Low- or standard-dose edoxaban versus antiplatelet therapy for leaflet thrombus and cerebral thromboembolism after TAVR: A prespecified analysis of randomized ADAPT-TAVR trial.

BACKGROUND: The risks of leaflet thrombosis and the associated cerebral thromboembolism are unknown according to different anticoagulation dosing after transcatheter aortic valve replacement (TAVR). The aim was to evaluate the incidence of leaflet thrombosis and cerebral thromboembolism between low-dose (30 mg) or standard-dose (60 mg) edoxaban and dual antiplatelet therapy (DAPT) after TAVR. METHODS: In this prespecified subgroup analysis of the ADAPT-TAVR trial, the primary endpoint was the incidence of leaflet thrombosis on 4-dimensional computed tomography at 6-months. Key secondary endpoints were new cerebral lesions on brain magnetic resonance imaging and neurological and neurocognitive dysfunction. RESULTS: Of 229 patients enrolled in this study, 118 patients were DAPT group and 111 were edoxaban group (43 [39.1%] 60 mg vs 68 [61.3%] 30 mg). There was a significantly lower incidence of leaflet thrombosis in the standard-dose edoxaban group than in the DAPT group (2.4% vs 18.3%; odds ratio [OR] 0.11; 95% confidence interval [CI], 0.01-0.55; P = .03). However, no significant difference was observed between low-dose edoxaban and DAPT (15.0% vs 18.3%; OR 0.79; 95% CI, 0.32-1.81; P = .58). Irrespective of different antithrombotic regiments, the percentages of patients with new cerebral lesions on brain MRI and worsening neurological or neurocognitive function were not significantly different. CONCLUSIONS: In patients without an indication for anticoagulation after TAVR, the incidence of leaflet thrombosis was significantly lower with standard-dose edoxaban but not with low-dose edoxaban, as compared with DAPT. However, this differential effect of edoxaban on leaflet thrombosis was not associated with a reduction of new cerebral thromboembolism and neurological dysfunction.

A Modified Tip-to-Base LAMPOON to Prevent Left Ventricular Outflow Tract Obstruction in Valve-in-Ring or Valve-in-Valve Transcatheter Mitral Valve Replacement.

Background: The Laceration of the Anterior Mitral leaflet to Prevent Outflow ObtructioN (LAMPOON) procedure may be performed from the leaflet tip to base to prevent left ventricular outflow tract obstruction (LVOTO) in patients with high-risk anatomy undergoing valve-in-valve (VIV) or valve-in-(complete)-ring (VIR) transcatheter mitral valve replacement (TMVR). Methods and Results: Thirteen consecutive patients (6 females, average age 67.7 years) with a mean left ventricular ejection fraction of 60%, a median STS score of 3.2%, and degenerative surgical mitral bioprosthesis or ring were treated with a combined, single-stage procedure of preventive LAMPOON and trans-septal TMVR with SAPIEN 3 valves (Edwards Lifesciences, Irvine, CA). Under real-time 3-dimensional transesophageal echocardiography (RT 3D-TEE) guidance, we included the rendezvous technique in the LAMPOON procedure, and all 13 patients were successfully treated by tip-to-base LAMPOON and TMVR. The use of a modified LAMPOON procedure, aided by a rendezvous technique and guided by RT 3D-TEE imaging, offers precise guidance for positioning and aligning the guidewire. This approach not only reduces the need for fluoroscopy and shortens procedure times, but also significantly increases the likelihood of a successful outcome. Importantly, none of the patients in our study experienced unintentional aortic or aortic valve injuries, nor did they develop significant LVOTO following TMVR. In 11 of the 13 (85%) patients, we used a transcatheter SENTINELTM cerebral protection device (Boston Scientific, Marlborough, MA) for stroke prevention and capture of debris ≥ 2 mm were detected in 8/11 (73%) of the cases. Conclusions: Utilizing intra-operative RT 3D-TEE in conjunction with the rendezvous technique can make the tip-to-base LAMPOON procedure even safer and more effective for patients undergoing VIV or VIR TMVR. Our study also suggests that cerebral protection is indicated in patients undergoing TMVR.

