cd /home/daytona/workspace/attachments/9eb5a6d0-62fc-48b5-820d-86bf2c9aaec0/ && …

cd /home/daytona/workspace/attachments/9eb5a6d0-62fc-48b5-820d-86bf2c9aaec0/ && …

cd /home/daytona/workspace/attachments/9eb5a6d0-62fc-48b5-820d-86bf2c9aaec0/ && …

mkdir -p /home/daytona/workspace/tavr_project/images && cd /home/daytona/workspa…

python3 -c " import pdfplumber from PIL import Image import io, os os.makedirs(…

python3 -c " from reportlab.lib.pagesizes import A4 from reportlab.lib.styles im…

~/tavr_project/generate_hy_notes.py

#!/usr/bin/env python3
from reportlab.lib.pagesizes import A4
from reportlab.lib.styles import getSampleStyleSheet, ParagraphStyle
from reportlab.lib.units import cm
from reportlab.lib import colors
from reportlab.platypus import (SimpleDocTemplate, Paragraph, Spacer, Table,
    TableStyle, HRFlowable, PageBreak, Image as RLImage, KeepTogether)
from reportlab.lib.enums import TA_LEFT, TA_CENTER, TA_JUSTIFY
import os

os.makedirs('/home/daytona/workspace/tavr_project/output', exist_ok=True)

doc = SimpleDocTemplate(
    '/home/daytona/workspace/tavr_project/output/TAVR_HY_Notes.pdf',
    pagesize=A4,
    rightMargin=2*cm, leftMargin=2*cm, topMargin=2*cm, bottomMargin=2*cm
)

styles = getSampleStyleSheet()

title_style = ParagraphStyle('TitleS', parent=styles['Title'],
    fontSize=20, textColor=colors.HexColor('#003366'), spaceAfter=6,
    fontName='Helvetica-Bold', alignment=TA_CENTER)

subtitle_style = ParagraphStyle('SubtitleS', parent=styles['Normal'],
    fontSize=12, textColor=colors.HexColor('#336699'), spaceAfter=10,
    fontName='Helvetica-Oblique', alignment=TA_CENTER)

h1_style = ParagraphStyle('H1S', parent=styles['Normal'],
    fontSize=13, textColor=colors.white, spaceAfter=6, spaceBefore=12,
    fontName='Helvetica-Bold', backColor=colors.HexColor('#003366'),
    leftIndent=0, rightIndent=0, borderPad=6)

h2_style = ParagraphStyle('H2S', parent=styles['Normal'],
    fontSize=11, textColor=colors.HexColor('#003366'), spaceAfter=4, spaceBefore=8,
    fontName='Helvetica-Bold')

body_style = ParagraphStyle('BodyS', parent=styles['Normal'],
    fontSize=10, leading=15, spaceAfter=4, fontName='Helvetica',
    alignment=TA_JUSTIFY)

bullet_style = ParagraphStyle('BulletS', parent=styles['Normal'],
    fontSize=10, leading=14, spaceAfter=3, fontName='Helvetica',
    leftIndent=15, firstLineIndent=0)

key_box_style = ParagraphStyle('KeyBoxS', parent=styles['Normal'],
    fontSize=10, leading=14, spaceAfter=6, fontName='Helvetica-Bold',
    backColor=colors.HexColor('#FFF3CD'), borderPad=4,
    textColor=colors.HexColor('#856404'), spaceBefore=4)

alert_style = ParagraphStyle('AlertS', parent=styles['Normal'],
    fontSize=10, leading=14, spaceAfter=6, fontName='Helvetica-Bold',
    backColor=colors.HexColor('#F8D7DA'), borderPad=4,
    textColor=colors.HexColor('#721C24'), spaceBefore=4)

def p(text, style=None):
    if style is None:
        style = body_style
    return Paragraph(text, style)

def b(text):
    return Paragraph('• ' + text, bullet_style)

def h(text, level=1):
    return Paragraph(text, h1_style if level == 1 else h2_style)

def sp(n=0.2):
    return Spacer(1, n*cm)

def make_table(data, col_widths=None, header=True):
    if col_widths is None:
        n = len(data[0])
        col_widths = [16.7*cm/n]*n
    t = Table(data, colWidths=col_widths, repeatRows=1 if header else 0)
    style_cmds = [
        ('BACKGROUND', (0,0), (-1,0), colors.HexColor('#003366')),
        ('TEXTCOLOR', (0,0), (-1,0), colors.white),
        ('FONTNAME', (0,0), (-1,0), 'Helvetica-Bold'),
        ('FONTSIZE', (0,0), (-1,-1), 9),
        ('ROWBACKGROUNDS', (0,1), (-1,-1), [colors.white, colors.HexColor('#EEF2F7')]),
        ('GRID', (0,0), (-1,-1), 0.4, colors.HexColor('#AAAAAA')),
        ('VALIGN', (0,0), (-1,-1), 'TOP'),
        ('LEFTPADDING', (0,0), (-1,-1), 5),
        ('RIGHTPADDING', (0,0), (-1,-1), 5),
        ('TOPPADDING', (0,0), (-1,-1), 4),
        ('BOTTOMPADDING', (0,0), (-1,-1), 4),
    ]
    t.setStyle(TableStyle(style_cmds))
    return t

def ph(text):
    return Paragraph(text, ParagraphStyle('TH', parent=styles['Normal'],
        fontSize=9, fontName='Helvetica-Bold', textColor=colors.white,
        alignment=TA_CENTER))

def pc(text):
    return Paragraph(text, ParagraphStyle('TC', parent=styles['Normal'],
        fontSize=9, fontName='Helvetica', alignment=TA_LEFT, leading=12))

story = []

# ============================= COVER =============================
story.append(sp(1.5))
story.append(p('CHAPTER 59', title_style))
story.append(p('TRANSCATHETER AORTIC VALVE REPLACEMENT (TAVR)', title_style))
story.append(sp(0.3))
story.append(p('High-Yield Teaching Notes for INI SS CET - CVTS', subtitle_style))
story.append(p('Edelman & Thourani | Sabiston & Spencer Surgery of the Chest', subtitle_style))
story.append(HRFlowable(width='100%', thickness=2, color=colors.HexColor('#003366')))
story.append(sp(0.4))

# Quick reference table
qr_data = [
    [ph('TOPIC'), ph('HIGH-YIELD POINT')],
    [pc('First TAVR'), pc('Alain Cribier, 2002 - antegrade via femoral vein + transseptal puncture (NOT retrograde TF)')],
    [pc('Gold standard access'), pc('Transfemoral (TF) retrograde - >95% of all TAVR; most preferred')],
    [pc('Min vessel size for TF'), pc('5.5 mm luminal diameter (non-circumferential calcium)')],
    [pc('Key pre-op imaging'), pc('Gated multidetector contrast CT (chest/abdomen/pelvis) - mandatory')],
    [pc('STS high-risk cutoff'), pc('>8% expected 30-day mortality')],
    [pc('AVA indications (TTE)'), pc('Vmax >=4.0 m/s OR mean gradient >=40 mmHg; AVA <=1.0 cm2')],
    [pc('PARTNER 1 (inoperable)'), pc('TAVR superior to medical therapy; 1yr mortality: TAVR 30.7% vs medical 49.7%')],
    [pc('Adams et al. (CoreValve high risk)'), pc('FIRST RCT showing TAVR survival benefit over SAVR; 14.2% vs 19.1% at 1yr (P=.04)')],
    [pc('PARTNER 3 (low risk)'), pc('TAVR superior to SAVR at 1yr (primary outcome 8.5% vs 15.1%, P=.001)')],
    [pc('BASILICA procedure'), pc('Electrosurgical leaflet laceration to prevent coronary obstruction in TAVR/ViV-TAVR')],
    [pc('VTC distance cutoff'), pc('<4 mm = HIGHEST risk of coronary obstruction (AUC 0.943)')],
    [pc('Coronary obstruction incidence'), pc('Native TAVR <1%; ViV TAVR 2.3%; mortality ~50%')],
    [pc('PPM rates (SE vs BE)'), pc('Self-expanding: 17-25.9% (CoreValve); Balloon-expandable: similar to SAVR in PARTNER 3')],
    [pc('LBBB after TAVR (PARTNER 3)'), pc('TAVR 23.7% vs SAVR 8.0%')],
    [pc('Mod/Severe PVR significance'), pc('Consistently associated with increased mortality in all trials')],
    [pc('ViV TAVR 30-day mortality (VIVID)'), pc('4.6%; higher post-deployment gradients (16 vs 9 mmHg) than native TAVR')],
]
story.append(make_table(qr_data, col_widths=[4.5*cm, 12.2*cm]))
story.append(sp(0.5))
story.append(PageBreak())

