w:1.55,h:0.38,fontSize:11,bold:true,color:t.c,fontFace:"Calibri",valign:"middle",margin:0});
    s.addText(t.surv,{x:8.1,y:2.62+i*0.98,w:1.65,h:0.38,fontSize:9.5,bold:true,color:C.white,fontFace:"Calibri",valign:"middle",align:"right",margin:0});
    s.addText(t.mech,{x:6.52,y:3.0+i*0.98,w:3.22,h:0.4,fontSize:8.5,color:C.grayLt,fontFace:"Calibri",valign:"top",margin:0});
  });

  card(s,0.2,4.62,9.63,0.72,C.panel2,C.crimson);
  s.addText("KEY POINT: Annual sudden death risk in ASYMPTOMATIC severe AS is <1%. Once SYMPTOMATIC → 50% mortality at 2–3 years without AVR. Symptom onset is the critical intervention trigger.",{x:0.32,y:4.62,w:9.4,h:0.72,fontSize:10.5,bold:true,color:C.white,fontFace:"Calibri",valign:"middle",margin:0});
  footer(s);
}

// ════════════════════════════════════════════════════════════════
// SLIDE 12 — SECTION: CLINICAL
// ════════════════════════════════════════════════════════════════
{ sectionTitle(pres.addSlide(),"04","Clinical Features & Investigations","Examination · ECG · CXR · Cardiac Catheterization",C.blue); }

// ════════════════════════════════════════════════════════════════
// SLIDE 13 — PHYSICAL EXAMINATION
// ════════════════════════════════════════════════════════════════
{
  let s = pres.addSlide(); bg(s);
  hdr(s,"Physical Examination Findings","Braunwald's Heart Disease 10e");

  const rows=[
    ["Finding","Clinical Sign","Mechanism / Notes"],
    ["Pulse","Pulsus parvus et tardus\n(slow-rising, small-volume, delayed)","Fixed reduced CO and delayed LV ejection. Note: may be ABSENT in elderly (large artery stiffening — false reassurance!)"],
    ["Apex beat","Sustained, forceful, non-displaced","Concentric hypertrophy — increased wall thickness, NOT chamber dilation → no displacement"],
    ["Systolic murmur","Harsh crescendo-decrescendo (diamond-shaped)\nSEM at right 2nd ICS → carotids","Turbulent flow through stenotic valve. LATE-PEAKING murmur = more severe stenosis"],
    ["Second heart sound","Absent A2 or single/paradoxically split S2","Calcified immobile leaflets → reduced or absent aortic valve closure sound"],
    ["S4 gallop","Prominent presystolic S4","Forceful atrial contraction against stiff non-compliant, hypertrophied LV"],
    ["Ejection click","Early systolic click (before SEM)","Abrupt halt of mobile valve at max opening. Present in bicuspid / early calcific AS"],
    ["Gallavardin phenomenon","Musical/squeaky component at apex — mimics MR","High-frequency component of AS murmur radiates to apex. Distinct from the basal harsher murmur"],
  ];

  const td=rows.map((row,ri)=>row.map((cell,ci)=>({
    text:cell,
    options:{
      bold:ri===0||ci===0,
      fontSize:ri===0?9.5:(ci===0?10.5:9.5),
      color:ri===0?C.navy:(ci===0?C.gold:C.off),
      fill:{color:ri===0?C.panel:(ri%2===0?C.mid:C.panel2)},
      valign:"middle",
    }
  })));

  s.addTable(td,{x:0.2,y:0.93,w:9.63,h:4.65,
    colW:[1.85,2.7,5.08],
    border:{pt:0.5,color:C.panel},
  });
  footer(s);
}

// ════════════════════════════════════════════════════════════════
// SLIDE 14 — ECG & CHEST X-RAY
// ════════════════════════════════════════════════════════════════
{
  let s = pres.addSlide(); bg(s);
  hdr(s,"Investigations — ECG & Chest X-Ray","Braunwald's Heart Disease 10e");

  card(s,0.2,0.93,4.7,4.35,C.mid,C.blue);
  pill(s,"ELECTROCARDIOGRAM (ECG)",0.2,0.93,C.blue);
  const ecg=[
    "LV Hypertrophy: Sokolov-Lyon: S(V1) + R(V5/V6) ≥ 35 mm",
    "Strain pattern: ST depression + T-wave inversion in lateral leads (I, aVL, V5–V6)",
    "Left axis deviation",
    "Left atrial enlargement (P-mitrale) — especially rheumatic AS with MS",
    "Left bundle branch block (LBBB) in advanced disease",
    "1st-degree AV block (PR prolongation)",
    "Atrial fibrillation — particularly in rheumatic AS with coexistent MS",
    "Q waves: non-specific; may suggest ischaemia / fibrosis",
  ];
  ecg.forEach((e,i)=>{
    s.addText(`• ${e}`,{x:0.32,y:1.27+i*0.48,w:4.48,h:0.45,fontSize:10.5,color:C.off,fontFace:"Calibri",valign:"middle",margin:0});
  });

  card(s,5.08,0.93,4.75,4.35,C.mid,C.teal);
  pill(s,"CHEST X-RAY",5.08,0.93,C.teal);
  const cxr=[
    "NORMAL HEART SIZE (concentric hypertrophy → no cardiomegaly initially — key point!)",
    "Post-stenotic dilatation of ascending aorta (esp. bicuspid AS)",
    "Aortic valve calcification — best seen on LATERAL view / fluoroscopy",
    "Cardiomegaly — LATE sign: indicates systolic dysfunction",
    "Pulmonary venous hypertension: upper lobe diversion → interstitial oedema → alveolar oedema",
    "Kerley B lines — horizontal lines in lung periphery (pulmonary oedema)",
    "Pleural effusions (late, decompensated)",
    "LA enlargement in rheumatic AS (associated MS)",
  ];
  cxr.forEach((c2,i)=>{
    s.addText(`• ${c2}`,{x:5.22,y:1.27+i*0.48,w:4.5,h:0.45,fontSize:10.5,color:C.off,fontFace:"Calibri",valign:"middle",margin:0});
  });
  footer(s);
}

