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Minimally Invasive Aortic Valve Replacement Performed Using Real-Time CT Imaging

By MedImaging International staff writers
Posted on 06 May 2022

Image: Minimally invasive aortic valve replacement done using real-time CT imaging (Photo courtesy of Pexels)

Cardiologists from the Hackensack University Medical Center (Hackensack, NJ, USA) have reported what is believed to be the very first patient with heart failure and a blood clot to undergo a minimally invasive transcatheter aortic valve replacement using CT (computed tomography) fusion imaging, a technique that employs two different imaging modalities.

The patient was a 78-year-old man with a history of obesity, high blood pressure, and coronary artery disease. He came to the hospital with worsening labored breathing on exertion and swelling in the lower extremities over three months. His imaging workup revealed severe stenosis of the aortic valve, left ventricular (LV) ejection fraction of 45% to 50%, and LV apical aneurysm with thrombus (an outpouching of the left ventricle with a blood clot). Ejection fraction is a measurement of the percentage of blood leaving the heart each time it contracts.

Cardiac catheterization showed severe coronary artery disease that was not amenable to minimally invasive procedures used to open clogged coronary arteries. He was started on anticoagulation with warfarin with planned follow-up. The patient returned to the hospital six months later due to loss of consciousness from low blood pressure. Four-dimensional volume-rendered computed tomography (CT) images showed persistent left ventricle apical thrombus. The Heart & Vascular Hospital team elected to proceed with transcatheter aortic valve replacement (TAVR) given his high surgical risk, poor functional status, lack of response to anticoagulation, and hospitalization for fainting. Because of the risk posed by the apical thrombus, TAVR with CT fusion imaging (CTFI) guidance and cerebral embolic protection was planned. The patient had an uneventful hospital course; there was no evidence of cerebral or systemic embolization. He was discharged in a few days and was doing well at his one month follow up appointment.

“We believe this case is potentially groundbreaking because of its successful outcome and the fact that the presence of left-ventricle thrombus or blood clot has historically been considered to be a contraindication to transcatheter aortic valve replacement, an alternative to open-heart surgery to replace heart valves in patients with heart disease,” said Rahul Vasudev, M.D. “Although the nature of catheter manipulation in the left ventricle during the procedure cannot guarantee absence of contact with the blood clot, advances in imaging technology and embolic protection may allow transcatheter aortic valve replacement, if a surgical alternative is not possible, to be performed with greater safety in this setting.”

“We believe this was the first case of TAVR with real-time CTFI to facilitate wire and catheter positioning to avoid disruption of the left ventricle thrombus,” said Tilak K. R. Pasala, interim director, Structural and Congenital Heart Disease Program.

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60 (!!!!! 9413.0039215088): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294792821 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294792821 AND published='1' LIMIT 1

61 (826.83563232422): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294792821 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294792821 AND published='1' LIMIT 1

62 (102.04315185547): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294792821 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294792821 AND published='1' LIMIT 1

63 (463.96255493164): select cover from jos_number where journalid in (5) and cover is not null order by left(issue,2)+right(issue,2)*12 desc limit 1

64 (468.96934509277): SELECT fid FROM jos_deeppockets WHERE id=294792821 AND published='1' union SELECT fid FROM jos_deeppockets_archive WHERE id=294792821 AND published='1' LIMIT 1

65 (!!!!! 1564.0258789062): SELECT id,name,sponsor_text FROM jos_deeppockets dp left outer join jos_channel_sponsor cs on dp.id=cs.fid WHERE cat=10 AND TYPE='file_folder' AND published=1 AND id=215 ORDER BY `ordering`

66 (!!!!! 3077.0301818848): select jos_twitters.link from jos_twitters where cat=10

67 (324.01084899902): select jos_facebook.link from jos_facebook where cat=10

68 (222.92137145996): select jos_google_plus.link from jos_google_plus where cat=10

