Chinese expert consensus on the construction of the fluoroless cardiac electrophysiology laboratory and related techniques.

Transcatheter radiofrequency ablation has been widely introduced for the treatment of tachyarrhythmias. The demand for catheter ablation continues to grow rapidly as the level of recommendation for catheter ablation. Traditional catheter ablation is performed under the guidance of X-rays. X-rays can help display the heart contour and catheter position, but the radiobiological effects caused by ionizing radiation and the occupational injuries worn caused by medical staff wearing heavy protective equipment cannot be ignored. Three-dimensional mapping system and intracardiac echocardiography can provide detailed anatomical and electrical information during cardiac electrophysiological study and ablation procedure, and can also greatly reduce or avoid the use of X-rays. In recent years, fluoroless catheter ablation technique has been well demonstrated for most arrhythmic diseases. Several centers have reported performing procedures in a purposefully designed fluoroless electrophysiology catheterization laboratory (EP Lab) without fixed digital subtraction angiography equipment. In view of the lack of relevant standardized configurations and operating procedures, this expert task force has written this consensus statement in combination with relevant research and experience from China and abroad, with the aim of providing guidance for hospitals (institutions) and physicians intending to build a fluoroless cardiac EP Lab, implement relevant technologies, promote the standardized construction of the fluoroless cardiac EP Lab.

Ezetimibe for the prevention of cardiovascular disease and all-cause mortality events.

BACKGROUND: Cardiovascular disease (CVD) remains an important cause of mortality and morbidity, and high levels of blood cholesterol are thought to be the major modifiable risk factors for CVD. The use of statins is the preferred treatment strategy for the prevention of CVD, but some people at high-risk for CVD are intolerant to statin therapy or unable to achieve their treatment goals with the maximal recommended doses of statin. Ezetimibe is a selective cholesterol absorption inhibitor, whether it has a positive effect on CVD events remains uncertain. Results from clinical studies are inconsistent and a thorough evaluation of its efficacy and safety for the prevention of CVD and mortality is necessary. OBJECTIVES: To assess the efficacy and safety of ezetimibe for the prevention of CVD and all-cause mortality. SEARCH METHODS: We searched the CENTRAL, MEDLINE, Embase and Web of Science on 27 June 2018, and two clinical trial registry platforms on 11 July 2018. We checked reference lists from primary studies and review articles for additional studies. No language restrictions were applied. SELECTION CRITERIA: We included randomised controlled trials (RCTs) that compared ezetimibe versus placebo or ezetimibe plus other lipid-modifying drugs versus other lipid-modifying drugs alone in adults, with or without CVD, and which had a follow-up of at least 12 months. DATA COLLECTION AND ANALYSIS: Two review authors independently selected studies for inclusion, extracted data, assessed risk of bias and contacted trialists to obtain missing data. We performed statistical analyses according to the Cochrane Handbook for Systematic Reviews of Interventions and used the GRADE to assess the quality of evidence. MAIN RESULTS: We included 26 RCTs randomising 23,499 participants. All included studies assessed effects of ezetimibe plus other lipid-modifying drugs compared with other lipid-modifying drugs alone or plus placebo. Our findings were driven by the largest study (IMPROVE-IT), which had weights ranging from 41.5% to 98.4% in the different meta-analyses.Ezetimibe with statins probably reduces the risk of major adverse cardiovascular events compared with statins alone (risk ratio (RR) 0.94, 95% confidence interval (CI) 0.90 to 0.98; a decrease from 284/1000 to 267/1000, 95% CI 256 to 278; 21,727 participants; 10 studies; moderate-quality evidence). Trials reporting all-cause mortality used ezetimibe with statin or fenofibrate and found they have little or no effect on this outcome (RR 0.98, 95% CI 0.91 to 1.05; 21,222 participants; 8 studies; high-quality evidence). Adding ezetimibe to statins probably reduces the risk of non-fatal myocardial infarction (MI) (RR 0.88, 95% CI 0.81 to 0.95; a decrease from 105/1000 to 92/1000, 95% CI 85 to 100; 21,145 participants; 6 studies; moderate-quality evidence) and non-fatal stroke (RR 0.83, 95% CI 0.71 to 0.97; a decrease 32/1000 to 27/1000, 95% CI 23 to 31; 21,205 participants; 6 studies; moderate-quality evidence). Trials reporting cardiovascular mortality added ezetimibe to statin or fenofibrate, probably having little or no effect on this outcome (RR 1.00, 95% CI 0.89 to 1.12; 19457 participants; 6 studies; moderate-quality evidence). The need for coronary revascularisation might be reduced by adding ezetimibe to statin (RR 0.94, 95% CI 0.89 to 0.99; a decrease from 196/1000 to 184/1000, 95% 175 to 194; 21,323 participants; 7 studies); however, no difference in coronary revascularisation rate was observed when a sensitivity analysis was limited to studies with a low risk of bias.In terms of safety, adding ezetimibe to statins may make little or no difference in the risk of hepatopathy (RR 1.14, 95% CI 0.96 to 1.35; 20,687 participants; 4 studies; low-quality evidence). It is uncertain whether ezetimibe increase or decrease the risk of myopathy (RR 1.31, 95% CI 0.72 to 2.38; 20,581 participants; 3 studies; very low-quality evidence) and rhabdomyolysis, given the wide CIs and low event rate. Little or no difference in the risk of cancer, gallbladder-related disease and discontinuation due to adverse events were observed between treatment groups. For serum lipids, adding ezetimibe to statin or fenofibrate might further reduce the low-density lipoprotein cholesterol (LDL-C), total cholesterol and triglyceride levels and likely increase the high-density lipoprotein cholesterol levels; however, substantial heterogeneity was detected in most analyses.None of the included studies reported on health-related quality of life. AUTHORS' CONCLUSIONS: Moderate- to high-quality evidence suggests that ezetimibe has modest beneficial effects on the risk of CVD endpoints, primarily driven by a reduction in non-fatal MI and non-fatal stroke, but it has little or no effect on clinical fatal endpoints. The cardiovascular benefit of ezetimibe might involve the reduction of LDL-C, total cholesterol and triglycerides. There is insufficient evidence to determine whether ezetimibe increases the risk of adverse events due to the low and very low quality of the evidence. The evidence for beneficial effects was mainly obtained from individuals with established atherosclerotic cardiovascular disease (ASCVD, predominantly with acute coronary syndrome) administered ezetimibe plus statins. However, there is limited evidence regarding the role of ezetimibe in primary prevention and the effects of ezetimibe monotherapy in the prevention of CVD, and these topics thus requires further investigation.

