Effect of EVAR on International Ruptured AAA Mortality-Sex and Geographic Disparities.

Background: We sought to investigate the differential impact of EVAR (endovascular aneurysm repair) vis-à-vis OSR (open surgical repair) on ruptured AAA (abdominal aortic aneurysm) mortality by sex and geographically. Methods: We performed a retrospective study of administrative data on EVAR from state statistical agencies, vascular registries, and academic publications, as well as ruptured AAA mortality rates from the World Health Organization for 14 14 states across Australasia, East Asia, Europe, and North America. Results: Between 2011-2016, the proportion of treatment of ruptured AAAs by EVAR increased from 26.1 to 43.8 percent among females, and from 25.7 to 41.2 percent among males, and age-adjusted ruptured AAA mortality rates fell from 12.62 to 9.50 per million among females, and from 34.14 to 26.54 per million among males. The association of EVAR with reduced mortality was more than three times larger (2.2 vis-à-vis 0.6 percent of prevalence per 10 percentage point increase in EVAR) among females than males. The association of EVAR with reduced mortality was substantially larger (1.7 vis-à-vis 1.1 percent of prevalence per 10 percentage point increase in EVAR) among East Asian states than European+ states. Conclusions: The increasing adoption of EVAR coincided with a decrease in ruptured AAA mortality. The relationship between EVAR and mortality was more pronounced among females than males, and in East Asian than European+ states. Sex and ethnic heterogeneity should be further investigated.

Surgical ligation, not transcatheter closure, associated with a higher severity of bronchopulmonary dysplasia in extremely preterm infant intervened for patent ductus arteriosus.

OBJECTIVE: Patent ductus arteriosus (PDA) is a common complication among premature infants, which may be responsible for prematurity-related complications such as bronchopulmonary dysplasia (BPD). It is unclear whether different interventional methods contribute to the severity of BPD, given the original National Institute of Child Health and Human Development (NICHD) 2001 definition. To date, surgical ligation and the transcatheter approach have been equally successful in premature infants with hemodynamically significant PDA after medical treatment failure. Immediate improvement in the respiratory condition has been reported after transcatheter closure. However, the short-term pulmonary outcome has not been clarified yet. METHODS: This retrospective study investigated infants born with a body weight <1000 g and who underwent either surgical ligation or transcatheter closure of PDA in a single tertiary institution. The infants were divided into groups according to the type of procedure (surgical ligation or transcatheter occlusion). The primary outcome was the severity of BPD at discharge or at a postmenstrual age of 36 weeks. The outcome was analyzed with logistic regression. RESULTS: Forty-four patients met the inclusion criteria, of whom 14 underwent transcatheter occlusion and 30 underwent surgical ligation. The overall birth body weights and gestational age ranges were not different. The univariate model revealed an association between the procedure type and BPD severity. After adjusting for confounders, the multivariate model confirmed associations between BPD severity and procedure type and severe respiratory distress syndrome requiring surfactant. CONCLUSION: Compared with the transcatheter approach, surgery for PDA in extremely preterm infants is associated with severe BPD at discharge. Further large-scale studies are needed to determine the exact mechanism.

Editor's Choice - Infective Native Aortic Aneurysms: A Delphi Consensus Document on Terminology, Definition, Classification, Diagnosis, and Reporting Standards.

OBJECTIVE: There is no consensus regarding the terminology, definition, classification, diagnostic criteria, and algorithm, or reporting standards for the disease of infective native aortic aneurysm (INAA), previously known as mycotic aneurysm. The aim of this study was to establish this by performing a consensus study. METHODS: The Delphi methodology was used. Thirty-seven international experts were invited via mail to participate. Four two week Delphi rounds were performed, using an online questionnaire, initially with 22 statements and nine reporting items. The panellists rated the statements on a five point Likert scale. Comments on statements were analysed, statements revised, and results presented in iterative rounds. Consensus was defined as ≥ 75% of the panel selecting "strongly agree" or "agree" on the Likert scale, and consensus on the final assessment was defined as Cronbach's alpha coefficient > .80. RESULTS: All 38 panellists completed all four rounds, resulting in 100% participation and agreement that this study was necessary, and the term INAA was agreed to be optimal. Three more statements were added based on the results and comments of the panel, resulting in a final 25 statements and nine reporting items. All 25 statements reached an agreement of ≥ 87%, and all nine reporting items reached an agreement of 100%. The Cronbach's alpha increased for each consecutive round (round 1 = .84, round 2 = .87, round 3 = .90, and round 4 = .92). Thus, consensus was reached for all statements and reporting items. CONCLUSION: This Delphi study established the first consensus document on INAA regarding terminology, definition, classification, diagnostic criteria, and algorithm, as well as reporting standards. The results of this study create essential conditions for scientific research on this disease. The presented consensus will need future amendments in accordance with newly acquired knowledge.