69 (!!!!! 7112.0262145996): select jos_linkedin.link from jos_linkedin where cat=10

70 (!!!!! 3025.0549316406): SELECT fid FROM jos_deeppockets WHERE id=294792821 AND published='1' union SELECT fid FROM jos_deeppockets_archive WHERE id=294792821 AND published='1' LIMIT 1

71 (305.8910369873): SELECT id,name,sponsor_text FROM jos_deeppockets dp left outer join jos_channel_sponsor cs on dp.id=cs.fid WHERE cat=10 AND TYPE='file_folder' AND published=1 AND id=215 ORDER BY `ordering`

72 (470.87669372559): SELECT fid FROM jos_deeppockets WHERE cat=10 AND id=294792821 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

73 (!!!!! 3201.961517334): SELECT fid FROM jos_deeppockets_archive WHERE cat=10 AND id=294792821 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

74 (335.9317779541): SELECT id,name,title FROM jos_deeppockets WHERE cat=10 AND TYPE='file_folder' AND published=1 AND id != 294743300 AND id != 294743301 AND id != 294743302 AND id != 294743303 AND id != 294743304 AND id != 294743305 AND id != 294743306 AND id != 294743307 AND id != 294743308 AND id != 294743309 AND id != 294743310 AND metakey != 'aacc' ORDER BY `ordering`

75 (!!!!! 9680.0327301025): SELECT show_live FROM jos_com_show_setting LIMIT 1

76 (!!!!! 8444.07081604): SELECT show_live FROM jos_com_show_setting LIMIT 1

77 (477.07557678223): SELECT show_live FROM jos_com_show_setting LIMIT 1

78 (!!!!! 1370.906829834): SELECT show_live FROM jos_com_show_setting LIMIT 1

79 (291.10908508301): SELECT show_live FROM jos_com_show_setting LIMIT 1

80 (143.05114746094): SELECT show_live FROM jos_com_show_setting LIMIT 1

81 (218.86825561523): SELECT show_live FROM jos_com_show_setting LIMIT 1

82 (125.16975402832): SELECT show_live FROM jos_com_show_setting LIMIT 1

83 (157.11784362793): SELECT show_live FROM jos_com_show_setting LIMIT 1

84 (642.77648925781): SELECT show_live FROM jos_com_show_setting LIMIT 1

85 (!!!!! 3695.011138916): SELECT show_live FROM jos_com_show_setting LIMIT 1

86 (252.96211242676): SELECT show_live FROM jos_com_show_setting LIMIT 1

87 (351.1905670166): SELECT show_live FROM jos_com_show_setting LIMIT 1

88 (40.054321289062): SELECT show_live FROM jos_com_show_setting LIMIT 1

89 (293.97010803223): SELECT fid FROM jos_deeppockets WHERE cat=10 AND id=294792821 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

90 (41.007995605469): SELECT fid FROM jos_deeppockets_archive WHERE cat=10 AND id=294792821 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

91 (431.06079101562): SELECT id,name,title FROM jos_deeppockets WHERE cat=10 AND TYPE='file_folder' AND published=1 AND id != 294743300 AND id != 294743301 AND id != 294743302 AND id != 294743303 AND id != 294743304 AND id != 294743305 AND id != 294743306 AND id != 294743307 AND id != 294743308 AND id != 294743309 AND id != 294743310 AND metakey != 'aacc' ORDER BY `ordering`