Edoxaban Versus Dual Antiplatelet Therapy for Leaflet Thrombosis and Cerebral Thromboembolism After TAVR: The ADAPT-TAVR Randomized Clinical Trial.

BACKGROUND: It is unknown whether the direct oral anticoagulant edoxaban can reduce leaflet thrombosis and the accompanying cerebral thromboembolic risk after transcatheter aortic valve replacement. In addition, the causal relationship of subclinical leaflet thrombosis with cerebral thromboembolism and neurological or neurocognitive dysfunction remains unclear. METHODS: We conducted a multicenter, open-label randomized trial comparing edoxaban with dual antiplatelet therapy (aspirin plus clopidogrel) in patients who had undergone successful transcatheter aortic valve replacement and did not have an indication for anticoagulation. The primary end point was an incidence of leaflet thrombosis on 4-dimensional computed tomography at 6 months. Key secondary end points were the number and volume of new cerebral lesions on brain magnetic resonance imaging and the serial changes of neurological and neurocognitive function between 6 months and immediately after transcatheter aortic valve replacement. RESULTS: A total of 229 patients were included in the final intention-to-treat population. There was a trend toward a lower incidence of leaflet thrombosis in the edoxaban group compared with the dual antiplatelet therapy group (9.8% versus 18.4%; absolute difference, -8.5% [95% CI, -17.8% to 0.8%]; P=0.076). The percentage of patients with new cerebral lesions on brain magnetic resonance imaging (edoxaban versus dual antiplatelet therapy, 25.0% versus 20.2%; difference, 4.8%; 95% CI, -6.4% to 16.0%) and median total new lesion number and volume were not different between the 2 groups. In addition, the percentages of patients with worsening of neurological and neurocognitive function were not different between the groups. The incidence of any or major bleeding events was not different between the 2 groups. We found no significant association between the presence or extent of leaflet thrombosis with new cerebral lesions and a change of neurological or neurocognitive function. CONCLUSIONS: In patients without an indication for long-term anticoagulation after successful transcatheter aortic valve replacement, the incidence of leaflet thrombosis was numerically lower with edoxaban than with dual antiplatelet therapy, but this was not statistically significant. The effects on new cerebral thromboembolism and neurological or neurocognitive function were also not different between the 2 groups. Because the study was underpowered, the results should be considered hypothesis generating, highlighting the need for further research. REGISTRATION: URL: https://www. CLINICALTRIALS: gov. Unique identifier: NCT03284827.

Factors Associated With the Utilization of Outpatient Virtual Clinics: Retrospective Observational Study Using Multilevel Analysis.

BACKGROUND: Although the COVID-19 pandemic has accelerated the adoption of telemedicine and virtual consultations worldwide, complex factors that may affect the use of virtual clinics are still unclear. OBJECTIVE: This study aims to identify factors associated with the utilization of virtual clinics in the experience of virtual clinic service implementation in Taiwan. METHODS: We retrospectively analyzed a total of 187,742 outpatient visits (176,815, 94.2%, in-person visits and 10,927, 5.8%, virtual visits) completed at a large general hospital in Taipei City from May 19 to July 31, 2021, after rapid implementation of virtual outpatient clinic visits due to the COVID-19 pandemic. Data of patients' demographic characteristics, disease type, physicians' features, and specialties/departments were collected, and physicians' opinions regarding virtual clinics were surveyed and evaluated using a 5-point Likert scale. Multilevel analysis was conducted to determine the factors associated with the utilization of virtual clinics. RESULTS: Patient-/visit-, physician-, and department-level factors accounted for 67.5%, 11.1%, and 21.4% of the total variance in the utilization of virtual clinics, respectively. Female sex (odds ratio [OR] 1.27, 95% CI 1.22-1.33, P<.001); residing at a greater distance away from the hospital (OR 2.36, 95% CI 2.15-2.58 if distance>50 km, P<.001; OR 3.95, 95% CI 3.11-5.02 if extensive travel required, P<.001); reimbursement by the National Health Insurance (NHI; OR 7.29, 95% CI 5.71-9.30, P<.001); seeking care for a major chronic disease (OR 1.33, 95% CI 1.24-1.42, P<.001); the physician's positive attitude toward virtual clinics (OR 1.50, 95% CI 1.16-1.93, P=.002); and visits within certain departments, including the heart center, psychiatry, and internal medicine (OR 2.55, 95% CI 1.46-4.46, P=.004), were positively associated with the utilization of virtual clinics. The patient's age, the physician's age, and the physician's sex were not associated with the utilization of virtual clinics in our study. CONCLUSIONS: Our results show that in addition to previously demonstrated patient-level factors that may influence telemedicine use, including the patient's sex and distance from the hospital, factors at the visit level (insurance type, disease type), physician level (physician's attitude toward virtual clinics), and department level also contribute to the utilization of virtual clinics. Although there was a more than 300-fold increase in the number of virtual visits during the pandemic compared with the prepandemic period, the majority (176,815/187,742, 94.2%) of the outpatient visits were still in-person visits during the study period. Therefore, it is of great importance to understand the factors impacting the utilization of virtual clinics to accelerate the implementation of telemedicine. The findings of our study may help direct policymaking for expanding the use of virtual clinics, especially in countries struggling with the development and promotion of telemedicine virtual clinic services.