// ════════════════════════════════════════════════════════════════
// SLIDE 15 — CARDIAC CATHETERIZATION
// ════════════════════════════════════════════════════════════════
{
  let s = pres.addSlide(); bg(s);
  hdr(s,"Cardiac Catheterization & Gorlin Formula","Braunwald's Heart Disease 10e · Schwartz 11e");

  card(s,0.2,0.93,5.6,3.0,C.mid,C.gold);
  pill(s,"GORLIN FORMULA — AORTIC VALVE AREA",0.2,0.93,C.gold);
  s.addText("          CO / (SEP × HR)\nAVA =  ─────────────────────\n       44.3 × √(Mean Gradient)",{x:0.32,y:1.27,w:5.38,h:1.08,fontSize:15,bold:true,color:C.white,fontFace:"Courier New",valign:"middle",margin:0});
  s.addText("CO = Cardiac Output (mL/min)\nSEP = Systolic Ejection Period (sec/beat)\nHR = Heart Rate (beats/min)\nMean Gradient = mean aortic–LV pressure difference (mmHg)",{x:0.32,y:2.38,w:5.38,h:1.45,fontSize:10.5,color:C.grayLt,fontFace:"Calibri",valign:"top",margin:0});

  card(s,0.2,4.02,5.6,1.32,C.panel2,C.crimson);
  pill(s,"INDICATIONS FOR CATHETERIZATION",0.2,4.02,C.crimson);
  bullets(s,["Echo inconclusive or technically inadequate","Discordant symptoms and echo findings","Pre-operatively: coronary angiography mandatory (CAD in 30–50%)","TAVI planning: CT angiography of aortic root + iliofemoral vessels"],0.32,4.32,5.38,0.97,{fs:10.5});

  card(s,5.97,0.93,4.06,4.41,C.mid,C.teal);
  pill(s,"HAEMODYNAMIC CATHETER DATA",5.97,0.93,C.teal);
  const hemRows=[
    ["Parameter","Normal","Mild AS","Severe AS"],
    ["LV systolic pressure (mmHg)","120","140–160",">180"],
    ["Aortic systolic pressure (mmHg)","120","110–120","90–110"],
    ["Aortic valve gradient (mmHg)","<5","10–30",">50"],
    ["Aortic valve area (cm²)","3.0–4.0","1.5–2.5","<1.0"],
    ["Cardiac index (L/min/m²)","≥2.5","2.0–2.5","Often ↓ (<2.0)"],
    ["PCWP (mmHg)","<12","12–18","Often elevated"],
  ];
  const hemTD=hemRows.map((row,ri)=>row.map((cell,ci)=>({
    text:cell,
    options:{bold:ri===0||ci===0,fontSize:ri===0?9:10,
      color:ri===0?C.navy:(ci===0?C.grayLt:(ci===3?C.crimson:C.off)),
      fill:{color:ri===0?C.panel:(ri%2===0?C.mid:C.panel2)},valign:"middle"}
  })));
  s.addTable(hemTD,{x:6.07,y:1.27,w:3.85,h:3.75,colW:[1.75,0.72,0.72,0.66],border:{pt:0.5,color:C.panel}});
  footer(s);
}

// ════════════════════════════════════════════════════════════════
// SLIDE 16 — SECTION: ECHOCARDIOGRAPHY
// ════════════════════════════════════════════════════════════════
{ sectionTitle(pres.addSlide(),"05","Echocardiography","Quantitation · Continuity Equation · CW Doppler · Low-flow Patterns",C.purple); }

// ════════════════════════════════════════════════════════════════
// SLIDE 17 — ECHO SEVERITY GRADING
// ════════════════════════════════════════════════════════════════
{
  let s = pres.addSlide(); bg(s);
  hdr(s,"Echocardiographic Severity Grading","Textbook of Clinical Echocardiography (Otto) · 2021 ACC/AHA");

  card(s,0.2,0.93,9.63,0.35,C.panel,C.crimson);
  s.addText("ACC / AHA SEVERITY CLASSIFICATION — AORTIC STENOSIS",{x:0.32,y:0.93,w:9.4,h:0.35,fontSize:10,bold:true,color:C.white,fontFace:"Calibri",valign:"middle",charSpacing:0.5,margin:0});

  const gradeData=[
    ["Parameter","Mild","Moderate","Severe","Very Severe"],
    ["Peak Jet Velocity (m/s)","< 3.0","3.0–4.0","> 4.0","> 5.0"],
    ["Mean Gradient (mmHg)","< 25","25–40","> 40","> 60"],
    ["Valve Area (cm²)","> 1.5","1.0–1.5","< 1.0","< 1.0"],
    ["Indexed AVA (cm²/m²)","—","—","< 0.6","< 0.6"],
    ["Doppler Velocity Index","> 0.50","0.25–0.50","< 0.25","< 0.20"],
    ["Velocity ratio (VTI_LVOT/VTI_AV)","—","—","< 0.25","—"],
  ];
  const gradeCols=[null,C.teal,C.gold,C.crimson,"#8E44AD"];
  const gTD=gradeData.map((row,ri)=>row.map((cell,ci)=>({
    text:cell,
    options:{
      bold:ri===0||ci===0,fontSize:ri===0?9.5:11,
      color:ri===0?(ci===0?C.navy:C.navy):(ci===0?C.grayLt:(ci===3||ci===4?C.crimson:ci===2?C.gold:ci===1?C.teal:C.off)),
      fill:{color:ri===0?(gradeCols[ci]||C.panel):(ri%2===0?C.mid:C.panel2)},
      valign:"middle",align:"center",
    }
  })));
  s.addTable(gTD,{x:0.2,y:1.31,w:9.63,h:3.3,colW:[2.6,1.6,1.6,1.62,1.61],border:{pt:0.5,color:C.panel}});

  card(s,0.2,4.68,9.63,0.65,C.panel2,C.gold);
  pill(s,"IMPORTANT NOTE",0.2,4.68,C.gold);
  s.addText("Valve gradients are FLOW-DEPENDENT. Always interpret in the context of cardiac output / forward flow. A low gradient does NOT always mean mild stenosis — consider low-flow states.",{x:0.32,y:4.68,w:9.4,h:0.65,fontSize:10,color:C.off,fontFace:"Calibri",valign:"middle",margin:0});
  footer(s);
}