92 (77.962875366211): SELECT show_live FROM jos_com_show_setting LIMIT 1

93 (40.054321289062): SELECT show_live FROM jos_com_show_setting LIMIT 1

94 (36.001205444336): SELECT show_live FROM jos_com_show_setting LIMIT 1

95 (32.186508178711): SELECT show_live FROM jos_com_show_setting LIMIT 1

96 (32.901763916016): SELECT show_live FROM jos_com_show_setting LIMIT 1

97 (31.948089599609): SELECT show_live FROM jos_com_show_setting LIMIT 1

98 (45.061111450195): SELECT show_live FROM jos_com_show_setting LIMIT 1

99 (31.948089599609): SELECT show_live FROM jos_com_show_setting LIMIT 1

100 (32.901763916016): SELECT show_live FROM jos_com_show_setting LIMIT 1

101 (31.948089599609): SELECT show_live FROM jos_com_show_setting LIMIT 1

102 (31.948089599609): SELECT show_live FROM jos_com_show_setting LIMIT 1

103 (33.140182495117): SELECT show_live FROM jos_com_show_setting LIMIT 1

104 (32.901763916016): SELECT show_live FROM jos_com_show_setting LIMIT 1

105 (31.948089599609): SELECT show_live FROM jos_com_show_setting LIMIT 1

106 (386.95335388184): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294792821 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294792821 AND published='1' LIMIT 1

107 (127.07710266113): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294792821 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294792821 AND published='1' LIMIT 1

108 (205.99365234375): SELECT dp.*, ch.title as channel, exp.name as author_name, exp.specialization as author_specialization, exp.images as author_photo FROM jos_deeppockets as dp LEFT JOIN jos_experts as exp ON exp.id = dp.author LEFT JOIN jos_deeppockets as ch ON dp.fid = ch.id WHERE 1=1 AND dp.cat=10 AND dp.id=294792821 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

109 (179.05235290527): SELECT dp.*, ch.title as channel, exp.name as author_name, exp.specialization as author_specialization, exp.images as author_photo FROM jos_deeppockets_archive as dp LEFT JOIN jos_experts as exp ON exp.id = dp.author LEFT JOIN jos_deeppockets as ch ON dp.fid = ch.id WHERE 1=1 AND dp.cat=10 AND dp.id=294792821 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

110 (!!!!! 1023.0541229248): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294792821 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294792821 AND published='1' LIMIT 1

111 (150.91896057129): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294792821 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294792821 AND published='1' LIMIT 1

112 (437.97492980957): SELECT dp.*, ch.title as channel, exp.name as author_name, exp.specialization as author_specialization, exp.images as author_photo FROM jos_deeppockets as dp LEFT JOIN jos_experts as exp ON exp.id = dp.author LEFT JOIN jos_deeppockets as ch ON dp.fid = ch.id WHERE 1=1 AND dp.id=294792821 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

113 (421.04721069336): SELECT dp.*, ch.title as channel, exp.name as author_name, exp.specialization as author_specialization, exp.images as author_photo FROM jos_deeppockets_archive as dp LEFT JOIN jos_experts as exp ON exp.id = dp.author LEFT JOIN jos_deeppockets as ch ON dp.fid = ch.id WHERE 1=1 AND dp.id=294792821 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

114 (102.99682617188): SELECT dp.*, ch.title as channel, exp.name as author_name, exp.specialization as author_specialization, exp.images as author_photo FROM jos_deeppockets as dp LEFT JOIN jos_experts as exp ON exp.id = dp.author LEFT JOIN jos_deeppockets as ch ON dp.fid = ch.id WHERE 1=1 AND dp.id=294792815 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

115 (550.98533630371): SELECT dp.*, ch.title as channel, exp.name as author_name, exp.specialization as author_specialization, exp.images as author_photo FROM jos_deeppockets_archive as dp LEFT JOIN jos_experts as exp ON exp.id = dp.author LEFT JOIN jos_deeppockets as ch ON dp.fid = ch.id WHERE 1=1 AND dp.id=294792815 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

