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.

Functional characterization of intracellular pH regulators responsible for acid extrusion in human radial artery smooth muscle cells.

Intracellular pH (pHi) is a critical factor influencing many important cellular functions. Acid extrusion carriers such as an Na⁺/H⁺ exchanger (NHE) Na⁺/HCO3⁻ cotransporter (NBC) and monocarboxylate transporters (MCT) can be activated when cells are in an acidic condition (pHi < 7.1). Human radial artery smooth muscle cells (HRASMC) is an important conduit in coronary artery bypass graft surgery. However, such far, the pHi regulators have not been characterized in HRASMCs. We therefore investigated the mechanism of pHi recovery from intracellular acidosis and alkalosis, induced by NH4Cl-prepulse and Na-acetate-prepulse, respectively, using intracellular 2',7'-bis(2-carboxethyl)-5(6)- carboxy-fluorescein (BCECF)-fluorescence in HRASMCs. Cultured HRASMCs were derived from the segments of human radial artery that were obtained from patients undergoing bypass grafting. The resting pHi is 7.22 ± 0.03 and 7.17 ± 0.02 for HEPES- (nominally HCO3⁻-free) and CO2/HCO3⁻- buffered solution, respectively. In HEPES-buffered solution, a pHi recovery from induced intracellular acidosis could be blocked completely by 30 µM HOE 694 (3-methylsulfonyl-4-piperidinobenzoyl, guanidine hydrochloride) a specific NHE inhibitor, or by removing [Na⁺]0. In 3% CO2/HCO3⁻-buffered solution, HOE 694 slowed the pHi recovery from the induced intracellular acidosis only, while adding together with DIDS (a specific NBC inhibitor) or removal of [Na⁺]0 entirely inhibited the acid extrusion. Moreover, α-cyano-4-hydroxycinnamate (CHC; a specific blocker of MCT) blocked the lactate-induced pHi changes. In conclusion, we demonstrate, for the first time, that 3 different pHi regulators responsible for acid extruding, i.e. NHE and NBC, and MCT, are functionally co-existed in cultured HRASMCs.

Comprehensive comparative efficacy and safety of potent P2Y12 inhibitors in patients undergoing coronary intervention: A systematic review and meta-analysis.

Potent P2Y12 receptor antagonists have been used widely for patients undergoing percutaneous coronary intervention with different results. Benefits from different regimens various between trials. Randomized controlled trials (RCTs) have restrictive inclusion and exclusion criteria; thus, they may limit the generalizability of the findings to a broader population. This study was aimed to comprehensively investigate the outcomes of potent P2Y12 inhibitors in patients undergoing PCI, including RCTs and real-world evidence (RWE) studies. Multiple electronic databases were systemically reviewed and searched on compared potent P2Y12 inhibitors with clopidogrel. The primary efficacy end point was composite ischemic cardiovascular event and primary safety endpoint was major bleeding. Overall estimates of proportions and incidence rates with 95 % confidence intervals (CI) were calculated using fixed-effects models. Total 24 studies (140,986 patients) underwent coronary intervention were included in this meta-analysis, including 18 RCTs and 6 large cohort studies with propensity score matching. The potent P2Y12 inhibitors including cangrelor, prasugrel, and ticagrelor, significantly decreased the risk of composite adverse cardiovascular ischemic events (95 % CI 0.89-0.96, p < 0.001), but increased major bleeding (95 % CI 1.15-1.33, p < 0.001) or any bleeding (95 % CI 1.21-1.33, p < 0.001) compared with Clopidogrel. This meta-analysis merges RCTs and RWE studies and comprehensively evidences newer potent P2Y12 inhibitors are significantly more effective than clopidogrel in reduction of composite adverse thrombotic events, but the incidence of major or any bleeding was higher compared with clopidogrel.

Emergent bedside real-time three-dimensional transesophageal echocardiography in a patient with cardiac arrest following a caesarean section.

Post-caesarean pulmonary embolism (PE) is associated with significant peri-operative morbidity and mortality. This report describes a case of sudden cardiac arrest 2 days post-caesarean due to massive PE diagnosed via bedside transesophageal echocardiography (TEE). Recognition of the PE at the bifurcation of the right and left pulmonary arteries was achieved by real-time three-dimensional TEE, but not two-dimensional TEE. Extracorporeal membrane oxygenation was immediately established and emergent pulmonary thromboembolectomy was performed. The patient was discharged without residual deficits on Day 22 of hospitalization.

