Selective placement of novel compression suture technique to reduce pacemaker implantation rate following surgical aortic valve replacement with rapid deployment INTUITY valve.

OBJECTIVE: The use of RDV in SAVR is associated with risk of conduction abnormality requiring PPM implantation, when compared to conventional bioprosthetic valves. We aimed to evaluate the outcome after selective placement of annular compression sutures during surgical aortic valve replacement (SAVR) using Intuity rapid deployment valve (RDV). METHODS: This is a retrospective study of prospectively enrolled patients receiving SAVR using Intuity RDV. Selective placement of commissural compression suture was assessed for all patients based on their annular morphology. Outcomes including operative mortality, rate of pacemaker rate, paravalvular leak and change in trans-valvular pressure gradient were analyzed. RESULTS: 56 consecutive patients underwent SAVR with the INTUITY RDV at our institution from January 2020 to November 2021. The Mean age of our cohort was 69.9 ± 10.6 years with a EuroSCORE II of 3.4 ± 2.4%. 28.6% (16/56) of patients had notable conduction abnormalities pre-operatively, which included atrial fibrillation and left/right bundle branch block. Compression sutures were selectively applied in 19/56 (33.9%) patients. Of which, 13 were bicuspid aortic valve. Post-operatively, we observed no conduction abnormality requiring PPM implantation. In addition, only 3 of the 56 (5.4%) had any degree of paravalvular leak on post-operative echocardiography (all ≤ mild). The mean reduction in trans-valvular gradient was 29.9 mmHg and the mean pressure gradient at 1 month and 1 year follow-up were 9.3 ± 3.6 mmHg and 10.2 ± 4.1 mmHg, respectively. CONCLUSIONS: Selective placement of compression suture helps to avoid unnecessary oversizing, which may reduce the risk of paravalvular leak and post-operative PPM implantation.

Blood Reflux-Induced Epigenetic Factors HDACs and DNMTs Are Associated with the Development of Human Chronic Venous Disease.

Blood reflux and metabolic regulation play important roles in chronic venous disease (CVD) development. Histone deacetylases (HDACs) and DNA methyltransferases (DNMTs) serve as repressors that inhibit metabolic signaling, which is induced by proatherogenic flow to promote aortic endothelial cell (EC) dysfunction and atherosclerosis. The aim of this study was to elucidate the relationship between blood reflux and epigenetic factors HDACs and DNMTs in CVD. Human varicose veins with different levels of blood reflux versus normal veins with normal venous flow were examined. The results show that HDAC-1, -2, -3, -5, and -7 are overexpressed in the endothelium of varicose veins with blood reflux. Blood reflux-induced HDACs are enhanced in the varicose veins with a longer duration time of blood reflux. In contrast, these HDACs are rarely expressed in the endothelium of the normal vein with normal venous flow. Similar results are obtained for DNMT1 and DNMT3a. Our findings suggest that the epigenetic factors, HDACs and DNMTs, are induced in venous ECs in response to blood reflux but are inhibited in response to normal venous flow. Blood reflux-induced HDACs and DNMTs could inhibit metabolic regulation and promote venous EC dysfunction, which is highly correlated with CVD pathogenesis.

Inkjet-printed flexible non-enzymatic lactate sensor with high sensitivity and low interference using a stacked NiOx/NiOx-Nafion nanocomposite electrode with clinical blood test verification.

In this paper, we present a flexible, inkjet-printed, non-enzymatic lactate sensor with high sensitivity and specificity, using a stacked nickel oxide-Nafion nanocomposite/nickel oxide working electrode. Instead of deploying a pure Nafion film on the top of the nickel oxide particles, the nickel oxide-Nafion nanocomposite layer in the new electrode scheme functions not only as an anti-interfering layer but also a reactive layer and the bottom pure nickel oxide layer free from interfering substances mainly participates in the redox reaction to enhance the sensing current. Experimental results show that the sensor with a working electrode printed using a 30 µL NiOx ink and a mixture of 30 µL NiO and 4 µL Nafion ink can exhibit an anti-interference ability of >95%, a sensitivity of 20.56 nA/mM/mm2, and limit of detection (LoD) of 0.27 mM satisfying the criteria for human lactate detection. In clinical trial, blood plasma test results show that lactate levels detected using this sensor have a strong linear correlation coefficient square of 0.959 with those measured using the colorimetry method used in hospitals, indicating its potential for application in the management of patients with abnormal lactate values requiring intensive care.

Risk stratification and cost-effectiveness analysis of adult patients receiving extracorporeal membrane oxygenation.