Different effects of neuropeptide Y on proliferation of vascular smooth muscle cells via regulation of Geminin.

The proliferation-promoting effect of neuropeptide Y (NPY) always functions in low-serum-cultured vascular smooth muscle cells (VSMCs), and the phenotypic switch of VSMCs is regulated by concentrations of serum. Whether the property of the NPY proliferative effect in VSMCs relies on phenotype of VSMCs is unclear. We aimed to explore the role of NPY on proliferation of different VSMC phenotypes in the pathogenesis of atherosclerosis. By stimulating A10 cells with 200 nM NPY in 0.5 or 10% serum, 3H-thymidine and 5-ethynyl-2'-deoxyuridine (EdU) and CCK8 measurements were used to detect VSMC proliferation. RT-PCR and Flow cytometry were performed to detect the factors involved in different properties of the NPY proliferative effect in VSMCs. Instead of facilitating proliferation, NPY had no significant effect on the growth of VSMCs when cultured in 10% serum (VSMCs stayed at synthetic states). The underlying mechanism may be involved in down-regulation of Y1 receptor (P < 0.05 vs. Vehicle) and up-regulation of Geminin (P < 0.05 vs. Vehicle) in 10% serum-cultured VSMCs co-incubated with 200 nM NPY. Besides, modulation of Geminin was effectively blocked by the Y1 receptor antagonist. The stimulation of NPY on proliferation of VSMCs could be a double-edged sword in the development of atherosclerosis and thus provides new knowledge for therapy of atherosclerosis.

Geminin interference facilitates vascular smooth muscle cell proliferation by upregulation of CDK-1.