Demoralization syndrome among cardiac transplant recipients.

AIMS AND OBJECTIVES: To investigate the characteristics and prevalence of demoralisation syndrome among heart transplantation patients in Taiwan. BACKGROUND: Patients with end-stage heart failure who have undergone cardiac transplantation are at risk of demoralisation syndrome. Demoralisation syndrome has been studied in cancer populations, but our understanding of the syndrome among heart transplant recipients is limited. DESIGN AND METHODS: The study adopted a cross-sectional design and analysed the baseline data from a longitudinal study with cardiac transplant patients at a heart centre in northern Taiwan. A structured questionnaire, namely the Demoralization Scale-Mandarin Version (DS-MV), was used to assess demoralisation syndrome. Hierarchical regression was applied to determine the predictors of demoralisation. Reporting was consistent with the STROBE checklist. RESULTS: There were a total of 84 participants with an average age of 51.9 years and a time since heart transplantation of around 4.1 years. Among them, the prevalence of demoralisation syndrome was 35.8%, and 57.1% coped well with stress. In addition, on the DS-MV, participants tended to choose sentences with positive rather than negative wording. Our data showed that cardiac transplant recipients with stress have higher possibility suffering from demoralisation syndrome; poor renal function and those who cannot relive from stress are predictors for loss of meaning. CONCLUSIONS: Chinese individuals tend to hide their weaknesses; nevertheless, demoralisation syndrome among cardiac transplant recipients, as related to stress status and kidney function, is still remarkable. RELEVANCE TO CLINICAL PRACTICE: Since demoralisation is preventable, further research on this phenomenon in the cardiac transplant population is warranted and needs to be developed.

Hes1 regulates anagen initiation and hair follicle regeneration through modulation of hedgehog signaling.

Adult hair follicles undergo repeated cycling of regression (catagen), resting (telogen), and growth (anagen), which is maintained by hair follicle stem cells (HFSCs). The mechanism underlying hair growth initiation and HFSC maintenance is not fully understood. Here, by epithelial deletion of Hes1, a major Notch downstream transcriptional repressor, we found that hair growth is retarded, but the hair cycle progresses normally. Hes1 is specifically upregulated in the lower bulge/HG during anagen initiation. Accordingly, loss of Hes1 results in delayed activation of the secondary hair germ (HG) and shortened anagen phase. This developmental delay causes reduced hair shaft length but not identity changes in follicular lineages. Remarkably, Hes1 ablation results in impaired hair regeneration upon repetitive depilation. Microarray gene profiling on HFSCs indicates that Hes1 modulates Shh responsiveness in anagen initiation. Using primary keratinocyte cultures, we demonstrated that Hes1 deletion negatively influences ciliogenesis and Smoothened ciliary accumulation upon Shh treatment. Furthermore, transient application of Smoothened agonist during repetitive depilation can rescue anagen initiation and HFSC self-renewal in Hes1-deficient hair follicles. We reveal a critical function of Hes1 in potentiating Shh signaling in anagen initiation, which allows sufficient signaling strength to expand the HG and replenish HFSCs to maintain the hair cycle homeostasis.