// ════════════════════════════════════════════════════════════════
// SLIDE 18 — CONTINUITY EQUATION & CW DOPPLER
// ════════════════════════════════════════════════════════════════
{
  let s = pres.addSlide(); bg(s);
  hdr(s,"Continuity Equation & CW Doppler","Textbook of Clinical Echocardiography (Otto)");

  card(s,0.2,0.93,5.55,2.45,C.mid,C.gold);
  pill(s,"CONTINUITY EQUATION — MOST ACCURATE AVA METHOD",0.2,0.93,C.gold);
  s.addText("Conservation of mass:\nFlow at LVOT = Flow at Aortic Valve",{x:0.32,y:1.27,w:5.33,h:0.55,fontSize:12,color:C.grayLt,fontFace:"Calibri",valign:"top",margin:0});
  s.addText("AVA = CSA_LVOT × VTI_LVOT\n              VTI_AV\n\n    = 0.785 × D_LVOT² × VTI_LVOT\n                  VTI_AV",{x:0.32,y:1.84,w:5.33,h:1.42,fontSize:13.5,bold:true,color:C.white,fontFace:"Courier New",valign:"top",margin:0});

  card(s,0.2,3.47,5.55,1.87,C.mid,C.teal);
  pill(s,"KEY MEASUREMENTS",0.2,3.47,C.teal);
  const meas=[
    ["D_LVOT","PLAX view, 0.5–1.0 cm below AV (internal diameter)"],
    ["VTI_LVOT","PW Doppler, apical 5-chamber, sample just below AV"],
    ["VTI_AV","CW Doppler from MULTIPLE windows (apex, right parasternal, suprasternal) — use HIGHEST velocity"],
  ];
  meas.forEach(([k,v],i)=>{
    s.addText(k+":",{x:0.32,y:3.8+i*0.48,w:1.2,h:0.44,fontSize:10,bold:true,color:C.teal,fontFace:"Calibri",valign:"middle",margin:0});
    s.addText(v,{x:1.55,y:3.8+i*0.48,w:4.05,h:0.44,fontSize:10,color:C.off,fontFace:"Calibri",valign:"middle",margin:0});
  });

  // CW Doppler image
  card(s,5.93,0.93,3.9,4.41,C.mid);
  s.addImage({data:img2,x:6.0,y:0.97,w:3.76,h:3.75});
  s.addText("Fig 11.9: CW Doppler waveforms. Valvular AS (symmetric peak) vs. Subaortic membrane (similar + valve flutter) vs. HCM (late-peaking 'dagger' pattern). Otto, Textbook of Clinical Echocardiography.",{x:5.93,y:4.72,w:3.9,h:0.58,fontSize:7.5,color:C.gray,fontFace:"Calibri",italic:true,align:"center"});
  footer(s);
}

// ════════════════════════════════════════════════════════════════
// SLIDE 19 — LOW-FLOW LOW-GRADIENT AS
// ════════════════════════════════════════════════════════════════
{
  let s = pres.addSlide(); bg(s);
  hdr(s,"Low-Flow, Low-Gradient Aortic Stenosis","Braunwald's Heart Disease 10e · 2021 ACC/AHA Guidelines");

  card(s,0.2,0.93,9.63,0.48,C.panel2,C.crimson);
  s.addText(">40% of older patients present with LOW gradient despite severe anatomical AS",{x:0.32,y:0.93,w:9.4,h:0.48,fontSize:12,bold:true,color:C.white,fontFace:"Calibri",valign:"middle",margin:0});

  const types=[
    {t:"TYPE 1 — Classical Low-Flow, Low-Gradient\n(Reduced EF < 50%) — Stage D2",
     d:["AVA < 1.0 cm² AND mean gradient < 40 mmHg AND LVEF < 50%","Low gradient due to REDUCED FORWARD FLOW from impaired LV","Differentiate 'True Severe' vs 'Pseudo-severe' AS with dobutamine stress echo","TRUE SEVERE: gradient rises ≥40 mmHg, AVA stays <1.0 cm²","PSEUDO-SEVERE: AVA opens to >1.0 cm² as contractility improves with dobutamine"],c:C.crimson,stage:"D2"},
    {t:"TYPE 2 — Paradoxical Low-Flow, Low-Gradient\n(Preserved EF ≥ 50%) — Stage D3",
     d:["AVA <1.0 cm², mean gradient <40 mmHg, EF ≥50%, BUT SVi <35 mL/m²","Small, concentrically hypertrophied LV with reduced stroke volume","More common in WOMEN, elderly, hypertensive patients","CT calcium scoring confirms: >2000 AU in men; >1200 AU in women","Prognosis SAME as high-gradient AS — benefit from AVR"],c:C.purple,stage:"D3"},
    {t:"TYPE 3 — High-Flow, Low-Gradient AS\n(Normal EF, AVA > 1.0 cm²)",
     d:["Vmax > 4 m/s BUT AVA > 1.0 cm²","Usually caused by LVOT diameter OVERESTIMATION","Other causes: high cardiac output state, moderate-severe AR","Does NOT generally benefit from AVR","Careful echo re-measurement required before labelling"],c:C.blue,stage:"Special"},
  ];

  types.forEach((t,i)=>{
    card(s,0.2+i*3.22,1.52,3.1,3.55,C.mid,t.c);
    s.addShape(pres.shapes.RECTANGLE,{x:0.2+i*3.22,y:1.52,w:3.1,h:0.4,fill:{color:t.c},line:{color:t.c}});
    s.addText(t.t,{x:0.28+i*3.22,y:1.52,w:2.94,h:0.4,fontSize:8.5,bold:true,color:C.navy,fontFace:"Calibri",align:"center",valign:"middle",margin:0});
    t.d.forEach((item,j)=>{
      s.addText(`• ${item}`,{x:0.3+i*3.22,y:1.97+j*0.62,w:2.93,h:0.58,fontSize:9.5,color:j===2||j===3?t.c:C.off,fontFace:"Calibri",valign:"middle",margin:0});
    });
  });

  card(s,0.2,5.12,9.63,0.35,C.panel2,C.gold);
  s.addText("DOBUTAMINE STRESS ECHO PROTOCOL (Type 1): Infuse 5–40 μg/kg/min. Flow-reserve positive (ΔSV ≥20%) — proceed to dobutamine-induced gradient interpretation.",{x:0.32,y:5.12,w:9.4,h:0.35,fontSize:9,color:C.off,fontFace:"Calibri",valign:"middle",margin:0});
  footer(s);
}

// ════════════════════════════════════════════════════════════════
// SLIDE 20 — SECTION: STAGING & INDICATIONS
// ════════════════════════════════════════════════════════════════
{ sectionTitle(pres.addSlide(),"06","Staging & Indications for Intervention","2021 ACC/AHA Valvular Heart Disease Guidelines · Stage A through D3",C.green); }