# ============================= SECTION 1 =============================
story.append(h('1.  INTRODUCTION &amp; HISTORICAL CONTEXT'))
story.append(sp(0.2))
story.append(h('Epidemiology', 2))
story.append(b('Aortic stenosis (AS): MOST frequent acquired valve disease in elderly.'))
story.append(b('By 2050 (US Census): 18.6 million >= 85 years; 85.7 million >= 65 years.'))
story.append(b('Historical treatment: SAVR via median sternotomy or minimally invasive approach.'))
story.append(p('<b>KEY FACT:</b> First TAVR - Alain Cribier (2002) - ANTEGRADE approach via femoral vein + transseptal puncture in inoperable patient with severe PAD. (NOT transfemoral retrograde!)', key_box_style))

story.append(h('TAVR Growth in USA (STS/ACC TVT Registry)', 2))
story.append(b('2011: 13,723 cases --&gt; 2019: 72,991 cases.'))
story.append(b('TAVR exceeded isolated SAVR annually: from 2015-2016.'))
story.append(b('TAVR exceeded ALL SAVR: from 2018-2019.'))
story.append(b('>95% of TAVR now via retrograde transfemoral (TF) route.'))
story.append(sp(0.3))

# ============================= SECTION 2 =============================
story.append(h('2.  INDICATIONS FOR TAVR'))
story.append(sp(0.2))

story.append(h('Classic Indications (2020 ACC/AHA Guidelines)', 2))
ind_data = [
    [ph('Parameter'), ph('Threshold / Detail')],
    [pc('Peak aortic-jet velocity (Vmax)'), pc('>= 4.0 m/s')],
    [pc('Mean aortic valve gradient'), pc('>= 40 mmHg')],
    [pc('Aortic valve area (AVA)'), pc('<= 1.0 cm2 (or AVAi <= 0.6 cm2/m2)')],
    [pc('Asymptomatic very severe AS'), pc('Vmax >= 5.0 m/s OR mean gradient >= 60 mmHg -> AVR recommended')],
    [pc('Low-flow low-gradient (LFLG) AS'), pc('Dobutamine stress echo to confirm true severity')],
    [pc('CT calcium score'), pc('Women >1300 AU, Men >2000 AU -> correlates with AS severity; adjunct in discordant cases')],
]
story.append(make_table(ind_data, col_widths=[6*cm, 10.7*cm]))
story.append(sp(0.3))

story.append(h('SAVR vs TAVR Decision Matrix (ACC/AHA 2020)', 2))
dec_data = [
    [ph('Patient Category'), ph('Preferred Approach')],
    [pc('Age <65 years, life expectancy >20 years'), pc('SAVR preferred (no durability data for TAVR beyond 5 years; young patients excluded from trials)')],
    [pc('Age >80 years OR life expectancy <10 years'), pc('TAVR preferred (non-inferiority confirmed with >5yr follow-up)')],
    [pc('Age 65-80 years'), pc('Either SAVR or TAVR - individualized, shared decision making with Heart Team')],
    [pc('Very young (<= 50 yrs), eligible for mechanical valve'), pc('SAVR mandatory')],
    [pc('TAVR ineligible (transfemoral)'), pc('Consider alternative access or SAVR')],
]
story.append(make_table(dec_data, col_widths=[6.5*cm, 10.2*cm]))
story.append(sp(0.2))
story.append(p('<b>EXCLUDED from trials (limited data exist):</b> Life expectancy &lt;1 year; creatinine &gt;3.0 mg/dL; preoperative hemodialysis; advanced neurologic disease; significant CAD; LVOT calcium; bicuspid aortic valves.', alert_style))
story.append(sp(0.3))

# ============================= SECTION 3 =============================
story.append(h('3.  PREOPERATIVE EVALUATION &amp; PLANNING'))
story.append(sp(0.2))

story.append(h('Mandatory 6-Point Pre-TAVR Checklist', 2))
pre_data = [
    [ph('#'), ph('Assessment Question'), ph('Preferred Modality')],
    [pc('1'), pc('Severity of AS'), pc('TTE (primary); TEE if poor TTE windows; Dobutamine echo for LFLG-AS')],
    [pc('2'), pc('Ilio-femoral vessel size, calcium, tortuosity'), pc('Gated contrast CT (chest/abdomen/pelvis); non-contrast CT + invasive angiogram for CKD')],
    [pc('3'), pc('Aortic valve leaflet anatomy & morphology'), pc('CT + TTE/TEE; annulus area and perimeter for sizing')],
    [pc('4'), pc('Annulus, sinotubular, sinus of Valsalva dimensions'), pc('CT gold standard; 3D TEE if IV contrast contraindicated')],
    [pc('5'), pc('Ventricular viability & function'), pc('TTE/TEE; LVEF')],
    [pc('6'), pc('Extent of coronary artery disease'), pc('Coronary angiogram (standard); CT coronary angio under evaluation')],
]
story.append(make_table(pre_data, col_widths=[0.8*cm, 5.5*cm, 10.4*cm]))
story.append(sp(0.2))

story.append(h('Key CT Measurements for TAVR Planning', 2))
story.append(b('Aortic annulus: area + perimeter used for valve sizing (each vendor has sizing chart).'))
story.append(b('Sinus of Valsalva: >27 mm accommodates smaller valves; >29 mm adequate for ALL devices.'))
story.append(b('VTC distance <4 mm = highest risk of coronary obstruction (AUC 0.943).'))
story.append(b('Minimum TF arterial diameter: 5.5 mm (if non-circumferential calcium).'))
story.append(b('Transaortic TAVR: cannulation site must be >7 cm from aortic root.'))
story.append(b('Transcaval target: level of L3 vertebra; free of calcium; between renal arteries and aortic bifurcation.'))
story.append(b('Bulky leaflet calcification increases risk of coronary obstruction or sinus rupture.'))
story.append(sp(0.3))

# ============================= SECTION 4 =============================
story.append(PageBreak())
story.append(h('4.  OPERATIVE TECHNIQUES - ACCESS ROUTES'))
story.append(sp(0.2))

access_data = [
    [ph('Access Route'), ph('Key Features'), ph('Contraindications / Limitations')],
    [pc('Transfemoral (TF)\n[PREFERRED; >95%]'),
     pc('- Least invasive\n- Ultrasound-guided CFA puncture\n- Pre-close: 2 Perclose Proglide devices\n- Heparin: ACT >250 sec\n- Stiff wire (Lundequist/Safari/Confida)\n- RV pacemaker via femoral vein\n- Rapid pacing 180-220 bpm; BP <60 mmHg'),
     pc('- Vessel <5.5 mm\n- Circumferential iliac calcium\n- Severe external iliac tortuosity')],
    [pc('Transcaval (TCa)'),
     pc('- Venous (femoral vein) approach - ergonomic advantage\n- Target: L3 aorta (between renal arteries + bifurcation; free of calcium adjacent to IVC)\n- Electrified 0.014" wire crosses IVC wall into aorta\n- Ductal occluder closes aorto-caval tract\n- Sequential balloon inflations for hemostasis\n- Covered stent if needed; success 99/100 patients'),
     pc('- Calcified aorta at IVC junction\n- Bowel overlying target')],
    [pc('Transcarotid (TC)'),
     pc('- Right CCA preferred (straighter path to AV; involves 1 vs 2 cerebrovascular vessels)\n- CCA diameter >6 mm, no stenosis\n- Systolic BP maintained ~150 mmHg\n- Cerebral oximetry monitored bilaterally throughout'),
     pc('- Significant carotid stenosis (treat first)\n- Left CCA: higher cerebrovascular risk')],
    [pc('Transsubclavian/\nAxillary (TS)'),
     pc('- Left subclavian preferred (more favorable curve; 1 vertebral artery vs 2 vessels on right)\n- Oblique incision deltopectoral groove\n- Synthetic graft (end-to-side) or direct access\n- ACT >250 sec'),
     pc('- Risk: brachial plexus injury (medial & lateral cords)\n- Heavy subclavian calcification\n- Previous LIMA (relative CI)')],
    [pc('Transaortic (TAo)'),
     pc('- Mini-sternotomy: below suprasternal notch to 2nd ICS ("J" configuration)\n- >7 cm from aortic root to cannulation site\n- For patients with poor respiratory function\n- Can combine with off-pump CABG'),
     pc('- Porcelain aorta (ABSOLUTE CI)\n- Previous sternotomy\n- LIMA overlying aorta\n- Hostile mediastinum (radiation)')],
    [pc('Transapical (TA)'),
     pc('- 4-5 cm anterolateral thoracotomy, 5th/6th ICS\n- Two apical pledgeted 3-0 Prolene purse strings (NOT transmural)\n- Wire into descending aorta via JR4 catheter\n- SAVR IS SUPERIOR to TA-TAVR in eligible patients (PARTNER 2)'),
     pc('- FEV1 <30% predicted\n- EF <20%\n- Should be LAST resort; inferior to all other approaches')],
]
story.append(make_table(access_data, col_widths=[2.8*cm, 8.5*cm, 5.4*cm]))
story.append(sp(0.2))

story.append(h('TF-TAVR Procedural Key Points', 2))
story.append(b('<b>Step 1:</b> 6F sheath in CFA + femoral vein; pigtail catheter to aortic root for aortography.'))
story.append(b('<b>Step 2:</b> Identify proper aortic plane: all 3 cusps at EQUAL HEIGHT on fluoroscopy.'))
story.append(b('<b>Step 3:</b> Cross AV with AL1 or JR4 catheter + straight/hydrophilic wire -> exchange for extra-small Safari wire or Confida wire.'))
story.append(b('<b>Step 4:</b> Balloon aortic valvuloplasty (BAV): usually unnecessary; if needed use Z-Med 20-23mm or True balloon under rapid pacing.'))
story.append(b('<b>Step 5 (SAPIEN Ultra - balloon-expandable):</b> Upper margin covers leaflet tips; lower end at/below annulus. Slow inflation; max inflate 4 sec; deflate fully before stopping pacing.'))
story.append(b('<b>Step 6 (CoreValve Evolut - self-expanding):</b> Upper part rests in ascending aorta above STJ. Cusp overlay technique minimizes conduction injury.'))
story.append(b('<b>Step 7:</b> Post-deployment aortography: confirm coronary patency + valve position.'))
story.append(b('<b>Valve too LOW:</b> May need second valve. <b>Valve too HIGH:</b> Risk of embolization into ascending aorta or coronary occlusion.'))
story.append(b('<b>Post-dilation:</b> If >mild PVR around correctly positioned valve -> balloon dilation to reduce leak.'))
story.append(sp(0.3))