Synthetic Poly(lactic-co-glycolic Acid) Microvesicles as a Feasible Carbon Monoxide-Releasing Platform for Cancer Treatment.

Biogenic microvesicles (MVs) play a pivotal role in intercellular signal communication, thus initiating critical biological responses such as the proliferation of cancer cells, gene and protein transport, and chemo-drug resistance. In addition, they have been recognized as having great potential in drug delivery applications. However, the productivity of biologically produced MVs is not sufficient for clinical applications. In this study, synthetic poly(lactic-co-glycolic acid) (PLGA) MVs were prepared via a double emulsion method. The PLGA MVs had a biogenic MV-mimic vesicular structure with a hydrophilic core/surface and hydrophobic interior of the shell, showing great potential for drug delivery. We successfully embedded hydrophobic iron carbonyl (IC), a carbon monoxide (CO) donor, in the PLGA shell region, enabling the delivery of IC in an aqueous solution. Because of the intrinsic properties of PLGA, it was susceptible to temperature, and the MVs could easily collapse in a warm environment, leading to the decomposition of IC into CO. The in vitro result indicated that the cell viability of A549 lung carcinoma cells significantly decreased to 14% after treatment with IC-loaded PLGA MVs for 24 h, suggesting that these synthetic PLGA MVs constitute an excellent drug delivery platform.

Potential of Autologous Progenitor Cells and Decellularized Porcine Artery Matrix in Construction of Tissue-engineered Vascular Grafts.

To develop a tissue-engineered vascular graft, we used pericardial effusion-derived progenitor cells (PEPCs) collected from drained fluid after open-heart surgery in children with congenital heart diseases to repopulate a decellularized porcine pulmonary artery. The PEPCs were compared with human fibroblasts (HS68) and human umbilical vein endothelial cells (HUVECs) in cell growth and migration. They were cultured with the matrices via an inner approach (intima), lateral approach (media), and outer approach (adventitia). PEPCs grew and migrated better than the other two cells 14 days after seeding in the decellularized vessel. In immunofluorescence assays, PEPCs expressed CD90 and CD105 indicating a vascular differentiation. PEPCs grew in a decellularized porcine pulmonary artery matrix may have the potential for producing tissue-engineered vascular grafts.

Mitral Valve Replacement Using Subvalvular Apparatus: A Systematic Review and Meta-Analysis.

BACKGROUND: To assess clinical outcomes among participants undergoing mitral valve replacement with preservation of subvalvular apparatus. METHODS: Electronic databases, including PubMed, Embase, Science Direct, World of Science, Scopus, Biosis, SciElo and Cochrane library, were probed using an extensive search strategy. Studies that reported at least one clinical outcome, such as morbidity, mortality, early 30-day mortality, myocardial failure, survival, late cerebrovascular events, length of stay, or major operative complications (stroke, prolonged ventilation, and reoperation for bleeding, renal failure, and sternal infection) were considered for inclusion. Data was extracted and pooled into a meta-analysis in RevMan (version 5.3) using a random-effects model. RESULTS: A total of 21 studies with 5,106 participants (age range: 27.3-69.2 years) were included in this meta-analysis. Preservation of the subvalvular apparatus during MVR significantly reduces the risk of long-term mortality (OR: 0.46; 95% CI: 0.33-0.64), but not early mortality (OR: 0.76; 95% CI: 0.12-4.93). No significant difference ejection fraction was observed (SMD: 0.10; 95% CI: -0.44-0.64). Similarly, there was no significant difference in the risk of stroke, renal failure, and pneumonia between C-MVR and in the control group. CONCLUSION: MVR with the preservation of subvalvular apparatus improves clinical outcomes, such as long-term mortality, hospital length of stay, pneumonia, and bleeding. There is no significant difference in the risk of stroke, renal failure, or ICU length of stay. However, there is very limited data available with respect to bleeding, sepsis, and nosocomial infections.