// ════════════════════════════════════════════════════════════════
// SLIDE 21 — STAGING TABLE
// ════════════════════════════════════════════════════════════════
{
  let s = pres.addSlide(); bg(s);
  hdr(s,"2021 ACC/AHA Staging of Aortic Stenosis","2021 ACC/AHA Valvular Heart Disease Guidelines");

  const stageRows=[
    ["Stage","Definition","Haemodynamics","Symptoms","LV Function"],
    ["A\nAt Risk","Risk factors for AS\n(bicuspid valve, age, hypertension, smoking)","Normal valve\nno obstruction","None","Normal"],
    ["B\nProgressive","Mild–moderate AS\nValve changes present","Vmax 2–3.9 m/s\nMean grad <40 mmHg\nAVA >1.0 cm²","None","Normal or early remodelling"],
    ["C1\nSevere Asymptomatic\nPreserved EF","Severe AS\nAsymptomatic","Vmax ≥4 m/s\nMean grad ≥40 mmHg\nAVA ≤1.0 cm²","None","LVEF ≥50%\nMay have early decompensation"],
    ["C2\nSevere Asymptomatic\nReduced EF","Severe AS\nAsymptomatic","As C1","None","LVEF <50%"],
    ["D1\nSevere Symptomatic\nHigh-Gradient","Severe AS","Vmax ≥4 m/s\nMean grad ≥40 mmHg","Angina\nSyncope\nHeart failure","Usually EF preserved initially"],
    ["D2\nLow-Flow Low-Gradient\nReduced EF","Severe AS\n(confirmed by DSE)","AVA <1.0 cm²\nMean grad <40 mmHg","Symptoms present","LVEF <50%"],
    ["D3\nLow-Flow Low-Gradient\nPreserved EF (Paradoxical)","Severe AS\n(confirmed by CT Ca score)","AVA <1.0, grad <40\nSVi <35 mL/m²","Symptoms present","LVEF ≥50%\n(small hypertrophied LV)"],
  ];

  const stageCols=[null,C.teal,C.teal,C.gold,C.gold,C.crimson,C.crimson,C.crimson];
  const sTD=stageRows.map((row,ri)=>row.map((cell,ci)=>({
    text:cell,
    options:{
      bold:ri===0||ci===0,
      fontSize:ri===0?8.5:9,
      color:ri===0?C.navy:(ci===0?(ri<=2?C.teal:ri<=4?C.gold:C.crimson):C.off),
      fill:{color:ri===0?C.panel:(ri%2===0?C.mid:C.panel2)},
      valign:"middle",
    }
  })));
  s.addTable(sTD,{x:0.2,y:0.93,w:9.63,h:4.65,
    colW:[1.65,1.95,2.05,1.4,2.58],
    border:{pt:0.5,color:C.panel},
  });
  footer(s);
}

// ════════════════════════════════════════════════════════════════
// SLIDE 22 — INDICATIONS FOR INTERVENTION
// ════════════════════════════════════════════════════════════════
{
  let s = pres.addSlide(); bg(s);
  hdr(s,"Indications for Intervention","2021 ACC/AHA Valvular Heart Disease Guidelines");

  const boxes=[
    {cls:"CLASS I",sub:"Benefit >> Risk — MUST DO",col:C.green,items:[
      "Symptomatic severe high-gradient AS (Stage D1) → AVR indicated (COR I, LOE B-NR)",
      "Severe AS (any stage) in patient undergoing other cardiac surgery → concomitant AVR (COR I, LOE B-NR)",
      "Asymptomatic severe AS with LVEF <50% (Stage C2) → AVR indicated (COR I, LOE B-NR)",
    ]},
    {cls:"CLASS IIa",sub:"Benefit > Risk — SHOULD DO",col:C.gold,items:[
      "Asymptomatic severe AS (C1) with very severe hemodynamics: Vmax ≥5 m/s or mean grad ≥60 mmHg → AVR reasonable",
      "Asymptomatic severe AS (C1) undergoing non-cardiac surgery → AVR first if feasible",
      "Low-flow, low-gradient severe AS (D2) confirmed by dobutamine stress echo → AVR",
      "Moderate AS (Stage B) in patients undergoing cardiac surgery for other indications",
    ]},
    {cls:"CLASS IIb",sub:"Uncertain Benefit — CONSIDER",col:C.orange,items:[
      "Asymptomatic severe AS (C1) with rapid progression (Vmax ↑≥0.3 m/s/yr) — AVR may be considered",
      "Asymptomatic severe AS (C1) with new onset AF or pulmonary hypertension",
      "Low-flow, low-gradient paradoxical AS (D3) with confirmed severity (CT calcium score)",
    ]},
  ];

  boxes.forEach((b,i)=>{
    const y=0.93+i*1.57;
    card(s,0.2,y,9.63,1.44,C.mid,b.col);
    s.addShape(pres.shapes.RECTANGLE,{x:0.2,y,w:9.63,h:0.35,fill:{color:b.col},line:{color:b.col}});
    s.addText(`${b.cls} — ${b.sub}`,{x:0.32,y,w:9.4,h:0.35,fontSize:10,bold:true,color:C.navy,fontFace:"Calibri",valign:"middle",margin:0});
    b.items.forEach((item,j)=>{
      s.addText(`• ${item}`,{x:0.32,y:y+0.38+j*0.34,w:9.3,h:0.33,fontSize:10.5,color:C.off,fontFace:"Calibri",valign:"middle",margin:0});
    });
  });

  card(s,0.2,5.66,9.63,0.0,C.mid); // spacer
  footer(s,"2021 ACC/AHA Guideline for the Management of Patients with Valvular Heart Disease — Key Recommendations for Aortic Stenosis");
}

// ════════════════════════════════════════════════════════════════
// SLIDE 23 — SECTION: SAVR
// ════════════════════════════════════════════════════════════════
{ sectionTitle(pres.addSlide(),"07","Surgical Aortic Valve Replacement","Operative Technique · Myocardial Protection · Prosthesis Selection",C.teal); }