RATIONALE, AIMS, AND OBJECTIVES: A more effective allocation of critical care resources is important as the cost of intensive care increases. A model has been developed to predict the probability of in-hospital death among patients who received extracorporeal membrane oxygenation (ECMO). Cost-effectiveness analyses (CEA) were performed regarding the relationship between hospitalization expenses and predicted survival outcomes. METHODS: Adult patients who received ECMO in a medical center in Taiwan (2005-2016) were included. A logistic regression model was applied to a spectrum of clinical measures obtained before and during ECMO institutions to identify the risk variables for in-hospital mortality. CEA were reported as a predictive risk in quintiles and defined as the cost of each quality-adjusted life-year (QALY). The distribution of the cost-effectiveness ratio (CER) was measured by the ellipse and acceptability curve methods. RESULTS: A total of 919 patients (659 males, mean age: 53.7 years) were enrolled. Ten variables emerged as significant predictors of in-hospital death. The area under the receiver operating characteristic curve was 0.75 (95% confidence interval: 0.72-0.79). In-hospital and total follow-up times were 40,366 and 660,205 person-days, respectively. The total in-hospital expense was $31,818,701 USD and the total effectiveness was 1687.3 QALY. For the lowest to the highest risk quintile, the mean mortality risks were 0.30, 0.48, 0.61, 0.75, and 0.88, and mean adjusted CER were $24,230, $43,042, $54,929, $84,973, and $149,095 per QALY, respectively. CONCLUSIONS: The efficient allocation of limited and costly resources is most important when one is forced to decide between groups of critically ill patients. The current analyses of ECMO outcomes should assist in identifying candidates with the greatest prospect for survival while avoiding futile treatments.

Low Levels of MicroRNA-10a in Cardiovascular Endothelium and Blood Serum Are Related to Human Atherosclerotic Disease.

BACKGROUND: MicroRNA-10a (miR-10a) inhibits transcriptional factor GATA6 to repress inflammatory GATA6/VCAM-1 signaling, which is regulated by blood flow to affect endothelial function/dysfunction. This study aimed to identify the expression patterns of miR-10a/GATA6/VCAM-1 in vivo and study their implications in the pathophysiology of human coronary artery disease (CAD), i.e., atherosclerosis. METHODS: Human atherosclerotic coronary arteries and nondiseased arteries were used to detect the expressions of miR-10a/GATA6/VCAM-1 in pathogenic vs. normal conditions. In addition, sera from CAD patients and healthy subjects were collected to detect the level of circulating miR-10a. RESULTS: The comparison of human atherosclerotic coronary arteries with nondiseased arteries demonstrated that lower levels of endothelial miR-10a are related to human atherogenesis. Moreover, GATA6/VCAM-1 (a downstream target of miR-10a) was highly expressed in the endothelium, accompanied by the reduced levels of miR-10a during the development of human atherosclerosis. In addition, CAD patients had a significantly lower concentration of miR-10a in their serum compared to healthy subjects. CONCLUSIONS: Our findings suggest that low miR-10a and high GATA6/VCAM-1 in the cardiovascular endothelium correlates to the development of human atherosclerotic lesions, suggesting that miR-10a signaling has the potential to be developed as a biomarker for human atherosclerosis.

Molecularly Imprinted Polymer/Anodic Aluminum Oxide Nanocomposite Sensing Electrode for Low-Concentration Troponin T Detection for Patient Monitoring Applications.

Various clinical studies have shown that myocardial troponin T (cTnT) is highly correlated with acute myocardial infarction (AMI). A highly sensitive molecularly imprinted polymer (MIP) sensing electrode for the detection of cTnT in patients' blood serum can enable cost-effective, rapid, and real-time testing for patients requiring intensive care. However, the existing MIP-based sensing electrode does not perform well for low-concentration detection of cTnT (<0.2 ng/mL). In this study, a new type of sensing electrode, an anodic aluminum oxide molecularly imprinted (MIP/AAO) nanocomposite electrode is developed. By incorporating the AAO structure, i.e., one-dimensional (1D) pillars, through a semiconductor-compatible process, the new electrode exhibits a great performance improvement, higher sensitivity of 1.08 × 10-4 and 4.25 × 10-4 in the low (<0.03 ng/mL)- and high-concentration regions, respectively, and a lower limit of detection (LoD) of 5.34 pg/mL. Because the composite electrode can maintain a linear characteristic in the measurement range of low-concentration cTnT, it can effectively improve the accuracy and reduce the error in cTnT measurement. In addition, the novel sensing electrode exhibits good reusability and specificity.