Post-Coronary Artery Bypass Medications in Dialysis Patients: Do We Need to Change Strategies?

BACKGROUND: Coronary artery bypass grafting (CABG) is frequently performed in patients with end-stage renal disease (ESRD) together with severe coronary artery disease, after which, patients with ESRD have higher surgical risk and poorer long-term outcomes. We report our experience in patients with ESRD who survived in CABG and identify predictors of long-term outcomes. METHODS: We retrospectively investigated 93 consecutive patients with ESRD who survived to discharge after isolated CABG between January 2005 and December 2016 at our institution. Long-term outcomes, including all-cause mortality after discharge, readmission due to major adverse cardiac events, and reintervention, were evaluated. Predictors affecting long-term outcomes were also analyzed. RESULTS: The rates of freedom from all-cause mortality after discharge in 1, 3, 5, and 10 years were 92.1, 81.3, 71.9, and 34.9%, respectively. The rates of freedom from readmission due to major adverse cardiac events in 1, 3, 5, and 10 years were 90.7, 79.1, 69.9, and 55.6%, respectively. The rates of freedom from reintervention in 1, 3, 5, and 10 years were 95.3, 86.5, 79.0, and 66.6%, respectively. Postoperative ß-blocker and statin use significantly improved overall long-term survival (ß-blocker, p = 0.013; statin, p = 0.009). After case-control matching, patients who received statins showed better long-term survival than those without statins. The comparison of long-term survival between patients with and without ß-blockers showed no significant difference after matching. CONCLUSIONS: After CABG, dialysis patients who survived to discharge had acceptable long-term overall survival. Post-CABG statin use in dialysis patients is a predictor of better long-term survival.

Progenitor Cells Derived from Drain Waste Product of Open-Heart Surgery in Children.

Human cardiac progenitor cells isolated from the same host may have advantages over other sources of stem cells. The aim of this study is to establish a new source of human progenitor cells collected from a waste product, pericardiac effusion fluid, after open-heart surgery in children with congenital heart diseases. The fluid was collected every 24 h for 2 days after surgery in 37 children. Mononuclear cells were isolated and expanded in vitro. These pericardial effusion-derived progenitor cells (PEPCs) exhibiting cardiogenic lineage markers, were highly proliferative and enhanced angiogenesis in vitro. Three weeks after stem cell transplantation into the ischemic heart in mice, cardiac ejection fraction was improved significantly without detectable progenitor cells. Gene expression profiles of the repaired hearts revealed activation of several known repair mechanisms including paracrine effects, cell migration, and angiogenesis. These progenitor cells may have the potential for heart regeneration.

Using cell-seeded electrospun patch for myocardial injury: in-vitro and in rat model.

Electrospinning has been widely used to fabricate scaffolds and commonly used biodegradable polymers. Cellular cardiomyoplasty is a type of regenerative medicine that has potential use for treatment of myocardial infarction or terminal cardiac failure. The aims of this study are to use electrospinning to create cardiovascular patches and to assess their potential therapeutic use by transplantation into the hearts of rats. Tissue engineering scaffolds were generated by use of electrospinning, in which the fibers consist of nanoscale-to-microscale fibers whose diameters are comparable to those of essential components of the extracellular matrix. A polymer solution was pumped at a constant rate through a syringe with a small-diameter needle that is connected to a high-voltage source, so that an electric field is created between the needle and a metallic collecting plate. The final product is a mat composed of individual continuous nanofibers. Cell survival, cell characteristics, and growth factors of electrospun patches of different thicknesses using bone marrow and human cardiac stem cells were tested. The results demonstrated that the cells can survive in Poly-caprolactone (PCL) patches, even deep within these patches. The PCL patches are nontoxic and do not alter cell properties. Transplantation of these patches into the hearts of a rat model of myocardial infarction led to strong compliance and good survival.The use of PCL cellular patches is feasible method for cellular transplantation. Future studies should attempt to use orientated electrospun cellular patches to improve overall cell survival within deeper layers of these patches.

Clinical ultrasound stimulating angiogenesis following drug-release from polymersomes on the ischemic zone for peripheral arterial occlusive disease.