Successful transcatheter closure of a residual patent ductus arteriosus with complex anatomy after surgical ligation using an amplatzer ductal occluder guided by live three-dimensional transesophageal echocardiography.

Residual patent ductus arteriosus (PDA) after surgical ligation is not common, but the anatomy of the residual duct may be distorted by the surgical ligation resulting in a difficult transcatheter closure. Such distorted anatomy of the duct may not be demonstrated by the two-dimensional transesophageal echocardiography (2D TEE). Fortunately, live 3D TEE provided the precise anatomy of the elongated distorted residual duct, and as in the case presented herein, guided the Amplatzer ductal occluder (ADO). We concluded that live 3D TEE provided novel images of complex residual ducts and successful guidance of a ductal occluder.

Successful intraoperative identification of an anomalous origin of the left coronary artery from the pulmonary artery using real time three-dimensional transesophageal echocardiography.

Anomalous origin of the left coronary artery (LCA) from the pulmonary artery (ALCAPA) is a rare congenital defect that presents only infrequently in adults. An adult diagnosed with ALCAPA, heart failure, and mitral regurgitation underwent surgical ligation of the anomalous origin of the LCA from the pulmonary artery (PA) and coronary artery bypass grafting (CABG). The anomalous origin in the PA and proximal segment of the left anterior descending artery (LAD) was successfully delineated via real time, three-dimensional transesophageal echocardiography during surgery. This modality allows for fast assessment and novel views of complex cardiac abnormalities and can aid in perioperative monitoring.

Live three-dimensional transesophageal echocardiography in an unusual case of aorto-left ventricular tunnel with a large interventricular septal aneurysm.

Aorto-left ventricular tunnel (ALVT) is a rare congenital malformation. We report an unusual case of ALVT with a large interventricular septal aneurysm causing severe aortic regurgitation and left ventricular outflow obstruction diagnosed with real time three-dimensional transesophageal echocardiography (3D TEE). Real time 3D TEE allows for assessment and novel views of complex cardiac abnormalities and can aid in perioperative monitoring.

[An investigation of the diet preferences of patients with metabolic syndrome who underwent coronary artery bypass graft surgery].

BACKGROUND: The coronary artery disease (CAD) patients are not free of disease recurrence following coronary artery bypass graft (CABG) surgery. There may be risk of restenosis or occlusion in coronary blood flow. Risk reduction, such as diet control, is needed for long-term vascular patency. PURPOSE: The purpose of this study was to explore the diet preferences of post coronary artery bypass graft surgery patients with metabolic syndrome. METHODS: A cross-section research design and purposive sampling were conducted in this study. The study was conducted at a general hospital in northern Taiwan. A total of 104 samples recruited. And given a respondent demographics questionnaire and Chinese food frequency questionnaire. Eata were managed and analyzed using SPSS 17.0 software. RESULTS: We found that postoperative patients ate less vegetables and milk and more fried food. They also used cooking oil more frequently. CONCLUSION: We recommend that patients after CABG surgery take more vegetables with less fried food and cooking oil. They should improve their diet preferences and eating habit. More than half of the patients have meals prepared by their spouses. More emphasis should be focused on improving the health knowledge of those who prepare food. We hope this result can provide more information about postoperative diet education for medical staff and help patients and their families consume a diet richer in healthy foods.

Clinical Experience of Patients With Hepatitis C Treated With Direct-Acting Antivirals After Heart Transplantation.

BACKGROUND: Hepatitis C increases the mortality and morbidity of patients after heart transplant. Direct-acting antivirals (DAAs) are the primary drugs for hepatitis C treatment. However, such drugs are expensive and frequently unaffordable for patients. In DAA treatment, the assessment of drug interaction is crucial. METHODS: We investigated a retrospective case series study from January 2017 to December 2019. Sustained virologic response 12 (SVR12) was used to assess the effectiveness of DAA treatment. Data on patients' demographic information, timing of hepatitis C virus (HCV) infection (before or after heart transplant), HCV genotypes and viral loads, DAAs used (branded drugs or generic drugs), and drug interaction assessments were collected. RESULTS: Fifteen heart transplant patients received hepatitis C treatments during the study period, 11 of whom were infected because their donors had hepatitis C. After DAA treatment, HCV was undetectable in all patients, and 93.3% of them achieved SVR12. Nine patients used the generic sofosbuvir/velpatasvir, and 88.9% of them achieved SVR12. A total of 256 drugs were used with DAAs; 51 records of drug interactions were noted, 3 of which were contraindications, and the remaining records were potential interactions. Patients who used sofosbuvir or elbasvir/grazoprevir experienced fewer drug interactions. CONCLUSIONS: DAA treatment is effective for hepatitis C treatment in patients after heart transplant. Patients who cannot afford branded drugs because of their prices can use generic drugs as an alternative. Drug interactions must be surveyed during DAA treatment.