// ════════════════════════════════════════════════════════════════
// SLIDE 24 — PRE-OP WORKUP & CPB SETUP
// ════════════════════════════════════════════════════════════════
{
  let s = pres.addSlide(); bg(s);
  hdr(s,"Pre-operative Workup & CPB Setup","Schwartz Principles of Surgery 11e · Sabiston 21e");

  card(s,0.2,0.93,4.7,4.42,C.mid,C.blue);
  pill(s,"PRE-OPERATIVE ASSESSMENT",0.2,0.93,C.blue);
  const preop=[
    "Doppler TTE: confirm severity, LV function, screen all valves",
    "Coronary angiography — MANDATORY (CAD in 30–50%)",
    "TEE: detailed valve morphology, annulus sizing",
    "CT angiography (for TAVI): annulus, root anatomy, coronary heights, iliofemoral access",
    "Carotid Doppler: significant stenosis → staged or combined procedure",
    "STS-PROM / EuroSCORE II: operative risk stratification",
    "Frailty assessment (TAVI candidates): 5-metre walk, grip strength, albumin, Katz ADL",
    "Pulmonary function tests (if significant respiratory symptoms)",
    "Renal function: eGFR, creatinine — affects contrast and anticoagulation",
  ];
  preop.forEach((p,i)=>{
    s.addText(`• ${p}`,{x:0.32,y:1.27+i*0.46,w:4.48,h:0.44,fontSize:10,color:C.off,fontFace:"Calibri",valign:"middle",margin:0});
  });

  card(s,5.08,0.93,4.75,4.42,C.mid,C.teal);
  pill(s,"CARDIOPULMONARY BYPASS SETUP",5.08,0.93,C.teal);
  const cpb=[
    "Aortic cannulation: distal ascending aorta (purse-string sutures)",
    "Venous cannulation: RA (single 2-stage) or bicaval for combined procedures",
    "LV vent: via right superior pulmonary vein or LV apex (decompresses LV)",
    "Temperature: mild–moderate hypothermia 28–32°C",
    "Antegrade cardioplegia: aortic root or direct coronary ostia cannulae",
    "Retrograde cardioplegia: coronary sinus cannula — especially useful in AVR",
    "Cold blood cardioplegia preferred (4:1 blood:crystalloid)",
    "Myocardial protection critical: hypertrophied LV less tolerant of ischaemia",
    "Target ACT >400 sec after heparin (300–400 IU/kg)",
  ];
  cpb.forEach((p,i)=>{
    s.addText(`• ${p}`,{x:5.22,y:1.27+i*0.46,w:4.5,h:0.44,fontSize:10,color:C.off,fontFace:"Calibri",valign:"middle",margin:0});
  });
  footer(s);
}

// ════════════════════════════════════════════════════════════════
// SLIDE 25 — OPERATIVE STEPS
// ════════════════════════════════════════════════════════════════
{
  let s = pres.addSlide(); bg(s);
  hdr(s,"Surgical AVR — Operative Steps","Schwartz Principles of Surgery 11e · Sabiston Textbook of Surgery 21e");

  const steps=[
    {n:"1",t:"Median sternotomy",d:"Oscillating saw; sternal retractor; pericardial stay sutures",c:C.blue},
    {n:"2",t:"Heparin & cannulation",d:"300–400 IU/kg heparin; ACT >400 s; aortic + venous cannulae; LV vent placed",c:C.blue},
    {n:"3",t:"CPB established",d:"Mild hypothermia 28–32°C; commence cardioplegia circuit; de-air lines",c:C.teal},
    {n:"4",t:"Aortic cross-clamp",d:"Applied across ascending aorta distal to cannulation site",c:C.teal},
    {n:"5",t:"Cardioplegia delivery",d:"Antegrade via aortic root (confirm with AV closure); retrograde via coronary sinus; repeat every 20 min",c:C.teal},
    {n:"6",t:"Aortotomy",d:"Transverse/oblique aortotomy 1.5–2 cm above right coronary ostium; extend into non-coronary sinus",c:C.gold},
    {n:"7",t:"Valve excision",d:"Leaflets excised at bases; meticulously DEBRIDE all calcium; CRITICAL — avoid injury to LCA/RCA ostia",c:C.gold},
    {n:"8",t:"Annular sizing",d:"Sequential sizers; choose largest valve that fits without tension; critical for PPM prevention",c:C.gold},
    {n:"9",t:"Prosthesis implantation",d:"Interrupted pledgeted sutures (2-0 Ticron); everted or inerted technique; confirm proper seating",c:C.orange},
    {n:"10",t:"Aortotomy closure",d:"Two-layer continuous Prolene; felt strip reinforcement; check for haemostasis",c:C.orange},
    {n:"11",t:"De-airing",d:"Vigorous de-air: fill LV via pulmonary vein; suction aortic root; needle aspiration through aorta",c:C.crimson},
    {n:"12",t:"Cross-clamp release & wean",d:"Assess rhythm (VF → defibrillate); warm reperfusion; wean from CPB gradually; TEE assessment",c:C.crimson},
  ];

  steps.forEach((st,i)=>{
    const col=i<6?0:1, row=i%6;
    const x=0.2+col*4.93, y=0.93+row*0.76;
    card(s,x,y,4.73,0.65,C.mid,st.c);
    s.addShape(pres.shapes.RECTANGLE,{x,y,w:0.42,h:0.65,fill:{color:st.c},line:{color:st.c}});
    s.addText(st.n,{x,y,w:0.42,h:0.65,fontSize:12,bold:true,color:C.navy,fontFace:"Calibri",align:"center",valign:"middle",margin:0});
    s.addText(st.t,{x:x+0.5,y:y+0.03,w:4.1,h:0.28,fontSize:10.5,bold:true,color:C.white,fontFace:"Calibri",valign:"middle",margin:0});
    s.addText(st.d,{x:x+0.5,y:y+0.32,w:4.1,h:0.3,fontSize:8.5,color:C.grayLt,fontFace:"Calibri",valign:"top",margin:0});
  });
  footer(s,"Operative mortality: 1–3% isolated AVR (elective) · 3–5% AVR+CABG · 5–10% redo sternotomy (STS database)");
}

// ════════════════════════════════════════════════════════════════
// SLIDE 26 — PROSTHETIC VALVE SELECTION
// ════════════════════════════════════════════════════════════════
{
  let s = pres.addSlide(); bg(s);
  hdr(s,"Prosthetic Valve Selection","Sabiston · Schwartz · 2021 ACC/AHA Guidelines");