116 (!!!!! 9091.1388397217): SELECT dp.name, dp.id, dp2.name as channel, ex.name as author_name, ex.specialization, ex.images FROM jos_deeppockets as dp LEFT JOIN jos_experts as ex ON ex.id = dp.author LEFT JOIN jos_deeppockets as dp2 ON dp2.id = dp.fid WHERE dp.author != 0 AND dp.cat = 10 AND dp.published = 1 AND ( (dp.fid = 294743300) OR (dp.fid = 294743301) OR (dp.fid = 294743302) OR (dp.fid = 294743303) OR (dp.fid = 294743304) OR (dp.fid = 294743305) OR (dp.fid = 294743306) OR (dp.fid = 294743307) OR (dp.fid = 294743308) OR (dp.fid = 294743309) OR (dp.fid = 294743310) ) ORDER BY RAND() LIMIT 1

117 (!!!!! 7974.1477966309): SELECT dp.name, dp.id, dp2.name as channel, ex.name as author_name, ex.specialization, ex.images FROM jos_deeppockets as dp LEFT JOIN jos_experts as ex ON ex.id = dp.author LEFT JOIN jos_deeppockets as dp2 ON dp2.id = dp.fid WHERE dp.author != 0 AND dp.cat = 10 AND dp.published = 1 AND ( (dp.fid = 294743300) OR (dp.fid = 294743301) OR (dp.fid = 294743302) OR (dp.fid = 294743303) OR (dp.fid = 294743304) OR (dp.fid = 294743305) OR (dp.fid = 294743306) OR (dp.fid = 294743307) OR (dp.fid = 294743308) OR (dp.fid = 294743309) OR (dp.fid = 294743310) ) ORDER BY RAND() LIMIT 1

118 (!!!!! 2237.08152771): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294792821 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294792821 AND published='1' LIMIT 1

119 (!!!!! 3640.1748657227): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294792821 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294792821 AND published='1' LIMIT 1

120 (!!!!! 4196.8822479248): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294792821 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294792821 AND published='1' LIMIT 1

121 (82.015991210938): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294792821 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294792821 AND published='1' LIMIT 1

122 (!!!!! 3631.1149597168): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294792821 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294792821 AND published='1' LIMIT 1

123 (215.05355834961): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294792821 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294792821 AND published='1' LIMIT 1

124 (347.85270690918): SELECT * FROM trending_articles WHERE `journal_id` = 10 AND `timestamp` <= NOW() + INTERVAL 7 DAY ORDER BY `order`

125 (!!!!! 154788.01727295): SELECT * FROM jos_deeppockets WHERE jos_deeppockets.cat = 10 AND jos_deeppockets.type = 'deeppockets_item' AND jos_deeppockets.published = 1 AND jos_deeppockets.created + INTERVAL 14 DAY >= NOW() ORDER BY jos_deeppockets.hits DESC LIMIT 7

126 (151.15737915039): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294792821 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294792821 AND published='1' LIMIT 1

127 (128.98445129395): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294792821 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294792821 AND published='1' LIMIT 1

128 (!!!!! 3979.9213409424): SELECT fid FROM jos_deeppockets WHERE cat=10 AND id=294792821 AND type='deeppockets_item' AND published='1' union SELECT fid FROM jos_deeppockets_archive WHERE cat=10 AND id=294792821 AND type='deeppockets_item' AND published='1' LIMIT 1

129 (!!!!! 1674000.0247955): ( SELECT dp.id, dp.name, dp.title, dp.video, dp.video_source, dp.created FROM jos_deeppockets AS dp WHERE dp.video != '' AND dp.video_source != '' AND dp.cat = 10 AND dp.published = 1 AND dp.type != 'deeppockets_item_link' ORDER BY created DESC LIMIT 3 ) UNION ( SELECT dpa.id, dpa.name, dpa.title, dpa.video, dpa.video_source, dpa.created FROM jos_deeppockets_archive AS dpa WHERE dpa.video != '' AND dpa.video_source != '' AND dpa.cat = 10 AND dpa.published = 1 AND dpa.type != 'deeppockets_item_link' ORDER BY created DESC LIMIT 3 ) ORDER BY created DESC LIMIT 3