The routine use of live three-dimensional transesophageal echocardiography in mitral valve surgery: clinical experience.

BACKGROUND: Perioperative monitoring of mitral valve (MV) anatomy, function, and pathology is essential for surgical management of different MV disease. AIMS: To overcome the several potential pitfalls of two-dimensional transesophageal echocardiography (2D TEE) and offline 3D TEE. METHODS: Live 3D TEE was used to assess 73 patients (44 men and 29 women) with Carpentier type II MV regurgitation undergoing MV surgery perioperatively. RESULTS: The isolated segment most frequently involved was A2/P2, but A1or P1 rarely was involved in an isolated lesion or combined lesions. The agreement between 3D TEE finding and surgery was 88% (64/73). In nine patients, the live 3D TEE images revealed more segments or scallops with prolapse than the surgeon noted intraoperatively. CONCLUSIONS: Live 3D TEE allows more sensitivity and was feasible identification of prolapse or flail of individual segments of MV leaflets during surgery. We conclude that live 3D TEE should be regarded as an important adjunct to the standard 2D TEE examination in making decisions about MV surgery.

Embolization of the stent to the right heart after a motor vehicle accident.

Endovascular stent grafts have become increasingly used in the management of arterial trauma, chronic vascular occlusive diseases, and deep vein thrombosis (DVT). Here, we describe a case of stent migration to the right heart due to a motor vehicle accident in a patient with iliac venous stent implanted for venous stenosis. Computed tomography (CT) scan imaging identification of a metallic stent was superior to the standard two-dimensional transesophageal echocardiography (TEE) techniques without imaging artifact from reverberation. However, real time three-dimensional (3D) TEE can precisely defined a metallic stent in right heart oriented with shape and direction without consuming time compared to that of CT scanning. The use of 3DTEE can facilitate identification of intracardiac metallic foreign bodies perioperatively in a patient with accident and emergent unstable condition. (Echocardiography 2010;27:587-589).

[Quality of life and related factors in metabolic syndrome patients who underwent coronary artery bypass grafting surgery].

BACKGROUND: Metabolic syndrome is a high-prevalence health problem worldwide. In Taiwan, some 16.1-20.4% of males and 13.3-15.3% of females have been diagnosed with metabolic syndrome. Cardiovascular disease is the second leading cause of death in Taiwan, and metabolic syndrome is a recognized risk factor for coronary artery disease. Coronary artery bypass grafting (CABG) is currently the most recommended treatment for coronary artery disease. In Taiwan, approximately 6,300 individuals underwent CABG surgery in 2007. PURPOSE: Research has found metabolic syndrome to be associated with poor outcomes following CABG. However, research focusing on quality of life in metabolic syndrome patients who have undergone CABG is lacking. The purpose of this study was to explore the quality of life of such patients in order to address this gap in understanding. METHODS: The cross-sectional quantitative research design with purposive sampling used for this study employed two instruments, including the Short Form 36-Health Survey and a demographic questionnaire. Seventy patients were recruited from a medical center in northern Taiwan. Data were analyzed using SPSS, Version 17.0 software. Data analysis addressed percentages, means, standard deviations, independent t-tests, one-way ANOVAs and Pearson correlation coefficients. RESULTS: With regard to SF-36 Taiwan version scores, results showed participant mean scores for general health and social functions to be higher than those of the general population, and, in keeping with this, the mean scores for limited role function due to emotional problems and physical pain due to the operation were lower. Nevertheless, overall, the mean score for physical functions was lower than that for the general population, as were mean scores for vitality and mental health. Metabolic syndrome indicators were significantly associated with gender, age, education level, and religious affiliation. In addition, quality of life differed significantly by gender, marital status, meal arrangements, and alcohol consumption. Finally, lower blood pressure was correlated with vitality and mental health. CONCLUSIONS: It is hoped that study findings will increase awareness among healthcare providers regarding quality of life in metabolic syndrome patients who have undergone CABG. Based on study results, healthcare providers may design specific interventions for this particular population in order to achieve optimal quality of life.

Guillain-Barré syndrome in a heart transplantation recipient.