# ============================= SECTION 5 =============================
story.append(PageBreak())
story.append(h('5.  LANDMARK CLINICAL TRIALS'))
story.append(sp(0.2))

trials_data = [
    [ph('Trial'), ph('Risk'), ph('n'), ph('Valve'), ph('Primary Outcome'), ph('Result / Key Finding')],
    [pc('PARTNER 1\n(Cohort B)'),pc('Inoperable'),pc('179'),pc('SAPIEN (BE)'),pc('1yr all-cause mortality vs medical therapy'),pc('TAVR SUPERIOR: 30.7% vs 49.7% (P<0.001). Established TAVR for inoperable AS.')],
    [pc('PARTNER 1\n(Cohort A)'),pc('High risk (STS >15%)'),pc('699'),pc('SAPIEN (BE)'),pc('Death/stroke at 1yr (non-inferiority vs SAVR)'),pc('NON-INFERIOR. 1yr: TAVR 24.2% vs SAVR 26.8% (NS). 5yr: No mortality difference. Mod/severe PVR -> increased 5yr mortality.')],
    [pc('CoreValve US\nPivotal (Adams et al.)'),pc('High risk'),pc('795'),pc('CoreValve (SE)'),pc('1yr all-cause mortality'),pc('TAVR SUPERIOR: 14.2% vs SAVR 19.1% (P=.04). FIRST RCT to show TAVR survival benefit over SAVR. PPM 22.3% in TAVR at 1yr.')],
    [pc('PARTNER 2'),pc('Intermediate (STS 4-8%)'),pc('2032'),pc('SAPIEN XT (BE)'),pc('Death/stroke at 5yr'),pc('NON-INFERIOR. TAVR 47.9% vs SAVR 43.4% (P=.21). TF cohort: equal. Transthoracic cohort: TAVR WORSE (59.3% vs 48.3%).')],
    [pc('SURTAVI'),pc('Intermediate'),pc('1736'),pc('CoreValve (SE)'),pc('Death/stroke at 2yr'),pc('NON-INFERIOR. TAVR 12.6% vs SAVR 14.0% (NS). PPM: TAVR 25.9% vs SAVR 6.6%. Mod-severe AR: 5.3% vs 0.6%.')],
    [pc('PARTNER 3'),pc('Low risk (STS <4%)'),pc('1000'),pc('SAPIEN 3 (BE)'),pc('Death/stroke/rehospitalization at 1yr & 2yr'),pc('TAVR SUPERIOR at 1yr: 8.5% vs 15.1% (P=.001). At 2yr still favored TAVR. LBBB: 23.7% vs 8.0%. No PPM difference.')],
    [pc('Evolut Low Risk'),pc('Low risk (STS <3%)'),pc('1468'),pc('CoreValve/Evolut R/Pro (SE)'),pc('Death/stroke at 2yr'),pc('NON-INFERIOR. TAVR: lower stroke (0.5% vs 1.7%), lower AKI (0.8% vs 2.8%). Higher PVR (3.5% vs 0.5%), higher PPM (17.4% vs 6.1%).')],
]
story.append(make_table(trials_data, col_widths=[2.5*cm, 1.8*cm, 0.8*cm, 2.2*cm, 3.2*cm, 6.2*cm]))
story.append(sp(0.2))
story.append(p('<b>MEMORY AID - TRIALS:</b><br/>Inoperable: PARTNER 1B -> TAVR WINS vs medical Rx<br/>High Risk (BE): PARTNER 1A -> NON-INFERIOR to SAVR | High Risk (SE): CoreValve (Adams) -> TAVR BETTER<br/>Intermediate: PARTNER 2 + SURTAVI -> Non-inferior<br/>Low Risk (BE): PARTNER 3 -> TAVR SUPERIOR at 1yr | Low Risk (SE): Evolut -> Non-inferior', key_box_style))
story.append(sp(0.3))

# ============================= SECTION 6 =============================
story.append(h('6.  COMPLICATIONS OF TAVR'))
story.append(sp(0.2))

story.append(h('A. Conduction Abnormalities', 2))
comp_data = [
    [ph('Complication'), ph('TAVR Rate'), ph('SAVR Rate'), ph('Key Pearls')],
    [pc('Permanent pacemaker (PPM)'), pc('SE: 17.4-25.9%\nBE (PARTNER 3): similar to SAVR'), pc('6.1-7.1%'), pc('Higher with CoreValve (SE); cusp overlay technique reduces risk; new PPM after TAVR -> increased HF hospitalization but NOT mortality in one study')],
    [pc('LBBB'), pc('23.7% (PARTNER 3)'), pc('8.0%'), pc('New LBBB after TAVR: worsening LVEF at 3yr; increased PPM need; associated with worse 2yr mortality in intermediate-risk (PARTNER 2)')],
    [pc('Need for second valve'), pc('Rare'), pc('N/A'), pc('Valve placed too low in ventricle -> need to deploy second valve above')],
]
story.append(make_table(comp_data, col_widths=[3.5*cm, 3.5*cm, 2.5*cm, 7.2*cm]))
story.append(sp(0.2))

story.append(h('B. Paravalvular Regurgitation (PVR)', 2))
story.append(b('Moderate or greater PVR -> consistently associated with INCREASED MORTALITY in ALL trials.'))
story.append(b('Mild PVR: benign in intermediate risk; worsens mortality in high-risk at 5 years (PARTNER 1).'))
story.append(b('CoreValve natural history: 80% of moderate PVL at 1 month improved to mild by 1 year.'))
story.append(b('PARTNER 3 (low risk): no difference in moderate/severe PVR between TAVR and SAVR.'))
story.append(b('Evolut Low Risk: higher PVR in TAVR (3.5% vs 0.5%).'))
story.append(b('Treatment: post-dilation balloon inflation if >mild PVR on correctly positioned valve.'))
story.append(b('Advantage of SAVR: SAVR has lower PVR vs even 3rd generation TAVR prostheses.'))
story.append(sp(0.2))

story.append(h('C. Coronary Obstruction', 2))
story.append(b('Rare (<1% native TAVR) but HIGH mortality event (~50% overall).'))
story.append(b('ViV TAVR: 2.3% incidence; OR 7.67 vs native TAVR.'))
story.append(b('LCA 72%; both LCA+RCA 20%; isolated RCA 8% (least common).'))
story.append(b('ViV risk: externally mounted leaflets 6.4%; stentless valves 3.7%; internally mounted 0.7%.'))
story.append(b('Timing: after valve implantation 58%; within 24hr 22%; after BAV 3%; after post-dilation 3%; late 14%.'))
story.append(b('Outcome: PCI attempted - 18% unsuccessful; mortality 22% (successful PCI), 100% (failed PCI), 50% (emergency CABG).'))
story.append(p('<b>VTC DISTANCE:</b> &lt;4 mm = HIGHEST risk (OR 0.22 per mm increase; AUC 0.943; P&lt;0.0001). Coronary HEIGHT alone is NOT predictive in ViV TAVR. Sinus sequestration: leaflets reach sinotubular junction and seal coronary sinus.', alert_style))
story.append(sp(0.2))

story.append(h('BASILICA Procedure', 2))
story.append(b('<b>B</b>ioprosthetic or Native <b>A</b>ortic <b>S</b>callop <b>I</b>ntentional <b>L</b>aceration to prevent <b>I</b>atrogenic <b>C</b>oronary <b>A</b>rtery obstruction.'))
story.append(b('Electrified guidewire passed through BASE of aortic cusp -> lacerates leaflet in MIDLINE -> leaflets splay LATERALLY on valve expansion -> coronary ostia remain patent.'))
story.append(b('NOW procedure of CHOICE to prevent coronary obstruction in both native and ViV TAVR.'))
story.append(b('BASILICA Registry (214 pts, 72.8% ViV): procedural success 86.9%; coronary obstruction despite BASILICA: 4.7%.'))
story.append(b('Coronary protection fallback: guidewire in LAD (+ circumflex); balloon/undeployed stent in threatened coronary; emergency LM stenting required in 20% of high-risk cases.'))
story.append(sp(0.3))