PURPOSE: Geminin has been correlated with vascular smooth muscle cell (VSMC) proliferation, but its mechanism is unclear. We selectively silenced the geminin gene of rat VSMCs by using RNAi technology and examined how geminin regulated VSMC proliferation. METHODS: By using RNA interference in A10 cells and flow cytometry, (3)H-thymidine and 5-ethynyl-2'-deoxyuridine (EdU) measurements were used to detect VSMC proliferation. We performed a Western blot, polymerase chain reaction, and immunohistochemistry to detect the expression and location of geminin and cyclin-dependent kinase-1 (CDK1) in VSMCs. RESULTS: Silencing geminin significantly increased (3)H-thymidine and EdU incorporation in VSMCs. We observed a significant increase in (3)H-thymidine incorporation 24 h after a serum challenge in the geminin-RNAi-lentiviral vector group (4401.38 ± 438.39 cpm/mg), versus the non-targeting geminin-lentiviral vector (2836.88 ± 476.18 cpm/mg) and control groups (3069.50 ± 508.18 cpm/mg; P < 0.05). In the geminin-RNAi-lentiviral vector group, the EdU-positive cell rate was significantly increased (0.75 ± 0.03; P < 0.05), versus the non-targeting geminin-lentiviral vector (0.41 ± 0.0) or control group (0.40 ± 0.03). Geminin promoted VSMC proliferation, accelerating G0/G1-S cell-cycle progression (G0/G1 cells, 10 % decrease; S-phase cells, approximate 6 % increase) 12 h after serum withdrawal. Both CDK1 protein and mRNA expression were significantly increased in the positive group versus the controls. The immunofluorescence and co-immunoprecipitation results revealed a close interaction existed between CDK1 and the geminin gene in VSMC proliferation. CONCLUSIONS: Geminin gene inhibition could augment VSMC proliferation by increasing CDK1 expression; thus, geminin may be a potential target for treating vascular diseases, specifically VSMCs.

Development of functional I f channels in mMSCs after transfection with mHCN4: effects on cell morphology and mechanical activity in vitro.

OBJECTIVE: To study the functional properties of I(f) channels and the changes in mechanical activity of mouse mesenchymal stem cells (mMSCs) transfected with mHCN4. METHODS: mMSCs were purified by using CD11b-immunomagnetic microbeads and transfected with pMSCV-mHCN4-EGFP or pMSCV-EGFP. We examined the kinetic characteristics of the mHCN4 channel. The morphological changes of positively transfected mMSCs were investigated at the same time. RESULTS: The I(f) current recorded from the experimental group was sensitive to extracellular Cs(+) (-44.5 +/- 4.2 vs. -5.5 +/- 1.0 pA/pF, p < 0.001). The half-maximal activation was -99.0 +/- 5.8 mV. The time constant of activation was 451 +/- 61 ms under -140 mV. The control cells did not show the current under the same conditions. The absolute values of half-maximal activation decreased in the presence of cAMP or cGMP in the experimental group (-78.6 +/- 10.4 and -85.7 +/- 8.6 vs. -99.0 +/- 5.8 mV, respectively, p < 0.05). mMSCs transfected with pMSCV-mHCN4-EGFP could form spontaneous beating cells. Extracellular Cs(+) decreased the beating rate significantly (196 +/- 50 vs. 66 +/- 23 bmp, p < 0.01). CONCLUSIONS: Functional I(f) channels can be reconstructed in mMSCs infected with mHCN4. mMSCs modified by successful transfection with mHCN4 can differentiate so as to develop spontaneous mechanical activity.

Clinical efficiency and safety analysis of transcatheter closure of multiple atrial septal defects in adults.

BACKGROUND: Transcatheter closure of atrial septal defects (ASDs) is currently a reliable alternative to surgery, even though challenging in patients with multiple ASDs. HYPOTHESIS: The aim of this study was to evaluate the clinical efficiency and safety of transcatheter closure in multiple ASDs. METHODS: Multiple ASDs were diagnosed by transthoracic echocardiography (TTE) or transesophageal echocardiography (TEE). The occlusive condition and distance between 2 adjacent ASDs were measured by TTE examination. Then, the number and size of the occluder(s) was determined. TTE examinations were performed after transcatheter closure as follow-up. RESULTS: The transcatheter procedure was successful in 15 patients with multiple ASDs, using a single occluder in 9 patients and 2 occluders in the remaining 6 patients. Overall, 21 ASD occluders were implanted. During a follow-up period of 6 mo to 5 y, a slight residual shunt was found in 1 patient without any symptoms; a moderate residual shunt was identified at the inferior vena cava and the occluder was removed by surgery 1 mo after procedure. Other complications, including endocarditis, arrhythmia, thromboembolism, and atrioventricular valve damage were not recorded in any of the 15 patients during the follow-up period. CONCLUSION: Transcatheter closure of multiple ASDs is safe and efficient. Two occluders are necessary for the distance of 2 ASDs more than 7 mm, and a single occluder is sufficient for those 7 mm or less.

Overexpression of UHRF1 promoted the proliferation of vascular smooth cells via the regulation of Geminin protein levels.