ABSTRACT: A rare case of a heart transplantation recipient with Guillain-Barré syndrome occurred, which was associated with peripheral nervous system damage. Based on a review of epidemiological research, the symptom development process, and diagnostic tools, the authors highlight the extreme rarity of this postinfectious immune disease. After diagnosis, plasma exchange and immunoregulatory therapy should be performed because they result in rapid recovery. If there is delayed diagnosis and treatment, there is a high risk of disability or death. When patients experience acute limb paralysis as the main symptom, nurse practitioners (NPs) should focus on the patient's history, particularly with regard to infectious agents. Closely monitoring the patient to detect respiratory failure and the need for early respiratory intervention can help the patient to avoid the severe complication of permanent brain injury. For NPs, performance of early differential diagnosis is important, especially among patients who have immunosuppressive dependence after transplantation.

Functional effects of urotensin-II on intracellular pH regulators in human radial artery smooth muscle cells.

The regulation of intracellular pH (pHi) plays a vital role in various cellular functions. We previously demonstrated that three different acid extruders, the Na+-H+ exchanger (NHE), Na+-HCO3- co-transporter (NBC) and H+-linked monocarboxylate transporter (MCT), functioned together in cultured human radial artery smooth muscle cells (HRASMCs). However, the functions of acid-loading transporters in HRASMCs remain poorly understood. Urotensin II (U-II), one of the most potent vasoconstrictors, is highly expressed in many cardiovascular diseases. The aim of this present study was to determine the concentration effect of U-II (3 pM∼100 nM) on the functional activity of pHi regulators in HRASMCs. Cultured HRASMCs were derived from segments of human radial arteries obtained from patients undergoing bypass grafting. Changes in pHi recovery due to intracellular acidification and alkalization induced by NH4Cl prepulse and Na-acetate prepulse, respectively, were detected by microspectrofluorimetry with the pH-sensitive fluorescent dye BCECF. Our present study showed that (a) U-II increased the activity of NHE in a concentration-dependent manner but did not change that of NBC or MCT or resting pHi, (b) the Cl--OH- exchanger (CHE) facilitated base extrusion, and (c) U-II induced a concentration-dependent increase in the activity of CHE. In conclusion, for the first time, our results highlight a concentration-dependent increase in the activity of NHE and CHE, but not NBC and MCT, induced by U-II in HRASMCs.

The utility of live three-dimensional echocardiography in the surgical treatment of bilateral coronary fistulas.

In patients with coronary and pulmonary arterial fistulas, the drainage sites may be difficult to identify if there are multiple connections by standard 2D echocardiography techniques. However, real time 3D TEE was used intraoperatively in our case to facilitate site identification, the number of fistulous connections, and documentation of the fistula ligation.

Live/Real time three-dimensional transthoracic echocardiographic assessment of pericardial disease.

We studied 19 patients with pericardial disease using two-dimensional and three-dimensional transthorathic echocardiography (2DTTE and 3DTTE, respectively) in order to determine whether 3DTTE provides incremental value on top of 2DTTE in the evaluation of these patients. With 3DTTE a more comprehensive assessment of pericardial effusion can be made and both the parietal and visceral layers of the pericardium can be visualized en face and examined for pathologies and fibrin deposits. In our series of patients, 3DTTE was superior to 2DTTE in uncovering mass lesions involving the pericardium such as tuberculous granulomas and metastatic disease. Furthermore, it provided a better assessment of the nature of pericardial lesions, such as pericardial and mediastinal hematomas, pericardial cysts, and metastatic disease to the pericardium by sequential cropping of the 3D data sets and visualizing the interior of the lesions in a manner not possible with 2DTTE. It was also valuable in determining the extent of pericardial calcification in pericardial constriction and in measuring the size of pericardial masses. These preliminary results suggest the superiority of 3DTTE over 2DTTE in the evaluation of pericardial diseases and that it provides incremental knowledge to the echocardiographer.

Comparison of real time two-dimensional with live/real time three-dimensional transesophageal echocardiography in the evaluation of mitral valve prolapse and chordae rupture.