130 (!!!!! 1788267.1356201): ( SELECT dp.id, dp.name, dp.title, dp.video, dp.video_source, dp.created FROM jos_deeppockets AS dp WHERE dp.video != '' AND dp.video_source != '' AND dp.cat = 10 AND dp.published = 1 AND dp.type != 'deeppockets_item_link' ORDER BY created DESC LIMIT 3 ) UNION ( SELECT dpa.id, dpa.name, dpa.title, dpa.video, dpa.video_source, dpa.created FROM jos_deeppockets_archive AS dpa WHERE dpa.video != '' AND dpa.video_source != '' AND dpa.cat = 10 AND dpa.published = 1 AND dpa.type != 'deeppockets_item_link' ORDER BY created DESC LIMIT 3 ) ORDER BY created DESC LIMIT 3

131 (!!!!! 7237.9112243652): SELECT dp.id, dp.name, dp.title, dp.video, dp.video_source, dp.created FROM jos_deeppockets AS dp WHERE dp.id = 294800513 LIMIT 1

132 (!!!!! 5816.9364929199): SELECT dp.id, dp.name, dp.title, dp.video, dp.video_source, dp.created FROM jos_deeppockets AS dp WHERE dp.id = 294800513 LIMIT 1

133 (!!!!! 3936.0523223877): SELECT dp.id, dp.name, dp.title, dp.video, dp.video_source, dp.created FROM jos_deeppockets AS dp WHERE dp.id = 294800359 LIMIT 1

134 (!!!!! 15317.916870117): SELECT dp.id, dp.name, dp.title, dp.video, dp.video_source, dp.created FROM jos_deeppockets AS dp WHERE dp.id = 294800359 LIMIT 1

135 (!!!!! 7813.9305114746): SELECT dp.id, dp.name, dp.title, dp.video, dp.video_source, dp.created FROM jos_deeppockets AS dp WHERE dp.id = 294800361 LIMIT 1

136 (!!!!! 7977.0088195801): SELECT dp.id, dp.name, dp.title, dp.video, dp.video_source, dp.created FROM jos_deeppockets AS dp WHERE dp.id = 294800361 LIMIT 1

137 (339.98489379883): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294792821 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

138 (345.94535827637): SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294792821 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

139 (154.97207641602): SELECT name FROM jos_deeppockets WHERE id=215

140 (46.014785766602): SELECT name FROM jos_deeppockets WHERE id=215

141 (576.97296142578): SELECT *, DATE_FORMAT(publish_up,'%d %b %Y') AS date_publish_up, DATE_FORMAT(publish_down,'%d %b %Y') AS date_publish_down FROM jos_events WHERE state=1 AND publish_up > NOW() and extra_info REGEXP '((;)|(^))215((;)|($))' AND catid IN (0,110) ORDER BY publish_up ASC LIMIT 3

142 (537.15705871582): SELECT *, DATE_FORMAT(publish_up,'%d %b %Y') AS date_publish_up, DATE_FORMAT(publish_down,'%d %b %Y') AS date_publish_down FROM jos_events WHERE state=1 AND publish_up > NOW() and extra_info REGEXP '((;)|(^))215((;)|($))' AND catid IN (0,110) ORDER BY publish_up ASC LIMIT 3

143 (!!!!! 1313.9247894287): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294792821 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294792821 AND published='1' LIMIT 1

144 (78.916549682617): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294792821 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294792821 AND published='1' LIMIT 1

145 (!!!!! 31728.029251099): TRUNCATE TABLE jos_trademed_module

146 (558.13789367676): SELECT dp.*, ch.title as channel, exp.name as author_name, exp.specialization as author_specialization, exp.images as author_photo FROM jos_deeppockets as dp LEFT JOIN jos_experts as exp ON exp.id = dp.author LEFT JOIN jos_deeppockets as ch ON dp.fid = ch.id WHERE 1=1 AND dp.cat=10 AND dp.id=294792821 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