# ============================= SECTION 7 =============================
story.append(PageBreak())
story.append(h('7.  SPECIAL POPULATIONS &amp; AREAS OF UNCERTAINTY'))
story.append(sp(0.2))

story.append(h('A. Young Patients', 2))
story.append(b('Low-risk trials mean age: 73-79 years; <10% were under 65 years.'))
story.append(b('Patients <= 50 years eligible for mechanical prosthesis -> SAVR mandatory.'))
story.append(b('TAVR explant mortality (STS): 19.4% overall; isolated AVR: 13.1%; observed/expected ratio 1.54 (high risk).'))
story.append(b('During SAVR in young patients: root enlargement/replacement to fit largest possible valve -> prepare for future ViV TAVR.'))
story.append(b('TAVR-in-TAVR appears relatively safe (limited data); ViV TAVR (TAVR-in-SAVR) safer than redo SAVR in registry data.'))
story.append(sp(0.1))

story.append(h('B. Bicuspid Aortic Valves', 2))
story.append(b('Major RCTs EXCLUDED bicuspid valve patients.'))
story.append(b('2020 ACC/AHA Guideline: Class IIb recommendation (WEAK) for TAVR in bicuspid AS.'))
story.append(b('Challenges: asymmetric annulus, heavy calcification, associated aortopathy (may need prophylactic aortic replacement).'))
story.append(b('Sievers classification determines leaflet asymmetry type.'))
story.append(b('STS/ACC TVT Registry: similar 30-day and 1-year mortality vs tricuspid; higher PVR (4.7% vs 3.5%); lower device success.'))
story.append(b('STROKE RATES HIGHER in bicuspid group with balloon-expandable TAVR.'))
story.append(sp(0.1))

story.append(h('C. Concomitant Coronary Artery Disease', 2))
story.append(b('Concomitant CABG during SAVR was TWICE as common as PCI during TAVR (low-risk trials).'))
story.append(b('SYNTAX >22 + residual SYNTAX >8 after TAVR -> higher mortality at 2 years.'))
story.append(b('Use SYNTAX score + ACC/AHA Myocardial Revascularization Guidelines to guide PCI vs CABG decision.'))
story.append(b('Post-TAVR coronary access is DIFFICULT - TAVR struts may obstruct coronary ostia.'))
story.append(b('TAo-TAVR + off-pump CABG is a described combined approach for high-risk AS + complex CAD.'))
story.append(sp(0.1))

story.append(h('D. Valve-in-Valve (ViV) TAVR', 2))
story.append(b('TAVR valve placed WITHIN failed surgical bioprosthesis - alternative to redo SAVR.'))
story.append(b('Indications: bioprosthetic structural valve deterioration (stenosis more common than regurgitation in VIVID Registry).'))

viv_data = [
    [ph('Registry/Study'), ph('n'), ph('30-day Mortality'), ph('Key Finding')],
    [pc('VIVID Registry'), pc('1168'), pc('4.6%'), pc('Small valve (<=23mm) + AS (not AR) -> higher mortality')],
    [pc('STS/ACC TVT Registry'), pc('1150'), pc('2.1%'), pc('Post-deployment gradients higher than native TAVR: 16 vs 9 mmHg')],
    [pc('PARTNER 2 ViV Registry'), pc('High-risk'), pc('—'), pc('3yr mortality 32.7%; gradient reduced from 35 to 17 mmHg; functional improvement')],
    [pc('Meta-analysis (pre-2015)'), pc('>14 series'), pc('8%'), pc('Historical baseline rate')],
    [pc('Propensity match\n(redo SAVR vs ViV)'), pc('Matched'), pc('Similar'), pc('Gradient >20mmHg lower with redo SAVR; hospital LOS shorter with ViV TAVR')],
]
story.append(make_table(viv_data, col_widths=[3.8*cm, 1.8*cm, 2.5*cm, 8.6*cm]))
story.append(sp(0.2))
story.append(b('Redo SAVR for failed bioprosthesis (STS 2011-2013, n=2213): 4.7% mortality; stroke 1.9%; PPM 11.5%; renal failure 4.2%.'))
story.append(b('Surgeons performing SAVR should MAXIMIZE valve size (root enlargement) to prepare for future ViV TAVR.'))
story.append(sp(0.3))

# ============================= SECTION 8 =============================
story.append(PageBreak())
story.append(h('8.  PROBABLE EXAMINATION QUESTIONS &amp; TEACHING PEARLS'))
story.append(sp(0.2))

pq_data = [
    [ph('Question Theme'), ph('Answer / Teaching Pearl')],
    [pc('First TAVR - year, surgeon, approach'), pc('Cribier, 2002; ANTEGRADE via femoral vein + transseptal puncture (NOT retrograde TF - patient had severe PAD)')],
    [pc('Most common TAVR access route'), pc('Transfemoral (TF) retrograde (>95% of all TAVR)')],
    [pc('Minimum vessel diameter for TF-TAVR'), pc('5.5 mm (non-circumferential calcium is key qualifier)')],
    [pc('Rapid pacing rate during TAVR'), pc('180-220 bpm; target BP <60 mmHg; prevents forceful contractions from moving balloon')],
    [pc('What defines high surgical risk (STS)?'), pc('STS score >8% predicted 30-day mortality')],
    [pc('Gold standard for TAVR annulus sizing'), pc('Gated contrast multidetector CT - area + perimeter measurement')],
    [pc('Alternative to CT for annulus sizing in CKD'), pc('3D TEE (for area and perimeter calculation)')],
    [pc('Absolute CI to Transaortic TAVR'), pc('Porcelain aorta')],
    [pc('Contraindications to Transapical TAVR'), pc('FEV1 <30% predicted; EF <20%')],
    [pc('Most feared complication of TA-TAVR'), pc('Left ventricular bleeding at apical site')],
    [pc('BASILICA: what, why, how?'), pc('Electrosurgical leaflet laceration to prevent coronary obstruction; guidewire lacerates midline of aortic cusp -> leaflets splay laterally on valve expansion')],
    [pc('VTC distance for coronary obstruction'), pc('<4 mm = highest risk; AUC 0.943; OR 0.22 per mm increase')],
    [pc('Most commonly obstructed coronary in TAVR'), pc('Left coronary artery (72%); LCA+RCA (20%); isolated RCA 8% (least common)')],
    [pc('Coronary obstruction in ViV vs native TAVR'), pc('2.3% (ViV) vs <1% (native); OR 7.67 for externally mounted leaflets')],
    [pc('PCI outcome after coronary obstruction'), pc('18% unsuccessful; mortality: 22% successful PCI, 100% unsuccessful, 50% emergency CABG')],
    [pc('PARTNER 1 Cohort B result'), pc('TAVR superior to medical therapy; 1yr mortality 30.7% vs 49.7% (P<0.001)')],
    [pc('Adams et al. CoreValve high-risk result'), pc('FIRST RCT showing TAVR survival benefit over SAVR; 14.2% vs 19.1% at 1yr (P=.04)')],
    [pc('PARTNER 3 primary outcome at 1yr'), pc('Death/stroke/rehospitalization: TAVR 8.5% vs SAVR 15.1% (P=.001) - TAVR SUPERIOR')],
    [pc('Evolut Low Risk PPM rate'), pc('TAVR 17.4% vs SAVR 6.1% (higher in self-expanding TAVR)')],
    [pc('PARTNER 3 LBBB rates'), pc('TAVR 23.7% vs SAVR 8.0%')],
    [pc('PVR natural history with CoreValve'), pc('80% with moderate PVL at 1 month improved to mild or better by 1 year')],
    [pc('Why higher gradients in ViV TAVR?'), pc('Fixed outer diameter of surgical prosthesis limits effective orifice area of inner TAVR valve')],
    [pc('Sinus of Valsalva sizing for TAVR'), pc('>27 mm accommodates smaller valves; >29 mm adequate for ALL devices')],
    [pc('PARTNER 2 transthoracic cohort finding'), pc('Death/stroke HIGHER with TAVR (59.3%) vs SAVR (48.3%) - thoracic access is INFERIOR to TF')],
    [pc('SURTAVI trial PPM finding'), pc('PPM: TAVR 25.9% vs SAVR 6.6% (CoreValve at 2yr)')],
    [pc('Transcaval closure method'), pc('Ductal occluder device; sequential balloon inflations; covered stent if needed; success 99/100 patients')],
    [pc('TAo-TAVR + CABG combination'), pc('Off-pump CABG + transaortic TAVR described for high-risk AS + severe complex CAD')],
    [pc('Bicuspid TAVR guideline recommendation'), pc('ACC/AHA Class IIb (weak) recommendation; higher stroke + PVR rates vs tricuspid')],
]
story.append(make_table(pq_data, col_widths=[6.5*cm, 10.2*cm]))
story.append(sp(0.3))

story.append(h('Quick Memory Aids', 2))
story.append(p('<b>ACCESS ROUTES (least to most invasive):</b> TF &gt; TC &gt; TCa &gt; TS &gt; TAo &gt; TA<br/><b>BASILICA = B</b>ioprosthetic or Native <b>A</b>ortic <b>S</b>callop <b>I</b>ntentional <b>L</b>aceration to prevent <b>I</b>atrogenic <b>C</b>oronary <b>A</b>rtery obstruction', key_box_style))
story.append(p('<b>TRIALS - RISK HIERARCHY:</b><br/>Inoperable: PARTNER 1B (TAVR beats medical)<br/>High Risk: PARTNER 1A BE (non-inferior) | CoreValve SE - Adams (TAVR BETTER)<br/>Intermediate: PARTNER 2 + SURTAVI (non-inferior)<br/>Low Risk: PARTNER 3 SAPIEN 3 (TAVR SUPERIOR) | Evolut (non-inferior)', key_box_style))
story.append(p('<b>CORONARY OBSTRUCTION RULE OF 72:</b> LCA 72% | LCA+RCA 20% | RCA alone 8%; ViV risk OR 7.67 for external leaflets; VTC &lt;4mm = danger zone', alert_style))