  // Mechanical vs tissue comparison
  const prosthRows=[
    ["Feature","Mechanical Valve","Bioprosthetic Valve"],
    ["Durability","30+ years — essentially indefinite","10–20 years; deterioration rate increases in younger patients"],
    ["Anticoagulation","LIFELONG warfarin (INR 2.0–3.0 for aortic position)","Aspirin 81 mg only (after 3–6 months); NO warfarin long-term"],
    ["Thromboembolism","~1–2% / year (with anticoagulation)","Lower; ~0.5–1% / year"],
    ["Structural failure","No structural deterioration","Calcification, leaflet tear, degeneration (SVD)"],
    ["Haemodynamics","Excellent (bileaflet)","Good (pericardial supra-annular best)"],
    ["Reoperation risk","Low (durable)","Higher with SVD (valve-in-valve TAVI option available)"],
    ["Examples","St Jude Regent, CarboMedics, Medtronic-Hall","Edwards Perimount Magna, Medtronic Mosaic, Sorin Mitroflow"],
    ["Best for","Age <60 y; patients already on anticoagulation; non-compliant with follow-up","Age >65 y; bleeding risk; cannot tolerate anticoagulation; preference"],
  ];
  const pTD=prosthRows.map((row,ri)=>row.map((cell,ci)=>({
    text:cell,
    options:{
      bold:ri===0||ci===0,fontSize:ri===0?9.5:10,
      color:ri===0?C.navy:(ci===0?C.grayLt:(ci===1?C.blue:C.off)),
      fill:{color:ri===0?C.panel:(ri%2===0?C.mid:C.panel2)},
      valign:"middle",
    }
  })));
  s.addTable(pTD,{x:0.2,y:0.93,w:9.63,h:3.6,colW:[1.9,3.87,3.86],border:{pt:0.5,color:C.panel}});

  // Age guidance
  card(s,0.2,4.62,9.63,0.72,C.mid,C.gold);
  pill(s,"2021 ACC/AHA PROSTHESIS CHOICE BY AGE",0.2,4.62,C.gold);
  const ageGuide=[
    {age:"< 50 years",rec:"Mechanical preferred (lifetime durability; young patients have higher SVD risk with tissue valves)",c:C.blue},
    {age:"50–65 years",rec:"Shared decision-making: discuss anticoagulation burden vs. reoperation risk",c:C.gold},
    {age:"> 65 years",rec:"Bioprosthetic preferred (slower SVD; avoid anticoagulation; valve-in-valve TAVI option for future failure)",c:C.crimson},
  ];
  ageGuide.forEach((a,i)=>{
    s.addText(a.age+":",{x:0.32+i*3.22,y:4.95,w:1.3,h:0.35,fontSize:10,bold:true,color:a.c,fontFace:"Calibri",valign:"middle",margin:0});
    s.addText(a.rec,{x:1.65+i*3.22,y:4.95,w:1.72,h:0.35,fontSize:8.5,color:C.off,fontFace:"Calibri",valign:"middle",margin:0});
  });
  footer(s);
}

// ════════════════════════════════════════════════════════════════
// SLIDE 27 — ROOT ENLARGEMENT & PPM
// ════════════════════════════════════════════════════════════════
{
  let s = pres.addSlide(); bg(s);
  hdr(s,"Root Enlargement Procedures & Patient-Prosthesis Mismatch","Schwartz 11e · Sabiston 21e");

  card(s,0.2,0.93,9.63,0.55,C.panel2,C.crimson);
  pill(s,"PATIENT-PROSTHESIS MISMATCH (PPM)",0.2,0.93,C.crimson);
  s.addText("Moderate PPM: Indexed EOA < 0.85 cm²/m²  |  Severe PPM: Indexed EOA < 0.65 cm²/m²  →  Results in residually elevated transvalvular gradients post-AVR → worse outcomes. PREVENT by upsizing prosthesis or root enlargement.",
    {x:0.32,y:1.1,w:9.3,h:0.35,fontSize:10,color:C.off,fontFace:"Calibri",valign:"middle",margin:0});

  const procs=[
    {t:"NICKS PROCEDURE",d:["Incise the non-coronary sinus inferiorly through annulus into the anterior mitral leaflet","Repair with a pericardial or Dacron patch","Allows 1–2 prosthesis size increase","Simplest and most commonly used root enlargement","Risk: AV block if incision too deep into interventricular fibrous body"],c:C.teal},
    {t:"MANOUGIAN PROCEDURE",d:["Incision through non-coronary / left coronary commissure into anterior mitral leaflet","More extensive enlargement than Nicks — allows larger prosthesis","Requires repair of both the aortic and mitral annuli","Takes more operating time; used when Nicks insufficient"],c:C.gold},
    {t:"KONNO-RASTAN PROCEDURE",d:["Most extensive — incision through RCA commissure, through aortic root into RVOT and interventricular septum","Separate Dacron patches for LVOT/aortic annulus and RVOT","Allows VERY large prosthesis (used in children, redo cases)","Risks: VSD, complete heart block (AV node proximity), RV injury","High complexity; reserved for extreme small annulus cases"],c:C.crimson},
  ];

  procs.forEach((p,i)=>{
    card(s,0.2+i*3.22,1.6,3.1,3.72,C.mid,p.c);
    s.addShape(pres.shapes.RECTANGLE,{x:0.2+i*3.22,y:1.6,w:3.1,h:0.36,fill:{color:p.c},line:{color:p.c}});
    s.addText(p.t,{x:0.28+i*3.22,y:1.6,w:2.94,h:0.36,fontSize:9.5,bold:true,color:C.navy,fontFace:"Calibri",align:"center",valign:"middle",margin:0});
    p.d.forEach((item,j)=>{
      s.addText(`• ${item}`,{x:0.3+i*3.22,y:2.0+j*0.66,w:2.92,h:0.63,fontSize:9.5,color:C.off,fontFace:"Calibri",valign:"middle",margin:0});
    });
  });
  footer(s);
}

// ════════════════════════════════════════════════════════════════
// SLIDE 28 — SECTION: TAVI
// ════════════════════════════════════════════════════════════════
{ sectionTitle(pres.addSlide(),"08","Transcatheter Aortic Valve Replacement","PARTNER Trials · Valve Types · Access Routes · Complications · Decision Guide",C.orange); }

// ════════════════════════════════════════════════════════════════
// SLIDE 29 — TAVI: VALVES, ACCESS, TRIALS
// ════════════════════════════════════════════════════════════════
{
  let s = pres.addSlide(); bg(s);
  hdr(s,"TAVI — Valve Types, Access Routes & Key Trials","Schwartz 11e · Braunwald's 10e · PARTNER / Evolut Trials");