Malnutrition, Family Support, and Possible Sarcopenia in Patients Undergoing Transcatheter Aortic Valve Implantation.

BACKGROUND: Possible sarcopenia, aortic valve stenosis, and malnutrition are important issues that afflict older adults. OBJECTIVE: The aims of this study were to compare the differences in nutritional status and family support in older adults with possible sarcopenia and those without sarcopenia after undergoing transcatheter aortic valve implantation (TAVI) and to identify the predictors of malnutrition and demonstrate changes in heart function over time after undergoing TAVI. METHODS: A case-control design was conducted. Possible sarcopenia was identified by measuring calf circumference, grip strength, and gait speed. The Mini Nutritional Assessment-Short Form and numerical family support rating scale were used to collect data. Left ventricular ejection fraction and New York Heart Association (NYHA) functional class were assessed at 5 time points to evaluate heart function. RESULTS: Eighty-one participants were categorized into those without sarcopenia (34) and those with possible sarcopenia (47). Logistic linear regression showed albumin and possible sarcopenia to be predictors of malnutrition (odds ratio, 5.5; 95% confidence interval, 1.02-30.19). Family support was associated with nutrition status (P = .019). For patient heart function, the results of NYHA functional class and left ventricular ejection fraction improved over time after TAVI. The improvement in NYHA functional class at T2 was significantly different between the 2 groups compared with that at T0. CONCLUSIONS: The nutrition level was higher among participants without sarcopenia than those with possible sarcopenia. Approximately 90% of the participants indicated that they had high family support. Demographic factors and albumin levels could be used to evaluate risk of malnutrition. Patients without possible sarcopenia showed greater improvement in NYHA class.

Delayed Coronary Obstruction after Transcatheter Aortic Valve Replacement - An Uncommon But Serious Complication.

As transcatheter aortic valve replacement (TAVR) becomes the mainstream treatment for valvular aortic stenosis, it is vitally important to recognize its associated procedural complications. Among the clinically relevant but uncommonly seen complications, the development of delayed coronary obstruction (DCO) occurring during the early post-procedural phase or even later following the index TAVR procedure, has been reported. These reports have raised concerns as TAVR comes more common in lower-risk patients. In this review article, we explored the implications of DCO for pre-procedural computed tomography evaluation, valve selection and sizing, intra-procedural manipulation, and approaches to post-procedural management.

Quantification of Stent Creep by Three-Dimensional Transesophageal Echocardiography in Patients Undergoing Transcatheter Aortic Valve-in-Valve Implantation for Failed Bioprostheses.

BACKGROUND: Transcatheter aortic valve-in-valve implantation (aVIV) has been used to treat bioprosthetic failure due to "stent creep", defined as inward flexion or bending of stent posts. The aim of this study was to develop quantitative three-dimensional transesophageal echocardiography (3D-TEE) geometric analysis of failed bioprostheses to determine the incidence of stent creep in patients undergoing aVIV and its contribution to the hemodynamics of those valves. METHODS: We retrospectively examined the 3D-TEE of 22 consecutive patients (age 74.4 ± 11.3 years; M/F = 12/10) who underwent aVIV for failed bioprostheses. The modes of bioprosthesis failure included stenosis (n = 8), regurgitation (n = 9), and combined (n = 5). The degree of stent creep was assessed by calculating the triangular area obtained by projecting the apex of stent posts on a reconstructed plane. This measured area was divided by that of the regular triangle defined by the base of stent posts to calculate a ratio, which we termed the "stent creep ratio" (SCR). RESULTS: The mean SCR was lower in the patients with failed prostheses than that in the controls (0.82 ± 0.16 vs. 0.96 ± 0.05, p = 0.02). The SCR was negatively correlated with the peak trans-aortic pressure gradient (r = -0.62, p < 0.01). An SCR cut-off point of 0.79 was associated with aortic peak velocity > 4 m/s (AUC = 0.81, sensitivity = 0.79, specificity = 0.83). Fourteen of the 22 patients had pre- and post-aVIV 3D-TEE, and the SCR was corrected satisfactorily from 0.81 ± 0.13 to 1.04 ± 0.19 (p < 0.01). CONCLUSIONS: SCR measured by 3D-TEE is feasible to quantitatively evaluate stent creep. Stent creep is an important mode of structural deterioration in surgical bioprostheses, which can be treated by aVIV.