story.append(sp(0.3))
story.append(HRFlowable(width='100%', thickness=1, color=colors.HexColor('#003366')))
story.append(p('Chapter 59 | Edelman &amp; Thourani | Transcatheter Aortic Valve Replacement | Prepared for INI SS CET CVTS Teaching',
    ParagraphStyle('Footer', parent=styles['Normal'], fontSize=8, textColor=colors.grey, alignment=TA_CENTER)))

doc.build(story)
print('HY Notes PDF generated successfully')

cd /home/daytona/workspace/tavr_project && python3 generate_hy_notes.py 2>&1

~/tavr_project/generate_mcqs.py

#!/usr/bin/env python3
"""
20 MCQs – Chapter 59 TAVR – INI SS CET CVTS format
Single Best Answer; includes image-based questions using extracted figures.
"""
from reportlab.lib.pagesizes import A4
from reportlab.lib.styles import getSampleStyleSheet, ParagraphStyle
from reportlab.lib.units import cm
from reportlab.lib import colors
from reportlab.platypus import (SimpleDocTemplate, Paragraph, Spacer, Table,
    TableStyle, HRFlowable, PageBreak, Image as RLImage, KeepTogether)
from reportlab.lib.enums import TA_LEFT, TA_CENTER, TA_JUSTIFY
import os, urllib.request, urllib.error

os.makedirs('/home/daytona/workspace/tavr_project/output', exist_ok=True)
IMG_DIR = '/home/daytona/workspace/tavr_project/images'

doc = SimpleDocTemplate(
    '/home/daytona/workspace/tavr_project/output/TAVR_20_MCQs.pdf',
    pagesize=A4,
    rightMargin=2*cm, leftMargin=2*cm, topMargin=2*cm, bottomMargin=2.2*cm
)

styles = getSampleStyleSheet()

title_s = ParagraphStyle('TitleS', parent=styles['Normal'],
    fontSize=18, textColor=colors.HexColor('#003366'),
    fontName='Helvetica-Bold', alignment=TA_CENTER, spaceAfter=4)

subtitle_s = ParagraphStyle('SubS', parent=styles['Normal'],
    fontSize=11, textColor=colors.HexColor('#336699'),
    fontName='Helvetica-Oblique', alignment=TA_CENTER, spaceAfter=6)

instr_s = ParagraphStyle('InstrS', parent=styles['Normal'],
    fontSize=9, textColor=colors.HexColor('#555555'),
    fontName='Helvetica', alignment=TA_CENTER, spaceAfter=2)

q_num_s = ParagraphStyle('QNum', parent=styles['Normal'],
    fontSize=11, textColor=colors.white,
    fontName='Helvetica-Bold', backColor=colors.HexColor('#003366'),
    leftIndent=0, borderPad=5, spaceAfter=4, spaceBefore=10)

q_stem_s = ParagraphStyle('QStem', parent=styles['Normal'],
    fontSize=10.5, leading=16, fontName='Helvetica-Bold',
    spaceAfter=6, alignment=TA_JUSTIFY)

opt_s = ParagraphStyle('OptS', parent=styles['Normal'],
    fontSize=10, leading=14, fontName='Helvetica',
    leftIndent=10, spaceAfter=3)

ans_box_s = ParagraphStyle('AnsBox', parent=styles['Normal'],
    fontSize=9.5, leading=13, fontName='Helvetica',
    backColor=colors.HexColor('#E8F4E8'), borderPad=5,
    textColor=colors.HexColor('#1A5E1A'), spaceAfter=4, spaceBefore=2)

img_cap_s = ParagraphStyle('ImgCap', parent=styles['Normal'],
    fontSize=8.5, fontName='Helvetica-Oblique',
    textColor=colors.HexColor('#555555'), alignment=TA_CENTER, spaceAfter=4)

para_s = ParagraphStyle('ParaS', parent=styles['Normal'],
    fontSize=10, leading=15, fontName='Helvetica',
    backColor=colors.HexColor('#F0F4FF'), borderPad=6,
    spaceAfter=6, alignment=TA_JUSTIFY)

hr_blue = HRFlowable(width='100%', thickness=1.5, color=colors.HexColor('#003366'))
hr_thin = HRFlowable(width='100%', thickness=0.5, color=colors.HexColor('#AAAAAA'))

def p(text, style=None):
    return Paragraph(text, style or styles['Normal'])

def sp(n=0.2):
    return Spacer(1, n*cm)

def img(path, width=10*cm, caption=''):
    elems = []
    if os.path.exists(path):
        try:
            from PIL import Image as PILImage
            im = PILImage.open(path)
            w, h = im.size
            aspect = h / w
            rl_img = RLImage(path, width=width, height=width*aspect)
            # Centre the image
            tbl = Table([[rl_img]], colWidths=[16.7*cm])
            tbl.setStyle(TableStyle([
                ('ALIGN', (0,0), (-1,-1), 'CENTER'),
                ('VALIGN', (0,0), (-1,-1), 'MIDDLE'),
            ]))
            elems.append(tbl)
            if caption:
                elems.append(Paragraph(caption, img_cap_s))
        except Exception as e:
            elems.append(Paragraph(f'[Image: {os.path.basename(path)}]', img_cap_s))
    return elems

# ─────────────────────────────────────────────────────────────────
# MCQ DATA
# ─────────────────────────────────────────────────────────────────
# Format: dict with keys:
#   num, vignette (optional), stem, options (list of 4 strings A-D),
#   answer, explanation, image_path (optional), image_caption (optional)
# ─────────────────────────────────────────────────────────────────