Geminin is an inhibitor of DNA replication licensing and cell cycle. Our previous study demonstrates that Geminin plays an important role in regulating phenotypic diversity and growth of vascular smooth cells (VSMCs). Ubiquitin-like with PHD and RING Finger domains 1 (UHRF1) is an epigenetic coordinator, whose RING domain confers intrinsic E3 ligase activity, mediating the ubiquitination of several proteins and the protein-protein interaction. Aberrant expression of UHRF1 was related to aggressiveness of multiple human malignancies, where knockdown of UHRF1 led to decreased proliferation of cancer cells. However, it is unclear whether proper UHRF1 function is involved in aberrant proliferation and phenotypic switching of VSMCs via altering Geminin protein levels. In present study, in UHRF1-overexpressing A10 cells, 3H-thymidine and 5-ethynyl-20-deoxyuridine (EdU) and CCK8 were used to examine the proliferation of VSMCs. RT-PCR and Western blot analyses were performed to investigate whether UHRF1-mediated effects were achieved by altering Geminin expression in VSMCs. RNA-seq analysis was performed to dissect related mechanisms or signaling pathways of these effects. The results of in vitro experiments suggested that UHRF1 prompted proliferation and cell cycle of VSMCs via the down-regulation of Geminin protein levels with no change in Geminin mRNA expression. Besides, PI3K-Akt signaling pathway was increased upon UHRF1 up-regulation. Our study demonstrated that overexpressing UHRF1 was involved in VSMCs proliferation through reducing inhibitory Geminin protein levels to promote cell cycle as well as activating PI3K-Akt signaling. This may provide key knowledge for the development of better strategies to prevent diseases related to VSMCs abnormal proliferation.

RNA interference targeting ORC1 gene suppresses the proliferation of vascular smooth muscle cells in rats.

BACKGROUND: The proliferation of vascular smooth muscle cells (VSMCs) plays an important role in the pathogenesis of vascular diseases such as atherosclerosis and postangioplasty restenosis. The largest subunit of the origin recognition complex (ORC), ORC1, plays a critical role during the initiation of DNA replication in eukaryotes. However, the involvement of ORC1 in the initiation of DNA replication in VSMCs has not been studied yet. OBJECTIVE: The aim of this study was to silence ORC1 gene selectively by using RNA interference and analyze the effects of ORC1 gene on the proliferation and apoptosis of rat VSMCs. METHODS: Freshly isolated rat VSMCs were transfected with siRNA targeting ORC1 gene capsulated in liposome. ORC1 protein expression was determined by Western blotting and ORC1 mRNA level by RT-PCR. DNA synthesis was analyzed by (3)H thymidine ((3)H-TdR) incorporation and cell proliferative activity and cell cycle distribution by flow cytometry. Two apoptosis-related proteins, Bax and Bcl-2, were examined immunohistochemically. RESULTS: Down-regulation of ORC1 mRNA and protein expression was observed in rat VSMCs at 24 h after transfection with the three pairs of siRNA targeting ORC1 gene and this reduction persisted at least 7 days post-transfection. Down-regulation of ORC1 mRNA (60%) and protein (80%) expression was observed at 72 h post-transfection in the cells transfected with B-ORC1 siRNA. A significant decrease in (3)H thymidine incorporation was observed in rat VSMCs with ORC1 gene silencing after serum challenge, but not in the non-silenced control. A significant increase in the proliferation index and a significant decrease in the percentage of cells at G(0)/G(1) phase after serum challenge were observed in the non-silenced control, but not in ORC1 gene silenced cells. A significant increase in the ratio of Bcl-2/Bax was observed after serum challenge in the non-silenced control, but only a slight increase was found in the ORC1 gene silenced cells. ORC1 gene silencing disappeared 7 days after transfection. Continuous serum challenge stimulated VSMCs to synchronously reenter the cell cycle as evidenced by increases in [(3)H] thymidine incorporation, the proliferation index, and the ratio of Bcl-2/Bax, as non-silenced cells were induced to resume cell cycle progression by the addition of 15% fetal bovine serum to the culture medium. CONCLUSION: ORC1 gene silencing causes rat VSMCs to enter a reversible G(0) quiescent, growth arrested state; thus, ORC1 gene may be an important new target for suppressing VSMCs proliferation.

Clinical efficiency and safety analysis of transcatheter interventional therapy for compound congenital cardiovascular abnormalities.