  // Valve types
  card(s,0.2,0.93,4.7,2.3,C.mid,C.teal);
  pill(s,"TRANSCATHETER VALVE TYPES",0.2,0.93,C.teal);

  card(s,0.28,1.27,2.18,1.82,C.panel2,C.blue);
  s.addText("BALLOON-EXPANDABLE\nEdwards SAPIEN 3 / Ultra",{x:0.35,y:1.3,w:2.04,h:0.42,fontSize:9,bold:true,color:C.blue,fontFace:"Calibri",align:"center",margin:0});
  bullets(s,["Co-Cr stent + bovine pericardial leaflets","Rapid ventricular pacing during deployment (~180 bpm)","Precise annular position","PPM rate: 5–10%"],0.35,1.74,2.04,1.28,{fs:9});

  card(s,2.6,1.27,2.18,1.82,C.panel2,C.teal);
  s.addText("SELF-EXPANDING\nMedtronic CoreValve / Evolut R",{x:2.67,y:1.3,w:2.04,h:0.42,fontSize:9,bold:true,color:C.teal,fontFace:"Calibri",align:"center",margin:0});
  bullets(s,["Nitinol frame + porcine pericardial","No rapid pacing; repositionable (Evolut R/PRO)","Supra-annular → better hemodynamics","PPM: 15–25% (AV node compression)"],2.67,1.74,2.04,1.28,{fs:9});

  // Access routes
  card(s,0.2,3.33,4.7,2.03,C.mid,C.gold);
  pill(s,"ACCESS ROUTES",0.2,3.33,C.gold);
  const routes=[
    {r:"Transfemoral (TF)",pct:"~90%",n:"Gold standard · ≥5.5 mm femoral artery · Best outcomes · Percutaneous closure",c:C.teal},
    {r:"Transaortic (TAo)",pct:"~4%",n:"Upper J ministernotomy · Severe peripheral vascular disease",c:C.gold},
    {r:"Transapical (TA)",pct:"~3%",n:"Left anterolateral thoracotomy · LV apex antegrade delivery · Higher morbidity",c:C.orange},
    {r:"Transaxillary",pct:"~3%",n:"Subclavian/axillary artery · Good alternative when femoral unsuitable",c:C.blue},
  ];
  routes.forEach((r,i)=>{
    s.addText(r.r,{x:0.32,y:3.68+i*0.41,w:1.75,h:0.38,fontSize:9,bold:true,color:r.c,fontFace:"Calibri",valign:"middle",margin:0});
    s.addText(r.pct,{x:2.1,y:3.68+i*0.41,w:0.45,h:0.38,fontSize:9,color:r.c,fontFace:"Calibri",align:"center",valign:"middle",margin:0});
    s.addText(r.n,{x:2.58,y:3.68+i*0.41,w:2.2,h:0.38,fontSize:8.5,color:C.grayLt,fontFace:"Calibri",valign:"middle",margin:0});
  });

  // Key Trials
  card(s,5.08,0.93,4.75,4.43,C.mid,C.crimson);
  pill(s,"LANDMARK CLINICAL TRIALS",5.08,0.93,C.crimson);
  const trials=[
    {t:"PARTNER B (2010)","pop":"Inoperable","find":"TAVI vs. medical Rx → 50% RRR all-cause mortality at 1 yr",c:C.teal},
    {t:"PARTNER A (2011)","pop":"High risk","find":"TAVI non-inferior to SAVR in mortality at 1 yr",c:C.teal},
    {t:"CoreValve HR (2014)","pop":"High risk","find":"Self-expanding TAVI superior to SAVR at 1 yr",c:C.teal},
    {t:"PARTNER 2 (2016)","pop":"Intermediate","find":"TAVI non-inferior; TF subgroup statistically superior",c:C.gold},
    {t:"SURTAVI (2017)","pop":"Intermediate","find":"Self-expanding TAVI non-inferior to SAVR",c:C.gold},
    {t:"PARTNER 3 (2019)","pop":"LOW RISK","find":"TAVI SUPERIOR to SAVR (composite: death/stroke/rehospitalisation) at 1 yr — landmark result",c:C.crimson},
    {t:"Evolut Low Risk (2019)","pop":"LOW RISK","find":"TAVI non-inferior to SAVR; SE valve excellent haemodynamics at 2 yrs",c:C.crimson},
  ];

  const trTD=[
    ["Trial","Population","Key Finding"].map(h=>({text:h,options:{bold:true,fontSize:8.5,color:C.navy,fill:{color:C.panel},valign:"middle"}})),
    ...trials.map(t=>[
      {text:t.t,options:{bold:true,fontSize:9,color:t.c,valign:"middle",fill:{color:C.mid}}},
      {text:t.pop,options:{fontSize:9,color:C.grayLt,valign:"middle",fill:{color:C.mid}}},
      {text:t.find,options:{fontSize:9,color:t.c===C.crimson?C.crimson:C.off,valign:"middle",fill:{color:C.mid}}},
    ])
  ];
  s.addTable(trTD,{x:5.2,y:1.27,w:4.5,h:3.96,colW:[1.45,0.9,2.15],border:{pt:0.5,color:C.panel}});
  footer(s);
}

// ════════════════════════════════════════════════════════════════
// SLIDE 30 — TAVI COMPLICATIONS, DECISION GUIDE & TAKE-HOME
// ════════════════════════════════════════════════════════════════
{
  let s = pres.addSlide(); bg(s);
  hdr(s,"TAVI — Complications, Decision Guide & Summary","Schwartz · Braunwald's · 2021 ACC/AHA");

  // Complications table
  card(s,0.2,0.93,5.5,0.3,C.panel,C.crimson);
  s.addText("TAVI COMPLICATIONS",{x:0.3,y:0.93,w:5.3,h:0.3,fontSize:9,bold:true,color:C.white,fontFace:"Calibri",valign:"middle",charSpacing:0.5,margin:0});
  const comps=[
    ["Complication","Rate","Management"],
    ["Stroke","2–5%","Cerebral embolic protection device (Sentinel); antiplatelet optimisation"],
    ["Paravalvular leak","5–15% (trace-mild); severe <3%","Post-dilatation; valve-in-valve if severe haemodynamically significant"],
    ["Permanent pacemaker (SE)","15–25%","PPM implant; LBBB alone may not require immediate pacing"],
    ["Permanent pacemaker (BE)","5–10%","As above"],
    ["Vascular access complications","5–10%","Surgical repair / covered endovascular stent"],
    ["Annular rupture","<1%","Emergency surgical conversion — often fatal; prevent by CT sizing"],
    ["Coronary occlusion","<1%","Emergency PCI / CABG; coronary protection wire mandatory in redo cases"],
  ];
  const cTD=comps.map((row,ri)=>row.map((cell,ci)=>({
    text:cell,
    options:{bold:ri===0,fontSize:ri===0?8.5:9,
      color:ri===0?C.navy:(ci===1?(parseFloat(cell)>=5||cell.includes("<1")?C.crimson:C.gold):C.off),
      fill:{color:ri===0?C.panel:(ri%2===0?C.mid:C.panel2)},valign:"middle"}
  })));
  s.addTable(cTD,{x:0.2,y:1.26,w:5.5,h:2.9,colW:[1.75,0.9,2.85],border:{pt:0.5,color:C.panel}});