mcqs = [
    {
        "num": 1,
        "stem": "The first transcatheter aortic valve replacement (TAVR) in a human was performed by Alain Cribier in 2002. Which of the following best describes the access route used in this index procedure?",
        "options": [
            "A. Retrograde transfemoral arterial approach",
            "B. Transapical approach via left thoracotomy",
            "C. Antegrade approach via femoral vein with transseptal puncture",
            "D. Transcaval approach through the inferior vena cava"
        ],
        "answer": "C",
        "explanation": "Cribier performed the first TAVR using an ANTEGRADE approach via the femoral vein and a transseptal puncture technique, because the index patient had severe peripheral artery disease precluding arterial access. The retrograde transfemoral approach later became the standard (>95% of TAVR today)."
    },
    {
        "num": 2,
        "stem": "A 74-year-old male with symptomatic severe aortic stenosis is being evaluated for TAVR. Transthoracic echocardiography shows a peak aortic jet velocity of 4.6 m/s and a mean gradient of 52 mmHg. CT scan shows the aortic annulus perimeter is 72 mm. Which of the following CT finding would most reliably identify this patient as HIGH RISK for coronary obstruction during TAVR?",
        "options": [
            "A. Sinus of Valsalva diameter of 32 mm",
            "B. Valve-to-coronary (VTC) distance of 3.2 mm",
            "C. Aortic valve calcium score of 2500 AU (male)",
            "D. Left ventricular outflow tract calcium"
        ],
        "answer": "B",
        "explanation": "A VTC distance <4 mm is the key CT predictor of coronary obstruction risk (AUC 0.943; OR 0.22 per mm increase; P<0.0001). A sinus of Valsalva >29 mm is actually reassuring (accommodates all devices). A high calcium score confirms AS severity but does not specifically predict coronary obstruction. LVOT calcium increases PVR risk, not specifically coronary obstruction."
    },
    {
        "num": 3,
        "image_path": os.path.join(IMG_DIR, 'p13_img1.png'),
        "image_caption": "Fig. 59.15A from Chapter 59 (Edelman & Thourani, Sabiston & Spencer Surgery of the Chest). The image shows an electrified guidewire being advanced toward the base of the left aortic cusp.",
        "stem": "The image above shows the first step of a procedure performed before TAVR deployment in a patient with a failed surgical bioprosthesis. What is the PRIMARY GOAL of this procedure?",
        "options": [
            "A. To dilate the stenotic native aortic valve before transcatheter valve deployment",
            "B. To lacerate the aortic leaflet and prevent coronary ostial obstruction during valve expansion",
            "C. To create a transcaval crossing tract between the aorta and the inferior vena cava",
            "D. To measure the aortic annulus dimensions for accurate valve sizing"
        ],
        "answer": "B",
        "explanation": "This is the BASILICA procedure (Bioprosthetic or Native Aortic Scallop Intentional Laceration to prevent Iatrogenic Coronary Artery obstruction). An electrified guidewire is passed through the BASE of the aortic cusp and lacerates it at the midline. As the TAVR valve expands, the lacerated leaflets splay LATERALLY, preventing coronary ostial occlusion. It is the procedure of choice for high-risk coronary obstruction cases, particularly in Valve-in-Valve TAVR."
    },
    {
        "num": 4,
        "vignette": "A 79-year-old woman with severe symptomatic aortic stenosis (AVA 0.7 cm², Vmax 4.9 m/s) is referred for TAVR. Her STS score is 6.2%. CT scan shows bilateral iliac artery calcification with minimum luminal diameters of 4.8 mm on the right and 5.1 mm on the left. The right iliac has circumferential calcium at its narrowest point.",
        "stem": "What is the MOST APPROPRIATE next step in this patient's management?",
        "options": [
            "A. Proceed with right transfemoral TAVR using the 4.8 mm access as the primary site",
            "B. Proceed with left transfemoral TAVR as 5.1 mm exceeds the minimum requirement",
            "C. Evaluate for alternative access routes (transcarotid, transcaval, or transsubclavian)",
            "D. Refer for surgical aortic valve replacement given ineligibility for transfemoral TAVR"
        ],
        "answer": "C",
        "explanation": "The minimum diameter for TF-TAVR is 5.5 mm for NON-CIRCUMFERENTIAL calcium. The right iliac has circumferential calcium (absolute barrier) at 4.8 mm. The left iliac is 5.1 mm, which is below the 5.5 mm threshold. Neither TF route is safe. Alternative non-thoracic access routes (TC, TCa, TS) should be evaluated next. Thoracic access (TA, TAo) is inferior to SAVR in eligible patients and is considered last resort. SAVR remains an option but alternative access TAVR should be explored first given her intermediate risk."
    },
    {
        "num": 5,
        "image_path": os.path.join(IMG_DIR, 'p5_img2.png'),
        "image_caption": "Fig. 59.6A from Chapter 59. Fluoroscopic image showing TAVR valve delivery system positioned at the aortic annulus prior to deployment.",
        "stem": "The fluoroscopic image above shows correct valve positioning before deployment of a balloon-expandable TAVR valve. Which of the following best describes the IDEAL fluoroscopic aortic plane for TAVR valve deployment?",
        "options": [
            "A. The left coronary cusp is visualized lower than the right and non-coronary cusps",
            "B. All three aortic cusps are visualized at equal height in the same plane",
            "C. The non-coronary cusp is visualized higher than both coronary cusps",
            "D. Only the left and right coronary cusps are visible; non-coronary cusp is foreshortened"
        ],
        "answer": "B",
        "explanation": "The CORRECT aortic valve plane is identified when ALL THREE cusps (left, right, and non-coronary) are visualized at an EQUAL HEIGHT in the same plane on fluoroscopy. This ensures the delivery system is coaxially aligned with the valve, minimizing risk of malposition, PVR, and conduction injury. This angle is predetermined on CT and confirmed with ascending aortic root angiography."
    },
    {
        "num": 6,
        "stem": "The PARTNER 3 trial enrolled 1000 low-risk patients (STS PROM <4%) with severe aortic stenosis and randomized them to TAVR (SAPIEN 3) vs SAVR. At 2 years, regarding new left bundle branch block (LBBB), which of the following findings was reported?",
        "options": [
            "A. No significant difference in LBBB rates between TAVR and SAVR",
            "B. LBBB was more common after SAVR (23.7%) than TAVR (8.0%)",
            "C. LBBB was more common after TAVR (23.7%) than SAVR (8.0%)",
            "D. LBBB rates were equal at ~15% in both groups"
        ],
        "answer": "C",
        "explanation": "In the PARTNER 3 trial, new LBBB occurred in 23.7% of TAVR patients vs only 8.0% of SAVR patients. This reflects the proximity of the TAVR valve to the His-Purkinje conduction system, particularly the left bundle branch, which runs immediately below the non-coronary/left coronary cusp junction. The cusp overlay technique for self-expanding valves aims to minimize depth of implantation and reduce this risk."
    },
    {
        "num": 7,
        "vignette": "A 76-year-old male with severe AS undergoes TAVR using a self-expanding CoreValve prosthesis. Post-deployment transoesophageal echo reveals moderate paravalvular regurgitation (PVR). The valve appears well-positioned fluoroscopically.",
        "stem": "What is the most appropriate IMMEDIATE management of this significant PVR?",
        "options": [
            "A. Observe; moderate PVR with CoreValve resolves spontaneously in 80% at 1 year",
            "B. Perform post-deployment balloon dilation using the delivery catheter balloon",
            "C. Deploy a second overlapping TAVR valve",
            "D. Convert to open surgical aortic valve replacement"
        ],
        "answer": "B",
        "explanation": "For >mild PVR around a CORRECTLY POSITIONED valve, the recommended immediate intervention is post-deployment balloon dilation using the balloon on the delivery catheter to further expand the valve and improve sealing against the annulus. Spontaneous improvement of CoreValve PVR (option A) is a longer-term phenomenon and is not appropriate for managing moderate PVR intraoperatively. A second valve is reserved for a valve that is too low in the ventricle. Conversion to SAVR is not appropriate as a first response to treatable PVR."
    },
    {
        "num": 8,
        "stem": "The Medtronic CoreValve US Pivotal Trial (Adams et al., 2014) enrolled 795 high-risk patients randomized to TAVR (CoreValve self-expanding) vs SAVR. This was the first prospectively randomized trial to demonstrate which landmark outcome?",
        "options": [
            "A. Non-inferiority of TAVR vs SAVR in high-risk patients at 1 year",
            "B. Superiority of TAVR over medical therapy in inoperable patients",
            "C. Superiority of TAVR over SAVR in 1-year all-cause mortality in high-risk patients",
            "D. Non-inferiority of TAVR vs SAVR in intermediate-risk patients at 2 years"
        ],
        "answer": "C",
        "explanation": "The CoreValve US Pivotal Trial (Adams et al., NEJM 2014) was the FIRST prospectively randomized comparison demonstrating improved SURVIVAL at 1 year for TAVR compared to SAVR (TAVR 14.2% vs SAVR 19.1%, P=.04). This was a landmark finding as prior TAVR trials had only shown non-inferiority. Note: mean STS score was ~7.4%, which was a 'less sick' group than the PARTNER 1 high-risk cohort (STS 11.8%). Permanent pacemaker implantation was higher for CoreValve (22.3% at 1yr vs 11.3% SAVR)."
    },
    {
        "num": 9,
        "image_path": os.path.join(IMG_DIR, 'p7_img1.png'),
        "image_caption": "Fig. 59.8A from Chapter 59. Fluoroscopic image during transcaval TAVR showing haemodynamic shunting after sheath removal and before closure.",
        "stem": "The fluoroscopy image above is from a transcaval TAVR procedure. After the TAVR sheath has been removed from the aorta but before the closure device is deployed, blood is seen shunting between two structures. What is the CORRECT direction of this blood shunt and why?",
        "options": [
            "A. From IVC to aorta, driven by respiratory variation in IVC pressure",
            "B. From aorta to IVC, driven by the decreasing pressure gradient from aorta through retroperitoneal space to IVC",
            "C. From aorta to IVC, due to gravity and patient positioning",
            "D. From IVC to aorta, because the IVC pressure exceeds aortic pressure during ventricular systole"
        ],
        "answer": "B",
        "explanation": "The transcaval procedure relies on the DECREASING PRESSURE GRADIENT from the aorta (high pressure) through the retroperitoneal space to the IVC (low pressure). Blood shunts from the aorta, across the retroperitoneal space, to the IVC, provided the tract remains unobstructed. This is the mechanism that allows venous return to be maintained during the procedure and also explains why the sheath must be fully withdrawn INTO the IVC before deploying the ductal occluder — failure to do so results in heavy retroperitoneal bleeding as the venous return path is lost."
    },
    {
        "num": 10,
        "stem": "In the PARTNER 2 trial involving 2032 intermediate-risk patients, the access route used had a significant impact on outcomes. Regarding patients in the TRANSTHORACIC access cohort compared to the TRANSFEMORAL cohort, which finding was demonstrated at 2 years?",
        "options": [
            "A. Death or disabling stroke was lower in TAVR than SAVR regardless of access route",
            "B. Death or disabling stroke was significantly higher in TAVR than SAVR in the transthoracic cohort (TAVR 59.3% vs SAVR 48.3%)",
            "C. Both cohorts showed equivalent outcomes, confirming that access route does not influence TAVR results",
            "D. Transthoracic TAVR was associated with lower stroke rates than transfemoral TAVR"
        ],
        "answer": "B",
        "explanation": "In the PARTNER 2 trial, the TRANSFEMORAL cohort showed NO DIFFERENCE in death or stroke between TAVR and SAVR. However, in the TRANSTHORACIC cohort, the rate of death or disabling stroke was significantly HIGHER after TAVR (59.3%) vs SAVR (48.3%), HR 1.02–1.71, confirming that thoracic alternative access (transapical/transaortic) is INFERIOR to SAVR in eligible patients. This is a critical teaching point: non-femoral THORACIC access should be avoided if the patient is eligible for SAVR."
    },
    {
        "num": 11,
        "stem": "During planning for TAVR in a 72-year-old with a previously implanted 21mm Carpentier-Edwards surgical bioprosthesis that has structurally failed (mean gradient 42 mmHg, AVA 0.75 cm²), the heart team is considering Valve-in-Valve (ViV) TAVR. Which ONE of the following statements regarding ViV TAVR coronary obstruction risk is CORRECT?",
        "options": [
            "A. Coronary obstruction in ViV TAVR occurs at the same rate as in native valve TAVR (<1%)",
            "B. Externally mounted leaflets in the surgical prosthesis confer an OR of 7.67 for coronary obstruction vs internally mounted leaflets",
            "C. Coronary height is the most reliable CT predictor of coronary obstruction in ViV TAVR",
            "D. The left and right coronary arteries are equally at risk during ViV TAVR"
        ],
        "answer": "B",