Use of Internal Endoconduit for Unfavorable Iliac Artery Anatomy in Patients Undergoing Transcatheter Aortic Valve Replacement - A Single Center Experience.

BACKGROUND: Transfemoral (TF) access is associated with lower rates of surgical conversion and mortality compared with non-TF access for transcatheter aortic valve replacement (TAVR). Therefore, efforts should be made to make this procedure even less invasive, allowing more TAVR procedures to be performed through femoral access. We herein describe our single-center experience of using one-stage percutaneous internal endoconduits for TAVR in patients with unfavorable iliac artery anatomy. METHODS: Between March 2013 andMarch 2016, 113 consecutive patients with severe aortic stenosis at high risk for conventional cardiac surgery underwent TAVR at the Cheng Hsin General Hospital. The patients can be divided into Cohort A (March 2013-December 2014) and Cohort B (January 2015-March 2016). RESULTS: In the Cohort A, 6 out of the 53 (11.4%) with unfavorable iliac artery anatomy were treated by trans-subclavian approach (n = 3, 5.7%) or direct aortic approach (n = 3, 5.7%); while in the Cohort B, none (0%) of the 5 patients with unfavorable iliac artery anatomy among 60 consecutive TAVR cases needed non-TF approach (Cohort A vs. Cohort B = 11.4% vs. 0%, p = 0.024) and they were all successfully treated with the use of an internal endoconduit. CONCLUSIONS: The use of internal endoconduits can further increase the number of patients who can be treated through femoral artery access for TAVR and substantially reduce the need of non-TF approaches.

Incremental benefit of three-dimensional transesophageal echocardiography in the assessment of a primary pericardial hemangioma.

Hemangiomas are rarely found in the heart and pericardial involvement is even more rare. We report a case of primary pericardial hemangioma, in which three-dimensional transesophageal echocardiography (3DTEE) provided incremental benefit over standard two-dimensional images. Our case also highlights the importance of systematic cropping of the 3D datasets in making a diagnosis of pericardial hemangioma with a greater degree of certainty. In addition, we also provide a literature review of the features of cardiac/pericardial hemangiomas in a tabular form.

Lifestyle changes in heart transplant recipients.

The purpose of this study was to understand the lifestyle; examine the relationships among lifestyle, medical factors, and stress status; and determine the predictors of better lifestyle in heart transplant recipients in Taiwan. A prospective design with convenience sampling was used. Data were collected through the Health-Promoting Lifestyle Profile-II and demographic questionnaires, which included personal information, stress status, and medical information. Pearson correlations, 1-way analysis of variance, independent t tests, paired t tests, and hierarchical regression were used to analyze the factors related to better lifestyle. A total of 80 heart transplant recipients participated. The mean score for lifestyle decreased from baseline to 3 months and was even lower at 6 months. Nevertheless, the trend for some participants was the opposite-their lifestyle improved over the 6-month period after baseline. Notably, the trend for each of the 6 subscales was not consistent with the mean of the total score. Stress status accounted for 12.8% of lifestyle. When stress status was combined with family income and creatinine, the 3 factors accounted for 32.2% of lifestyle. This study demonstrated that maintenance of a healthy lifestyle fluctuates after transplantation. Demographic factors and stress status can help to identify people who are more likely to have a poor lifestyle.

Circulating Adiponectin Levels Following Treatment Can Predict Late Clinical Outcomes in Chronic Heart Failure.

BACKGROUND: Circulating adiponectin concentration increases in patients with chronic heart failure (HF). We sought to explore the prognostic value of temporal changes in adiponectin concentration following treatment for chronic HF. METHODS: Serum adiponectin levels were measured at baseline and after a 3-month anti-failure treatment in 124 patients with symptomatic chronic systolic HF. Major adverse cardiac events (MACE) including death, heart transplantation, or hospitalization with worsening HF during a median follow-up period of 752 days were determined. RESULTS: Univariate and multivariate analysis showed that high levels of adiponectin after a 3-month treatment were associated with a 3.8-fold increased risk of MACE (p = 0.03), independent of amino-terminal pro-B-type natriuretic peptide (NT-proBNP) levels. Moreover, the combining of circulating levels of adiponectin with NT-proBNP provided independent and additional prognostic value in identifying high risk patients with MACE during follow-up. CONCLUSIONS: Changes in adiponectin and NT-proBNP over time provide prognostic information. When adiponectin is used in conjunction with NT-proBNP in chronic HF, the prognostic value may be better than if each biomarker is used separately.