Peripheral Arterial Occlusive Disease (PAOD) is an aging disease that affects the quality of life of many people by its intermittent claudication and critical limb ischemia presentations. Traditional treatment and management of PAOD are asking patients to make a life change and medication with antiplatelet, statins and cilostazol, which decrease the possibility of clot formation. Our strategy has employed a magnetic Fe3O4-PLGA polymersome to carry the cilostazol into the ischemic area by magnetic attraction following remote-control drug release through low-energy ultrasound exposure. In the animal studies, the cilostazol-loaded Fe3O4-PLGA polymersomes were injected and accumulated at ischemic leg through magnetic attraction. Then, using a clinical-use ultrasound machine the leg was irradiated to forward cilostazol release from the accumulated polymersomes. Dramatically, we found an observable result of bloody flux recovery in the leg after 7 days compared to the non-treated leg that showed no evidence of the blood recovery.

Handmade trileaflet valve design and validation for patch-valved conduit reconstruction using generalized regression machine learning model.

Pulmonary valve diseases include the different degrees of aortic stenosis or congenital defects in children or adults. Valve repair or replacement surgery is commonly performed to relieve valvular dysfunction and improve the significant flow regurgitation in the aortic valve and the pulmonary valve. However, commercial valve stents and valved conduits are sometimes not available for children or patients with special conditions. The handmade trileaflet valve design has been used with different range of diameters for patch-valved conduit reconstruction. Thus, we propose a multiple regression model, as a generalized regression neural network (GRNN), to determine the optimal trileaflet parameters, including the width, length, and upper lower curved structure. Through computed tomography pulmonary angiography, while the diameter of the main pulmonary artery is determined, a leaflet template can be rapidly sketched and made. Using an experimental pulmonary circulation loop system, the efficacy of the valved conduit can be validated using the regurgitation fraction method. In contrast to commercial valve stents, experimental results indicate that the handmade trileaflet valve can also improve severe pulmonary regurgitations.

Applicability of handmade expanded polytetrafluoroethylene trileaflet-valved conduits for pulmonary valve reconstruction: An ex vivo and in vivo study.

OBJECTIVE: The handmade expanded polytetrafluoroethylene (ePTFE) trileaflet-valved conduit could potentially be used as a substitute pulmonary valve replacement material, especially in children. The current study investigated (1) the function of the ePTFE trileaflet-valved conduits in an ex vivo experimental system and (2) the short-term performance of the conduit in a porcine model to verify its clinical applicability. METHODS: The competency of the ePTFE trileaflet-valved conduits was estimated through ex vivo (using a pulmonary mock circulation loop) and in vivo (in a porcine model with a damaged pulmonary valve) experiments. Explants were examined by gross morphology and histopathologic examination. RESULTS: In the ex vivo experiment, the ePTFE trileaflet-valved conduits were determined to effectively increase mean pulmonary pressure from 10.2 to 14.4 mm Hg compared with defective silicon-valved conduits. In addition, the regurgitation fraction value of ePTFE trileaflet-valved conduits was 15.9% to 18.1%, which was significantly better than the defective valve conduits (regurgitation fraction = 73.5%-85.7%). In the in vivo experiment, the valved conduits were confirmed to be with good valve position maintenance, and the valve and leaflets showed no signs of thickening or peeling after a short-term implantation period. There were also no significant signs of inflammation reaction on histopathologic examination. CONCLUSIONS: The ePTFE trileaflet-valved conduits for pulmonary valve reconstruction showed acceptable performance and outcomes in the ex vivo and in vivo experiments. The ePTFE trileaflet-valved conduit may be clinically useful, although additional studies in animals should be conducted to determine its long-term outcomes.

Role of Endovascular Aortic Repair in the Treatment of Infected Aortic Aneurysms Complicated by Aortoenteric or Aortobronchial Fistulae.