        "explanation": "Coronary obstruction in ViV TAVR (2.3%) is MORE THAN 7 TIMES as likely as in native valve TAVR (<1%), with an OR of 7.67 for valves with externally mounted leaflets (6.4%) vs internally mounted leaflets (0.7%). Stentless valves also carry higher risk (3.7%). Importantly, coronary HEIGHT did NOT differ between patients with and without coronary obstruction in ViV TAVR — making VTC distance, not coronary height, the more reliable predictor. The LEFT coronary is more commonly obstructed (72%) than both coronaries (20%) or the isolated right coronary (8%)."
    },
    {
        "num": 12,
        "vignette": "A 70-year-old male with severe AS is scheduled for transcarotid TAVR after bilateral iliac disease excluded transfemoral access. During the procedure, the right common carotid artery is exposed at the base of the neck. Cerebral oximetry from both hemispheres is being monitored.",
        "stem": "Which of the following is the PRIMARY REASON the RIGHT common carotid artery is PREFERRED over the left for transcarotid TAVR?",
        "options": [
            "A. The right CCA is larger in diameter and can accommodate larger sheaths",
            "B. The right CCA provides a straighter path towards the aortic valve compared to the left",
            "C. The left CCA approach risks injury to the thoracic duct",
            "D. The right CCA approach avoids the need for systemic anticoagulation"
        ],
        "answer": "B",
        "explanation": "The right CCA is preferred because it provides a STRAIGHTER PATH towards the aortic valve compared to the left CCA, which makes valve delivery system advancement easier. Additionally, the right-sided approach directly involves only ONE vertebral artery (right vertebral), whereas the left approach would involve TWO cerebrovascular vessels (right vertebral + right common carotid if right CCA is also cannulated as vascular access). The systolic BP is maintained at ~150 mmHg during the procedure and cerebral oximetry is monitored bilaterally throughout."
    },
    {
        "num": 13,
        "image_path": os.path.join(IMG_DIR, 'p11_img2.png'),
        "image_caption": "Fig. 59.12 from Chapter 59. PARTNER 2 trial 5-year analysis: Kaplan-Meier curves for death or disabling stroke between TAVR and SAVR in intermediate-risk patients.",
        "stem": "The Kaplan-Meier graph above shows the 5-year outcomes from the PARTNER 2 trial in 2032 intermediate-risk patients. Which of the following best interprets the result shown?",
        "options": [
            "A. TAVR was significantly superior to SAVR with a p-value of 0.001",
            "B. SAVR was significantly superior to TAVR with a hazard ratio favoring SAVR",
            "C. There was no significant difference between TAVR and SAVR (HR 1.09, 95% CI 0.95-1.25, P=0.21)",
            "D. TAVR showed significantly lower rates of death/stroke at 1 year but converged at 5 years"
        ],
        "answer": "C",
        "explanation": "The PARTNER 2 trial at 5-year follow-up showed NO SIGNIFICANT DIFFERENCE in death or disabling stroke between TAVR (47.9%) and SAVR (43.4%), HR 1.09 (95% CI 0.95–1.25), P=0.21. This demonstrates NON-INFERIORITY of TAVR to SAVR in intermediate-risk patients. However, there were more TAVR patients with at least mild PVR and repeat hospitalizations. Re-intervention was more common in TAVR (3.2% vs 0.8%), mostly due to progressive stenosis or regurgitation. This is one of the key landmark trials establishing TAVR across the risk spectrum."
    },
    {
        "num": 14,
        "stem": "Which of the following statements about the EVOLUT LOW RISK TRIAL is CORRECT regarding its comparison of self-expanding TAVR vs SAVR in low surgical risk patients (STS PROM <3%)?",
        "options": [
            "A. TAVR showed higher rates of acute kidney injury (2.8% vs 0.8%) compared to SAVR",
            "B. TAVR showed lower stroke rates (0.5% vs 1.7%) and lower AKI (0.8% vs 2.8%) than SAVR, but higher PVR (3.5% vs 0.5%) and pacemaker rates (17.4% vs 6.1%)",
            "C. There was no significant difference in stroke, AKI, PVR or pacemaker rates between groups",
            "D. The primary endpoint of death or disabling stroke at 2 years significantly favored TAVR over SAVR (P<0.05)"
        ],
        "answer": "B",
        "explanation": "The Evolut Low Risk Trial (Popma et al., NEJM 2019) showed TAVR was non-inferior to SAVR. TAVR had ADVANTAGES: lower stroke (0.5% vs 1.7%) and lower AKI (0.8% vs 2.8%). TAVR had DISADVANTAGES: higher moderate/severe PVR (3.5% vs 0.5%) and higher pacemaker implantation rate (17.4% vs 6.1%). The primary endpoint (death or stroke) was NOT significantly different (non-inferiority). This contrasts with PARTNER 3 (balloon-expandable, SAPIEN 3) where NO difference in PPM was found but TAVR was superior for the composite outcome at 1 year."
    },
    {
        "num": 15,
        "vignette": "A 68-year-old male with a bicuspid aortic valve and severe AS (Vmax 4.8 m/s) is referred for valve replacement. He is a non-smoker with no significant comorbidities and has an STS score of 1.8%. Echocardiography reveals moderately impaired LV function (EF 40%). CT scan confirms a Sievers type 1 bicuspid valve with a large burden of calcification. The aortic root diameter is 41 mm.",
        "stem": "According to current 2020 ACC/AHA guideline recommendations and the chapter content, what is the MOST APPROPRIATE management strategy for this patient?",
        "options": [
            "A. Transfemoral TAVR given his low STS score of 1.8%",
            "B. SAVR with consideration of concomitant prophylactic aortic root replacement given aortopathy",
            "C. Transcaval TAVR to avoid thoracotomy in the setting of reduced EF",
            "D. Balloon aortic valvuloplasty as a bridge to definitive intervention"
        ],
        "answer": "B",
        "explanation": "This patient is 68 years old with a bicuspid aortic valve, aortopathy (root 41 mm), and is low surgical risk (STS 1.8%). The ACC/AHA 2020 guidelines give only a Class IIb (WEAK) recommendation for TAVR in bicuspid AS. Major trials excluded bicuspid patients. The benefits of SAVR here include: (1) resection of heavily calcified leaflets (reducing PVR), (2) prophylactic replacement of the dilated aortic root (41 mm meets criteria for consideration), and (3) avoidance of the higher stroke and PVR rates seen with TAVR in bicuspid disease. SAVR is clearly preferred in this younger low-risk patient with anatomy that favors surgery."
    },
    {
        "num": 16,
        "stem": "During transsubclavian TAVR, a 73-year-old patient develops left arm weakness and tingling on the operating table while the oblique deltopectoral incision is being deepened. The most likely structure injured is:",
        "options": [
            "A. Long thoracic nerve, causing serratus anterior palsy",
            "B. Medial or lateral cord of the brachial plexus",
            "C. Thoracodorsal nerve to latissimus dorsi",
            "D. Phrenic nerve causing ipsilateral hemidiaphragm elevation"
        ],
        "answer": "B",
        "explanation": "During transsubclavian/axillary TAVR, GREAT CARE must be taken to avoid injury to the MEDIAL AND LATERAL CORDS OF THE BRACHIAL PLEXUS, as they travel in close association with the axillary artery, particularly in its second portion. Injury to these cords produces arm weakness and sensory changes as described. Division of the head of pectoralis minor (sometimes needed for exposure) and lateral retraction of pectoralis minor increase the risk of brachial plexus injury. This is the most feared neurological complication of this access route."
    },
    {
        "num": 17,
        "vignette": "A 77-year-old man underwent SAVR with a 23 mm Hancock porcine bioprosthesis 12 years ago. He now presents with severe dyspnea (NYHA III) and echocardiography confirms structural valve deterioration with a mean gradient of 38 mmHg and AVA of 0.8 cm² through the prosthesis. His STS PROM is 8.5%.",
        "stem": "The heart team opts for Valve-in-Valve (ViV) TAVR. Compared to native valve TAVR performed in the same center, which of the following post-deployment hemodynamic differences is expected?",
        "options": [
            "A. Lower post-deployment mean gradients in ViV TAVR compared to native TAVR (10 vs 16 mmHg)",
            "B. Higher post-deployment mean gradients in ViV TAVR compared to native TAVR (16 vs 9 mmHg)",
            "C. Similar post-deployment gradients in both ViV and native TAVR",
            "D. ViV TAVR results in lower gradients due to improved supra-annular positioning"
        ],
        "answer": "B",
        "explanation": "The STS/ACC TVT Registry data demonstrated that perioperative outcomes (stroke, PPM, PVR) were BETTER in ViV TAVR than native valve TAVR. However, post-deployment mean gradients were HIGHER in ViV TAVR (16 mmHg) compared to native valve TAVR (9 mmHg). This is because the TAVR valve must fit within the fixed outer diameter of the surgical prosthesis, limiting the effective orifice area. The presence of a small surgical valve (<=23 mm) and aortic stenosis (rather than regurgitation) were both associated with increased mortality in the VIVID Registry. Redo SAVR achieves lower mean gradients but at the cost of longer hospital stay."
    },
    {
        "num": 18,
        "stem": "According to Chapter 59, which of the following is an ABSOLUTE CONTRAINDICATION to the transaortic (TAo) TAVR approach?",
        "options": [
            "A. Previous median sternotomy",
            "B. Porcelain aorta",
            "C. Severe COPD with FEV1 <30%",
            "D. Left internal mammary artery (LIMA) graft overlying the aorta"
        ],
        "answer": "B",
        "explanation": "PORCELAIN AORTA is the ABSOLUTE CONTRAINDICATION to the transaortic (TAo) approach, because safe aortic cannulation with placement of purse-string sutures is impossible when the ascending aorta is heavily calcified throughout. The other options are relative contraindications or complicating factors: previous sternotomy adds technical difficulty; LIMA overlying the aorta creates hazard; hostile mediastinum (including prior radiation) increases risk. FEV1 <30% and EF <20% are contraindications to TRANSAPICAL (TA) TAVR, not TAo. The TAo approach is actually preferred over TA TAVR in patients with poor pulmonary function."
    },
    {
        "num": 19,
        "image_path": os.path.join(IMG_DIR, 'p14_img1.png'),
        "image_caption": "Fig. 59.16 from Chapter 59. Fluoroscopic/angiographic image showing a Valve-in-Valve TAVR with a transcatheter prosthesis deployed within a previously implanted surgical bioprosthesis.",
        "stem": "The image above demonstrates a Valve-in-Valve (ViV) TAVR procedure. In the largest dataset to report this procedure (VIVID Registry, n=1168), which combination of factors was associated with HIGHEST MORTALITY in ViV TAVR patients?",
        "options": [
            "A. Large surgical valve size (>27 mm) with aortic regurgitation",
            "B. Small surgical valve size (<=23 mm) with aortic stenosis",
            "C. Younger age (<70 years) with high ejection fraction",
            "D. Externally mounted leaflets with right coronary artery dominance"
        ],
        "answer": "B",
        "explanation": "In the VIVID Registry (the largest ViV TAVR dataset at the time), presence of a SMALL SURGICAL VALVE (<=23 mm) and AORTIC STENOSIS (rather than regurgitation) were associated with INCREASED MORTALITY. A small valve creates a constrained inner diameter, resulting in higher residual gradients after ViV TAVR (prosthesis-patient mismatch). Pre-existing prosthesis-patient mismatch before ViV TAVR further worsens outcomes. These findings highlight why surgeons performing the original SAVR should maximize valve size using root enlargement techniques to facilitate safer future ViV TAVR."
    },
    {
        "num": 20,
        "vignette": "A 72-year-old woman is being evaluated by the Heart Team for treatment of severe AS (mean gradient 55 mmHg, AVA 0.65 cm²). She has an STS score of 3.1% and is otherwise suitable for either SAVR or transfemoral TAVR. She reports that she is a long-distance runner who wishes to have the 'most durable treatment' and 'avoid repeat procedures in the future'. She is fully informed about both options.",
        "stem": "Which of the following best summarizes the ACC/AHA 2020 guideline recommendation for a patient such as this?",
        "options": [
            "A. TAVR is recommended as the procedure of choice for all patients with an STS score <4%",
            "B. SAVR is recommended given that the patient is under 80 years and has expressed preference for durability and avoiding re-intervention",
            "C. Either SAVR or TAVR is acceptable; the decision should be individualized with shared decision making by the Heart Team considering patient age, life expectancy, anatomy, and patient preference",
            "D. SAVR must be offered first; TAVR is only appropriate after SAVR has been declined by the patient"
        ],
        "answer": "C",
        "explanation": "For patients aged 65–80 years (she is 72), the 2020 ACC/AHA Guideline states that EITHER SAVR or TAVR is recommended, based on individual patient factors — including suitability for TF access, valve morphology, LVOT calcium burden, comorbid conditions, AND patient preference. The guidelines emphasize SHARED DECISION MAKING between the patient and Heart Team. Her preference for durability and avoiding re-intervention is a valid consideration that could favor SAVR (more long-term data; lower PVR; no TAVR valve-related durability uncertainty beyond 5–10 years). However, this does not make TAVR contraindicated — the Heart Team must weigh all factors together. The STS score alone does not determine the choice."
    },
]