Transcatheter Closure of Atrial Septal Defect with Attenuated Anterior Rim after Transcatheter Aortic Valve Implantation: Can It Be Carried out as a Single Procedure?

Transcatheter aortic valve replacement (TAVR) has emerged as a highly effective minimally invasive treatment for symptomatically critical aortic stenosis (AS) in patients at high or prohibitive surgical risk. We report a case of staged transcatheter management of critical AS combined with an atrial septal defect (ASD) with attenuated anterior superior rim. The clinical result of this case suggests that both procedures can be safely performed simultaneously. Therefore, combined transcatheter treatment may appear as a possible strategy in patients with concomitant cardiac conditions.

Incremental value of live/real time three-dimensional transthoracic echocardiography over the two-dimensional technique in assessing carcinoid heart disease involving the aortic valve.

We present a case of an adult with metastatic carcinoid heart disease, in whom live/real time three-dimensional transthoracic echocardiography provided incremental value over two-dimensional transthoracic echocardiography in assessing involvement of the aortic valve.

Three-Dimensional Speckle-Tracking Echocardiographic Monitoring of Acute Rejection in Heart Transplant Recipients.

OBJECTIVES: This study assessed the use of 3-dimensional (3D) speckle-tracking echocardiography for noninvasive monitoring and diagnosis of acute rejection in heart transplant recipients. METHODS: Fifteen heart transplant recipients underwent 32 endomyocardial biopsies; echocardiography was performed within 3 hours before biopsy. Twenty-four biopsies (acute rejection-negative group) showed grade 0 or 1A rejection, and 8 biopsies (acute rejection-positive group) showed grade 1B or higher rejection (based on the International Society for Heart and Lung Transplantation criteria). Two-dimensional, M-mode, pulsed Doppler, and tissue Doppler echocardiography were performed to assess conventional heart structure and function, and 3D full-volume echocardiography was recorded and analyzed. RESULTS: Global peak longitudinal strain was significantly lower in the acute rejection-negative group compared to the positive group (mean ± SD, -7.38% ± 1.34% versus -10.88% ± 3.81%; P = .017). Differences in left ventricular global peak radial strain (28.79% ± 10.79% versus 24.32% ± 5.24%; P= .272), global peak circumferential strain (-12.16% ± 4.87% versus -12.61% ± 2.38%; P = .806), and ejection fraction (49.42% ± 12.17% versus 50.68% ± 7.26%; P = .824) between the negative and positive groups were not significant. Significant correlations were observed between the left ventricular ejection fraction and global peak longitudinal, global peak radial, and global peak circumferential (r = -0.72; P < .001; r = 0.60; P < 0.001; and r = -0.69; P < 0.001, respectively). Receiver operating characteristic curve analysis showed that a global peak longitudinal strain cutoff value of less than -9.55% could predict grade 1B or higher rejection with sensitivity of 87.50% and specificity of 54.17%. CONCLUSIONS: Three-dimensional speckle-tracking echocardiography-derived global peak longitudinal strain is a useful parameter for detecting acute rejection; thus, 3D speckle-tracking echocardiography can monitor dynamic and acute rejection (≥1B) in heart transplant recipients.

In-Hospital Tele-ECG Triage and Interventional Cardiologist Activation of the Infarct Team for STEMI Patients is Associated with Improved Late Clinical Outcomes.