147 (521.89826965332): SELECT dp.*, ch.title as channel, exp.name as author_name, exp.specialization as author_specialization, exp.images as author_photo FROM jos_deeppockets_archive as dp LEFT JOIN jos_experts as exp ON exp.id = dp.author LEFT JOIN jos_deeppockets as ch ON dp.fid = ch.id WHERE 1=1 AND dp.cat=10 AND dp.id=294792821 AND (dp.type='deeppockets_item' OR dp.type='deeppockets_item_link') AND dp.published='1' LIMIT 1

148 (!!!!! 2018.928527832): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294792821 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

149 (!!!!! 1904.0107727051): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294792821 AND (type='deeppockets_item' OR type='deeppockets_item_link') AND published='1' LIMIT 1

150 (601.05323791504): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294792821 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294792821 AND published='1' LIMIT 1

151 (394.82116699219): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294792821 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294792821 AND published='1' LIMIT 1

152 (!!!!! 3602.0278930664): SELECT jos_item.* FROM jos_item INNER JOIN jos_number ON jos_item.numberID=jos_number.id WHERE 1=1 AND (jos_item.imgMini<>'') AND jos_item.type='L' AND jos_item.numberID= ( SELECT jos_number.id FROM jos_number WHERE jos_number.journalID IN (10) and jos_number.id in (select distinct jos_number.id from jos_number join jos_item on jos_item.numberid=jos_number.id where jos_item.type='P') ORDER BY (CONVERT(SUBSTRING(issue,1,2),SIGNED) + (CONVERT(SUBSTRING(issue,3,2),SIGNED)*100)) DESC LIMIT 0,1 ) ORDER BY RAND() DESC LIMIT 6

153 (438.92860412598): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294792821 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294792821 AND published='1' LIMIT 1

154 (410.79521179199): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294792821 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294792821 AND published='1' LIMIT 1

155 (!!!!! 3228.9028167725): SELECT fid FROM jos_deeppockets WHERE cat=10 AND id=294792821 AND type='deeppockets_item' AND published='1' union SELECT fid FROM jos_deeppockets_archive WHERE cat=10 AND id=294792821 AND type='deeppockets_item' AND published='1' LIMIT 1

156 (66.041946411133): select distinct links.* from jos_textlinks links join jos_textlinks_placement placement on links.id=placement.link_id where journal_id=(10) and (channel_id=0 or channel_id is null)

157 (38.862228393555): select distinct links.* from jos_textlinks links join jos_textlinks_placement placement on links.id=placement.link_id where journal_id=(10) and (channel_id=0 or channel_id is null)

158 (52.213668823242): SELECT livesite FROM jos_dp_categories WHERE id=10 AND published='1' LIMIT 1

159 (!!!!! 3760.0994110107): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294792821 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294792821 AND published='1' LIMIT 1

160 (558.13789367676): SELECT * FROM jos_deeppockets WHERE 1=1 AND id=294792821 AND published='1' union SELECT * FROM jos_deeppockets_archive WHERE 1=1 AND id=294792821 AND published='1' LIMIT 1

161 (162.83988952637): select jos_twitters.link from jos_twitters where cat=10

162 (38.862228393555): select jos_facebook.link from jos_facebook where cat=10

163 (36.001205444336): select jos_google_plus.link from jos_google_plus where cat=10

164 (36.001205444336): select jos_linkedin.link from jos_linkedin where cat=10

165 (351.90582275391): update jos_bannersmanager_banner set impmade=impmade+1 where id in(14615,14202,14203)

166 (!!!!! 9493.1125640869): insert into jos_banners_delta values (14615,'2025-06-17 20:27:51','216.73.216.120','view'),(14202,'2025-06-17 20:27:51','216.73.216.120','view'),(14203,'2025-06-17 20:27:51','216.73.216.120','view')

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