# ─────────────────────────────────────────────────────────────────
# BUILD PDF
# ─────────────────────────────────────────────────────────────────
story = []

# COVER
story.append(sp(0.8))
story.append(p('INI SS CET — CARDIOVASCULAR &amp; THORACIC SURGERY', title_s))
story.append(p('CHAPTER 59 | TRANSCATHETER AORTIC VALVE REPLACEMENT (TAVR)', title_s))
story.append(sp(0.3))
story.append(hr_blue)
story.append(sp(0.3))
story.append(p('20 Single Best Answer Questions — Practice MCQ Paper', subtitle_s))
story.append(p('Based on: Edelman &amp; Thourani, Sabiston &amp; Spencer Surgery of the Chest, Chapter 59', subtitle_s))
story.append(sp(0.2))

# Instructions box
instr_data = [[
    Paragraph('<b>INSTRUCTIONS</b><br/>'
              '&#x2022; This paper contains 20 questions. Each question carries equal marks.<br/>'
              '&#x2022; Each question has ONE single best answer from options A to D.<br/>'
              '&#x2022; Some questions are preceded by a clinical vignette — read carefully before answering.<br/>'
              '&#x2022; Image-based questions include the figure with source attribution.<br/>'
              '&#x2022; Answers with explanations are provided at the end of each question.<br/>'
              '&#x2022; Time allowed: 40 minutes (2 min/question)',
              ParagraphStyle('InstrBox', parent=styles['Normal'],
                  fontSize=9.5, leading=14, fontName='Helvetica',
                  textColor=colors.HexColor('#1A3A5C')))
]]
instr_tbl = Table(instr_data, colWidths=[16.7*cm])
instr_tbl.setStyle(TableStyle([
    ('BACKGROUND', (0,0), (-1,-1), colors.HexColor('#EEF5FF')),
    ('BOX', (0,0), (-1,-1), 1, colors.HexColor('#003366')),
    ('LEFTPADDING', (0,0), (-1,-1), 10),
    ('RIGHTPADDING', (0,0), (-1,-1), 10),
    ('TOPPADDING', (0,0), (-1,-1), 8),
    ('BOTTOMPADDING', (0,0), (-1,-1), 8),
]))
story.append(instr_tbl)
story.append(sp(0.5))
story.append(hr_thin)
story.append(PageBreak())

# QUESTIONS
for q in mcqs:
    elems = []

    # Question number banner
    elems.append(p(f'  QUESTION {q["num"]}  /  20', q_num_s))

    # Vignette (if any)
    if q.get('vignette'):
        elems.append(p(q['vignette'], para_s))

    # Image (if any)
    if q.get('image_path'):
        img_elems = img(q['image_path'], width=11*cm, caption=q.get('image_caption', ''))
        elems.extend(img_elems)

    # Stem
    elems.append(p(q['stem'], q_stem_s))

    # Options
    for opt in q['options']:
        elems.append(p(opt, opt_s))

    elems.append(sp(0.2))

    # Answer + explanation
    ans_text = (f'<b>ANSWER: {q["answer"]}</b><br/>'
                f'<b>Explanation:</b> {q["explanation"]}')
    elems.append(p(ans_text, ans_box_s))

    elems.append(hr_thin)
    elems.append(sp(0.1))

    # Keep question together if short; allow page break for long ones
    if q.get('image_path') or q.get('vignette'):
        story.extend(elems)
    else:
        story.append(KeepTogether(elems))

# END PAGE
story.append(PageBreak())
story.append(sp(1))
story.append(p('--- END OF PAPER ---', subtitle_s))
story.append(sp(0.5))
story.append(hr_blue)
story.append(sp(0.3))
story.append(p(
    'Source: Chapter 59 — Transcatheter Aortic Valve Replacement. '
    'Edelman JJ, Thourani VH. In: Sellke FW, del Nido PJ, Swanson SJ (eds). '
    'Sabiston and Spencer Surgery of the Chest, 9th Edition. Elsevier.<br/>'
    'Images sourced from Chapter 59 of the above textbook (pp. 1105-1120).<br/>'
    'MCQs prepared for INI SS CET CVTS examination practice. All trial data cited from original publications.',
    ParagraphStyle('SrcS', parent=styles['Normal'],
        fontSize=8.5, fontName='Helvetica', textColor=colors.HexColor('#555555'),
        alignment=TA_CENTER, leading=13)))

doc.build(story)
print('MCQ PDF generated successfully')

cd /home/daytona/workspace/tavr_project && python3 generate_mcqs.py 2>&1

ls -lh /home/daytona/workspace/tavr_project/output/ && python3 -c " from pypdf i…