BACKGROUND: Due to recent advances, door-to-balloon time (D2BT) has been reduced significantly for patients with ST-segment elevation myocardial infarction (STEMI). However, whether this reduction can be translated into a concrete mortality or morbidity benefit is still the subject of controversy. We conducted a before-and-after study to determine the impact of in-hospital tele-electrocardiography (ECG) triage and interventional cardiologist activation of the infarct team on D2BT and long-term clinical outcomes in STEMI patients undergoing primary percutaneous coronary intervention (PPCI). METHODS: A total of 272 consecutive patients with acute STEMI undergoing PPCI were enrolled in our study, comprising 102 tele-ECG patients and 170 conventional triage patients. Major adverse cardiovascular and cerebral vascular events (MACCE), including death, recurrent nonfatal MI, nonfatal stroke, and angina-driven target vessel revascularization were recorded during a 3-year follow-up. RESULTS: The median D2BT of the tele-ECG group was significantly shorter than control group (79 minutes vs. 109 minutes, p < 0.001). The tele-ECG triage group had a higher percentage of patients reaching the D2BT goal (< 90 minutes) (78% vs. 55%; p < 0.001). The MACCE rate was significantly lower in the Tele-ECG versus the control group (23.5% vs. 38.2%, p = 0.012). Tele-ECG group had a lower mortality rate which did not reached statistical significance (2% vs. 5.9%, p = 0.102). In multivariable Cox proportional hazards analyses, the implementation of tele-ECG triage (HR = 0.43, p = 0.003) and the presence of moderate or severe mitral regurgitation at presentation (HR = 1.87, p = 0.029) were discovered as independently associated with MACCE. CONCLUSIONS: In-hospital tele-ECG triage and interventional cardiologist activation can shorten D2BT and is associated with improved late clinical outcomes during a 3-year follow-up in STEMI patients undergoing PPCI.

Three-dimensional transesophageal echocardiographic study of aortic-mitral valve coupling after coronary artery bypass grafting.

AIMS: To observe the geometric changes in aortic-mitral valve coupling (AMC) on three-dimensional transesophageal echocardiography and the factors leading to decreased mitral regurgitation (MR) after coronary artery bypass grafting (CABG). METHODS AND RESULTS: This study included 23 patients undergoing CABG for coronary artery disease. Fifteen patients with moderate to severe MR were separately analyzed to determine whether the severity of MR influences the geometric change in AMC. Echocardiographic examinations were performed pre- and post-CABG, and the studied parameters were obtained using Siemens Auto Valve Analysis software. The effective mitral regurgitant orifice area, left ventricular ejection fraction (LVEF), end-diastolic volume (EDV), and end-systolic volume (ESV) were measured pre- and post-CABG using Philips QLAB software. Ischemic MR, EDV, and ESV significantly decreased (all P < 0.05) and LVEF significantly improved (P < 0.05) after CABG. There were no significant differences between the pre- and post-CABG mitral valve (MV) parameters, aortic valve parameters, aortic-mitral annular angle, or centroid distance (all P > 0.05). Patients with moderate to severe MR exhibited the same results. CONCLUSION: The results of this study show that CABG does not cause an acute change in the geometry of AMC. Improved left ventricular function might increase the closing force of the MV, leading to decreased MR after CABG alone. MR significantly improved after CABG alone without MV treatment in the present study. This result may help to guide surgeons in choosing the optimal surgical methods for individual patients.

Anatomic Consideration of Stitch Depth in Tricuspid Valve Annuloplasty.

BACKGROUND: The durability of De Vega's tricuspid valve annuloplasty might be related to tension of the annulus and could be reinforced by increasing stich depth. However, depth of stitches to date has not been addressed in the literature. Thus, it is important to better understand the anatomical distance between the tricuspid valve annulus and the right coronary artery. METHODS: From 1998 to 2009, we measured the distances between TV annulus and RCA (TRD) on 46 explanted human hearts during heart transplantation. Five points were measured from the anterior/septal leaflet commissure to the posterior/septal leaflet commissure clockwise. Statistical significance was tested in the analyses. RESULTS: We found the TRD were independent from sex, age, body weight, and etiology. With a minimum of 10 mm at the posterior/septal leaflet commissure, the distances increased counterclockwise to the maximum of 20 mm at the anterior/septal leaflet commissure. CONCLUSIONS: Stitch depth within 10 millimeter will not injure the right coronary artery in making De Vega's tricuspid annuloplasty. KEY WORDS: De Vega's tricuspid valve annuloplasty.