BACKGROUND: The aim of this study was to compare outcomes and identify factors related to increased mortality of open surgical and endovascular aortic repair (EVAR) of primary mycotic aortic aneurysms complicated by aortoenteric fistula (AEF) or aortobronchial fistula (ABF). METHODS: Patients with primary mycotic aortic aneurysms complicated by an AEF or ABF treated by open surgery or endovascular repair between January 1993 and January 2014 were retrospectively reviewed. Outcomes were compared between the open surgery and endovascular groups, and a Cox's proportional hazard model was used to determine factors associated with mortality. RESULTS: A total of 29 patients included 14 received open surgery and 15 received endovascular repair. Positive initial bacterial blood culture results included Salmonella spp., oxacillin-resistant Staphylococcus aureus, and Klebsiella pneumoniae. Mortality within 1 month of surgery was higher in the open surgery than in the endovascular group (43 vs. 7%, respectively, p = 0.035). Shock, additional surgery to repair gastrointestinal (GI) or airway pathology, and aneurysm rupture were associated with a higher risk of death. Compared with patients without resection surgery, the adjusted hazard ratio of death within 4 years in patients with resection for GI/bronchial disease was 0.25. Survival within 6 months was better in the endovascular group (p = 0.016). CONCLUSION: The results of this study showed that EVAR/thoracic EVAR (TEVAR) is feasible for the management of infected aortic aneurysms complicated by an AEF or ABF, and results in good short-term outcomes. However, EVAR/TEVAR did not benefit long-term survival compared with open surgery.

Apparatus for Comparison of Pullout Forces for Various Thoracic Stent Grafts at Varying Neck Angulations and Oversizes.

BACKGROUND: The purpose of this study is to provide an apparatus for comparison of pullout forces for various thoracic stent grafts at varying neck angulations and oversizes. METHODS: An in vitro platform capable of performing pullout tests was used on stent grafts in angulated silicone tubes designed for this study (0°, 45°, 90°, and 135° with a 32-mm inner diameter) in a temperature-controlled chamber (37 ± 2°C). Three commercial stent grafts with sizes commonly used in Taiwan (Valiant: 34, 36, 38, and 40 mm; Zenith TX2: 34, 36, 38, and 40 mm; and TAG: 34, 37, and 40 mm) were used, and each size was tested 8 times for each angulation condition. RESULTS: The mean dislodgement forces (DFs) at 0° angulation within 10-20% oversize were approximately 22.7, 9.6, and 9.0 N for the Valiant, Zenith TX2, and TAG devices, respectively, whereas the mean DFs decreased by 46%, 38%, and 50% to 12.3, 5.9, and 4.5 N when the angulation reached 135°. Regression analysis shows that neck angulation was a significant factor for the Valiant and Zenith TX2 devices (P < 0.0001 and P < 0.0001, respectively) but not for the TAG device (P = 0.483). In addition, oversize and interactions between variables (angulation × oversize) exhibited significant effects on the DFs for all devices (P < 0.0001). CONCLUSIONS: We successfully built up an apparatus for comparison of pullout forces for various thoracic stent grafts at varying neck angulations and oversizes. With the empirical comparative data of different brand stent grafts under various conditions shown and compared, our findings suggest that aortic neck angulation has a negative correlation with stent-graft fixation. To have better stent-graft fixation and seal in the aortic arch for thoracic endovascular aortic repair, a longer landing zone with cautiously selected oversize is a more suitable selection.

Cerebral Hyperperfusion Syndrome After Surgical Repair of Congenital Supravalvular Aortic Stenosis.

Although cerebral hyperperfusion syndrome is rarely encountered, this condition can be serious after procedures that increase cerebral blood flow; most reports are related to carotid revascularization. Sharp cerebral hemodynamic changes, along with impaired cerebrovascular autoregulation, are the main mechanisms contributing to this syndrome. We report a patient who underwent surgical correction for congenital supravalvular aortic stenosis and presented with postoperative hypertension, headache, impairment of consciousness, and cerebral edema 2 days after operation. He recovered well when the blood pressure declined and the brain edema subsided. Cerebral hyperperfusion syndrome was considered, and this uncommon neurologic complication of cardiac operations is discussed.

Infantile cardiac vascular tumour: from prenatal diagnosis to postnatal treatment.

Primary vascular tumour of the heart is rare, especially in neonates and infants. We report a male premature newborn with a right atrial tumour associated with a large amount of pericardial effusion detected by screening foetal echography. Diagnosis of capillary haemangioma was confirmed by histopathological examination after complete surgical resection. Other vascular tumours in the neonates and infants reported in the English literatures are reviewed, and one algorithm for both prenatal and postnatal management is proposed.