Incidence and management of metabolic acidosis with sodium bicarbonate in the ICU: An international observational study.

BACKGROUND: Metabolic acidosis is a major complication of critical illness. However, its current epidemiology and its treatment with sodium bicarbonate given to correct metabolic acidosis in the ICU are poorly understood. METHOD: This was an international retrospective observational study in 18 ICUs in Australia, Japan, and Taiwan. Adult patients were consecutively screened, and those with early metabolic acidosis (pH < 7.3 and a Base Excess < -4 mEq/L, within 24-h of ICU admission) were included. Screening continued until 10 patients who received and 10 patients who did not receive sodium bicarbonate in the first 24 h (early bicarbonate therapy) were included at each site. The primary outcome was ICU mortality, and the association between sodium bicarbonate and the clinical outcomes were assessed using regression analysis with generalized linear mixed model. RESULTS: We screened 9437 patients. Of these, 1292 had early metabolic acidosis (14.0%). Early sodium bicarbonate was given to 18.0% (233/1292) of these patients. Dosing, physiological, and clinical outcome data were assessed in 360 patients. The median dose of sodium bicarbonate in the first 24 h was 110 mmol, which was not correlated with bodyweight or the severity of metabolic acidosis. Patients who received early sodium bicarbonate had higher APACHE III scores, lower pH, lower base excess, lower PaCO2, and a higher lactate and received higher doses of vasopressors. After adjusting for confounders, the early administration of sodium bicarbonate was associated with an adjusted odds ratio (aOR) of 0.85 (95% CI, 0.44 to 1.62) for ICU mortality. In patients with vasopressor dependency, early sodium bicarbonate was associated with higher mean arterial pressure at 6 h and an aOR of 0.52 (95% CI, 0.22 to 1.19) for ICU mortality. CONCLUSIONS: Early metabolic acidosis is common in critically ill patients. Early sodium bicarbonate is administered by clinicians to more severely ill patients but without correction for weight or acidosis severity. Bicarbonate therapy in acidotic vasopressor-dependent patients may be beneficial and warrants further investigation.

Comparison of warfarin dosage fluctuation with time in therapeutic range for bleeding or thromboembolism rate in Chinese patients.

BACKGROUND/PURPOSE: Warfarin treatment benefits vary with the clinical skill of warfarin dosage adjustment. However, optimal dosage adjustment in response to the out-of-range international normalized ratio (INR) is not completely understood. METHODS: Data for 2014-2016 from an integrated health care information system of a single hospital were analyzed. Based on their warfarin dosage fluctuation (WDF), defined as the standard deviation of all prescribed warfarin dosages divided by the mean dosage, the patients were classified into Groups 1 (0-0.10), 2 (0.10-0.20), and 3 (>0.20). Target and in-range INRs were 2.0-2.5 and 1.5-3.0, respectively. Based on time in therapeutic range (TTR), patients were also categorized into Groups 1 (<0.6), 2 (0.6-0.9), and 3 (>0.9). The primary outcome was emergency department visits for bleeding or thromboembolism (TE) events. RESULTS: Eighty-three events were retrieved from 17,397 records (1834 patients). Annual incidence rates were 0.9%, 2.5%, and 4.5% for WDF Groups 1, 2, and 3, respectively (p < 0.05), and 2.3%, 1.7%, and 1.7% for TTR Groups 1, 2, and 3, respectively (p = 0.41). Area under the receiver operator characteristic curves for WDF and TTR were 0.686 and 0.519, respectively, indicating that WDF exhibited superior predictive performance than TTR. CONCLUSION: High WDF rather than low TTR was associated with increased bleeding and TE incidence rates.

MicroRNA-21 and Venous Neointimal Hyperplasia of Dialysis Vascular Access.