We compared live/real time three-dimensional transesophageal echocardiography (3D TEE) with real time two-dimensional transesophageal echocardiography (2D TEE) in the assessment of individual mitral valve (MV) segment/scallop prolapse and associated chordae rupture in 18 adult patients with a flail MV undergoing surgery for mitral regurgitation. 2D TEE was able to diagnose the prolapsing segment/scallop and associated chordae rupture correctly in only 9 of 18 patients when compared to surgery. In three of these, 2D TEE diagnosed an additional segment/scallop not confirmed at surgery. In the remaining nine patients, surgical findings were missed by 2D TEE. On the other hand with 3D TEE, the prolapsed segment/scallop and associated ruptured chords correlated exactly with the surgical findings in the operating room in 16 of 18 patients. The exceptions were two patients. In one, 3D TEE diagnosed prolapse and ruptured chordae of the A3 segment and P3 scallop, while the surgical finding was chordae rupture of the A3 segment but only prolapse without chordae rupture of the P3 scallop. In the other patient, 3D TEE diagnosed prolapse and chordae rupture of P1 scallop and prolapse without chordae rupture of the A1 and A2 segments, while at surgery chordae rupture involved A1, A2, and P1. This preliminary study demonstrates the superiority of 3D TEE over 2D TEE in the evaluation of individual MV segment/scallop prolapse and associated ruptured chordae.

High-output heart failure resulting from an obscure traumatic arteriovenous fistula.

Traumatic arteriovenous fistula (AVF) is not an uncommon disorder, but late discovery and the presentation of high-output heart failure is very rare. This patient did not know that he had traumatic AVF after a gunshot injury in the left thigh 14 years ago. The major presentation of the AVF was signs of heart failure. We performed surgical repair after making the diagnosis. The patient recovered with an uneventful course. This report stresses the importance of history-taking and physical examination in making the diagnosis of traumatic AVF.

Functional and molecular characterization of transmembrane intracellular pH regulators in human dental pulp stem cells.

OBJECTIVE: Homeostasis of intracellular pH (pHi) plays vital roles in many cell functions, such as proliferation, apoptosis, differentiation and metastasis. Thus far, Na+-H+ exchanger (NHE), Na+-HCO3- co-transporter (NBC), Cl-/HCO3- exchanger (AE) and Cl-/OH- exchanger (CHE) have been identified to co-regulate pHi homeostasis. However, functional and biological pHi-regulators in human dental pulp stem cells (hDPSCs) have yet to be identified. DESIGN: Microspectrofluorimetry technique with pH-sensitive fluorescent dye, BCECF, was used to detect pHi changes. NH4Cl and Na+-acetate pre-pulse were used to induce intracellular acidosis and alkalosis, respectively. Isoforms of pHi-regulators were detected by Western blot technique. RESULTS: The resting pHi was no significant difference between that in HEPES-buffered (nominal HCO3--free) solution or CO2/HCO3-buffered system (7.42 and 7.46, respectively). The pHi recovery following the induced-intracellular acidosis was blocked completely by removing [Na+]o, while only slowed (-63%) by adding HOE694 (a NHE1 specific inhibitor) in HEPES-buffered solution. The pHi recovery was inhibited entirely by removing [Na+]o, while adding HOE 694 pulse DIDS (an anion-transporter inhibitor) only slowed (-55%) the acid extrusion. Both in HEPES-buffered and CO2/HCO3-buffered system solution, the pHi recovery after induced-intracellular alkalosis was entirely blocked by removing [Cl-]o. Western blot analysis showed the isoforms of pHi regulators, including NHE1/2, NBCe1/n1, AE1/2/3/4 and CHE in the hDPSCs. CONCLUSIONS: We demonstrate for the first time that resting pHi is significantly higher than 7.2 and meditates functionally by two Na+-dependent acid extruders (NHE and NBC), two Cl--dependent acid loaders (CHE and AE) and one Na+-independent acid extruder(s) in hDPSCs. These findings provide novel insight for basic and clinical treatment of dentistry.

Gender differences in quality of life for post coronary artery bypass grafting patients in Taiwan.

The purpose of this study was to investigate gender differences in quality of life for post Coronary Artery Bypass Grafting (CABG) patients in Taiwan. Cross-sectional survey research design and purposive sampling were used in this study, for which 100 subjects, including 50 males and 50 females, were recruited from a medical center in northern Taiwan. Quality of life was measured by Short Form 36, while gender role function and demographic data were collected using a demographic questionnaire. An Independent t test and one way ANOVA were employed to analyze data. Study results showed significant differences in quality of life between genders. There was a statistically significant difference in the physical component summary score, post-CABG, between males (M=45.5) and females (M=40.1, p< .05), which indicates that men demonstrated higher physical functioning than women. Within this component, the greatest difference between the genders was noted in sub-items related to physical functions. Men and women achieved mean scores of 42.2 and 37.9, respectively (p< .05). For the mental component summary section, sub-items related to vitality also demonstrated statistical significance; with men achieving a mean score of 49.6 and women a mean score of 45.2 (p< .05). Of interest, post-CABG patients who had greater role responsibilities, such as taking care of elderly or doing housework, obtained significantly higher quality of life scores.