  // Decision guide
  card(s,5.88,0.93,3.95,3.23,C.mid,C.gold);
  pill(s,"TAVI vs SAVR — DECISION GUIDE",5.88,0.93,C.gold);
  const dec=[
    {a:"< 50 years",r:"SAVR strongly preferred",c:C.blue},
    {a:"50–65 years",r:"SAVR preferred; shared decision (heart valve team)",c:C.teal},
    {a:"65–80 years",r:"Shared decision — either TAVI or SAVR acceptable",c:C.gold},
    {a:"> 80 years",r:"TAVI preferred",c:C.crimson},
    {a:"Prohibitive risk",r:"TAVI or palliative care",c:C.crimson},
    {a:"Redo bioprosthesis",r:"Valve-in-Valve TAVI — avoids redo sternotomy",c:C.teal},
    {a:"Bicuspid AS + young",r:"SAVR preferred (TAVI limited experience in bicuspid)",c:C.blue},
    {a:"Significant AR",r:"SAVR preferred (TAVI anchoring unreliable)",c:C.orange},
  ];
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  });

  // Bottom: Special procedures quick ref
  const specials=[
    {t:"ROSS PROCEDURE",d:"Native PV autograft → aortic position. Best for young patients / athletes. No anticoagulation. 10-yr survival 90%. Risk: autograft dilation, pulmonary homograft stenosis.",c:C.purple},
    {t:"BENTALL PROCEDURE",d:"Composite graft (valve + aortic tube). For AS + aortic aneurysm or bicuspid aortopathy (≥4.5–5.0 cm). Classic: mechanical + Dacron. Tissue variant: Bio-Bentall.",c:C.gold},
    {t:"DAVID PROCEDURE",d:"Valve-sparing root replacement. Native valve reimplanted in Dacron tube. Ideal when valve morphology normal. Preserves native leaflets — no anticoagulation needed.",c:C.teal},
  ];
  specials.forEach((sp,i)=>{
    card(s,0.2+i*3.27,4.25,3.1,1.1,C.mid,sp.c);
    s.addText(sp.t,{x:0.32+i*3.27,y:4.28,w:2.88,h:0.28,fontSize:8.5,bold:true,color:sp.c,fontFace:"Calibri",valign:"middle",margin:0});
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  });

  footer(s,"Sources: Braunwald's Heart Disease 10e · Schwartz's Principles of Surgery 11e · Sabiston Textbook of Surgery 21e · Fuster & Hurst's The Heart 15e · Textbook of Clinical Echocardiography (Otto)");
}

// ════════════════════════════════════════════════════════════════
// SLIDE 31 — TAKE-HOME MESSAGES
// ════════════════════════════════════════════════════════════════
{
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  s.addText("Aortic Stenosis — MCh Cardiology Teaching Rounds",{x:0.3,y:0.68,w:9.5,h:0.37,fontSize:12,color:C.grayLt,fontFace:"Calibri",italic:true});

  const msgs=[
    {n:"1",t:"RHD = Molecular Mimicry",d:"Streptococcal M-protein mimics cardiac laminin → cross-reactive immune attack → Aschoff bodies → commissural fusion (pathognomonic of rheumatic AS, distinguishes it from calcific)",c:C.crimson},
    {n:"2",t:"Calcific AS is most common",d:"Bicuspid AV accounts for 2/3 of AS in adults <70 yr. Always screen for associated aortopathy (50% risk). Bicuspid AS presents ~10–15 years earlier than degenerative AS.",c:C.gold},
    {n:"3",t:"Symptom onset = critical point",d:"'5-3-2 rule': Angina → 5 yr, Syncope → 3 yr, Heart Failure → <2 yr survival without intervention. Annual sudden death risk in asymptomatic severe AS is <1%.",c:C.teal},
    {n:"4",t:"Echo is definitive",d:"AVA <1.0 cm², mean gradient >40 mmHg, Vmax >4 m/s = severe. Continuity equation (conservation of mass) is most accurate for AVA. Beware low-flow, low-gradient AS.",c:C.blue},
    {n:"5",t:"No drug modifies natural history",d:"Statins (SEAS/ASTRONOMER trials) showed NO benefit. Balloon valvuloplasty is palliative only in calcific AS (restenosis at 6–12 months). Surgery is the ONLY proven treatment.",c:C.purple},
    {n:"6",t:"TAVI has transformed management",d:"PARTNER 3 (2019): TAVI superior to SAVR in low-risk patients at 1 year. Age <65 → SAVR preferred; 65–80 → shared decision; >80 → TAVI preferred. Heart valve team is mandatory.",c:C.orange},
    {n:"7",t:"Surgical nuances matter",d:"Prevent PPM with root enlargement (Nicks/Manougian/Konno). Ross procedure is ideal for young patients (no anticoagulation, growth potential). Valve-in-Valve TAVI for failed bioprostheses.",c:C.green},
  ];

  msgs.forEach((m,i)=>{
    const col=i<4?0:1, row=i%4;
    const x=col===0?0.2:5.08, y=1.12+row*1.1;
    const w=col===0?4.72:4.75;
    card(s,x,y,w,0.97,C.mid,m.c);
    s.addShape(pres.shapes.RECTANGLE,{x,y,w:0.5,h:0.97,fill:{color:m.c},line:{color:m.c}});
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    s.addText(m.t,{x:x+0.58,y:y+0.06,w:w-0.68,h:0.3,fontSize:10.5,bold:true,color:m.c,fontFace:"Calibri",valign:"middle",margin:0});
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  footer(s,"Sources: Braunwald's Heart Disease 10e · Schwartz's Principles of Surgery 11e · Sabiston Textbook of Surgery 21e · Fuster & Hurst's The Heart 15e · Otto: Textbook of Clinical Echocardiography");
}

// ── WRITE ─────────────────────────────────────────────────────────
pres.writeFile({fileName:"/home/daytona/workspace/aortic-stenosis-ppt/AS_MCh_Teaching_30slides.pptx"})
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