BACKGROUND AND OBJECTIVES: There is increasing evidence that microRNAs (miRNAs) play crucial roles in the regulation of neointima formation. However, the translational evidence of the role of miRNAs in dialysis vascular access is limited. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: miRNA expression in tissues was assessed by using venous tissues harvested from ten patients on dialysis who received revision or removal surgery, and ten patients who were predialysis and received creation surgery of arteriovenous fistulas served as controls. To extend these findings, 60 patients who received angioplasty of dialysis access were enrolled and the levels of circulating miRNAs were determined before and 2 days after angioplasty. Clinical follow-up was continued monthly for 6 months. The primary outcome of angioplasty cohort was target lesion restenosis within 6 months after angioplasty. RESULTS: In the surgery cohort, the expressions of miR-21, miR-130a, and miR-221 were upregulated in stenotic tissues, whereas those of miR-133 and miR-145 were downregulated. In situ hybridization revealed similar expression patterns of these miRNAs, localized predominantly in the neointima region. Twenty eight patients in the angioplasty cohort developed restenosis within 6 months. The levels of circulating miR-21, miR-130a, miR-221, miR-133, and miR-145 significantly increased 2 days after angioplasty. Kaplan-Meier plots showed that patients with an increase of miR-21 expression level >0.35 have a higher risk of patency loss (hazard ratio, 4.45; 95% confidence interval, 1.68 to 11.7). In a multivariable analysis, postangioplasty increase of miR-21 expression was independently associated with restenosis (hazard ratio, 1.20; 95% confidence interval, 1.07 to 1.35 per one unit increase of miR-21 expression level; P=0.001). CONCLUSIONS: Certain miRNAs are differentially expressed in the stenotic venous segments of dialysis accesses. An increase in blood miR-21 level with angioplasty is associated with a higher risk of restenosis.

Long-term outcomes of surgical treatment for intravascular leiomyomatosis.

BACKGROUND: Intravascular leiomyomatosis (IVL) is relatively rare. The optimal surgical method and long-term outcomes are not completely understood. METHODS: Medical records between 2007 and 2017 in our hospital were analyzed to identify IVL cases with surgical intervention. Their medical records, operative details, and follow-up were collected by chart review and telephone communication. RESULTS: Eight patients with IVL were included in the study, accounting for 0.26% of all uterine leiomyoma cases. Primary IVL was confined to pelvic cavity in three patients, extended to the inferior vena cava (IVC) below renal vein in one, reached IVC and right atrium in three, and reached main pulmonary artery in one. One-stage operation was performed for seven patients. Cardiopulmonary bypass was done in four patients, and aortic cross-clamp and temporary circulatory arrest was performed in two patients. None of the four patients with intrapulmonary tumors received concomitant pulmonary tumor resection. There was no operative mortality and four morbidities, including ureter injury (2), bladder injury (1), and femoral vein thrombosis (1). During follow-up, two patients exhibited local recurrence of the tumor in the pelvis, and one patient had rapidly growing intrapulmonary tumor three months post-operatively. Intrapulmonary tumors in the other three patients remained stationary at 6, 84, and 120 months post-operatively. CONCLUSION: One-stage operation to completely remove IVL is feasible and with good long-term outcomes, which is recommended if the patient can tolerate the operation. Concomitant intrapulmonary tumors can be followed up watchfully except when associated with pleural effusion or the pathology indicating trend of increasing malignancy.

Very late recurrence of sinus of Valsalva aneurysm rupture after patch repair.

BACKGROUND: Sinus of Valsalva aneurysm (SVA) is an uncommon cardiac defect accounting for only 1% of congenital cardiac anomalies and the most common complication is ruptured into the atrium or ventricle. Very late recurrence of ruptured SVA after patch repair is extremely rare. CASE PRESENTATION: We present a case of 57-year-old man had received repair for ruptured Sinus of Valsalva aneurysm at 19 ages. In the clinics, he presented with exertional dyspnea and leg swelling. The serial examination disclosed he had bicuspid aortic valve and very late rupture of SVA connecting to right atrium. After surgical repair again, he was discharged smoothly. CONCLUSION: A very late recurrence of ruptured SVA after surgical repair was rare. We reported a case with unique echocardiographic presentation and a successful repair.

Left pulmonary artery coarctoplasty by using the right pulmonary artery flap near the arterial duct.

Coarctation of the left pulmonary artery may coexist with tetralogy of Fallot or pulmonary atresia with ventricular septal defect. Various surgical methods, such as autologous pericardial patching and intraoperative pulmonary artery stenting, have been used for solving this condition. We proposed a simple and effective technique for treating patients with left pulmonary artery coarctation and pulmonary atresia with ventricular septal defect by using the right pulmonary artery flap for left pulmonary artery coarctoplasty, plus central shunt creation by V-Y plasty.

Restoration of transposed great arteries to nature.

Surgical correction of transposition of the great arteries was proposed by many in the past half-century and was claimed as the anatomical correction, but the treatment of choice was ever changing. The current technique usually includes the Lecompte maneuver to bring the pulmonary bifurcation in front of the aorta. Although the ventricular-arterial connection is corrected, it is not "normal." This review describes an innovative technique to reconstruct the great arteries in spiral fashion, which is the natural relationship of the aorta and pulmonary artery. The surgical principles of nature and even distribution using autologous tissues are emphasized. The structural and functional studies of the spiral great arteries in the last 2 decades are also presented.