OBJECTIVE: To investigate the efficiency and safety of transcatheter interventional therapy for compound congenital cardiovascular abnormalities. METHODS: From Nov 2001 to Jun 2006, a total of 36 patients (17 male, 19 female), aged 17.20 +/- 10.52, with compound congenital cardiovascular abnormalities underwent transcatheter interventional procedure. These patients included 11 with perimembranous ventricular septal defect (PVSD) and patent ductus arteriosus (PDA), 8 patients with PVSD and atrial septal defect (ASD), 8 patients with ASD and PDA, 7 patients with ASD and pulmonary stenosis (PS), 1 patient with ASD and mitral stenosis(MS), 1 patient with coarctation of aorta (COA) and PDA. According to the principle of "easy first, hard second," balloon valvuloplasties of PS or MS were performed before the closure of PVSD, and of PDA and ASD. Electrocardiogram and transthoracic echocardiogram were examined at 4 days, 1, 2, 6 and 12 months, respectively, after each procedure. RESULTS: Transcatheter interventional therapy for compound congenital cardiovascular abnormalities was successful in all patients. Among these, 2 occluders were planted in each of 27 patients, 7 patients with ASD combined with PS and 1 patient with ASD combined with MS underwent successfully performed balloon valvuloplasty and ASD closure, 1 patient with COA combined with PDA underwent successfully performed balloon valvuloplasty and subsequent covered stent implantation. No patient encountered serious adverse events during the (30.5 +/- 14.6) months of follow-up. CONCLUSIONS: Transcatheter interventional therapy for compound congenital cardiovascular abnormalities could obtain satisfactory results with technical feasibility.

[Expression of origin recognition complex 1 gene in DNA replication of vascularsmooth muscle cells].

OBJECTIVE: To explore the expression of origin recognition complex 1 (ORC1) during the DNA replication of vascular muscle cells (VSMC). METHODS: VSMC of thoracic aorta in rats were obtained by the adherence method of tissue culture. The cell synchrony was obtained by the method of double-thymidine block, colchicine treatment and serum starvation. The expression of ORC1 mRNA at different cell cycles of VSMC was determined by RT-PCR and the protein expression of ORC1 was analyzed by Western blot. RESULTS: Cultured VSMC were identified by light microscope and immunocytochemistry. Significant expression of ORC1 mRNA and protein in a quiescent stage of VSMC were not observed. Upon synchronization, the expression of ORC1 mRNA was significantly higher at G(1)/S phase of VSMC than that at S and G(2)/M phases. The expression of ORC1 protein followed same changes as the ORC1 mRNA expression at different stages of cell cycles. CONCLUSION: ORC1 may be an important regulatory factor at the initiation of proliferative process of VSMC.

Application of 3D printing technology to left atrial appendage occlusion.

BACKGROUND: Three-dimensional printing (3DP) has undergone rapid development in medical applications. However, only a few reports have described its applications in left atrial appendage (LAA) occlusion. We assessed the feasibility and effectiveness of the 3DP technology for left atrial appendage (LAA). METHODS: Forty-two patients with atrial fibrillation (average age: 69.3±7.8years) were randomly assigned to two groups equally (3DP and control). The transoesophageal echocardiography (TOE), LAA angiography, and cardiac computed tomography angiography measurements of the LAA orifice size between the groups. The procedure times, radiographic exposure, contrast agent volumes, residual shunt and costs were presented between the two groups. RESULTS: All patients underwent a successful LAA occlusion operation with the Watchman device. TOE, LAA angiography, and cardiac computed tomography angiography measurements of the LAA orifice size between the groups were 20.4±2.5 vs. 20.1±3.3mm, 19.6±2.2 vs. 19.5±2.8mm, and 20.8±2.1 vs. 20.2±3.0mm, respectively (p>0.05). After the occlusion, the immediate TOE examination showed 3 mild residual shunt cases in the control group. The radiation exposure was significantly reduced in the 3DP compared with the control group (p<0.05). The patients were followed for an average of 7.7±2.5months. No postoperative complications, device-related thrombosis, or ischemic events occurred. CONCLUSIONS: LAA occlusion guided by 3DP technology is feasible. 3DP increases the working efficiency and ensures the effectiveness of occlusion, making it valuable for clinical application.

The immediate and follow-up results of transcatheter occlusion of the ruptured sinus of Valsalva aneurysm with duct occluder.

BACKGROUND: Percutaneous transcatheter closure is an alternative strategy to traditional conventional surgical repair for ruptured sinus of Valsalva aneurysm (RSVA). The immediate and follow-up results of transcatheter occlusion in 13 patients were reported. METHODS: From February 2004 to June 2009, a total of 13 patients (9 males, 4 females), ages 18-38 years, were involved in the report. The diagnosis of RSVA was made based on a combination of several imaging modalities. None of the patients had other associated congenital heart disease, and all underwent local anesthesia. Transthoracic echocardiography was used during the procedure. All patients received aspirin (100 mg/day) and clopidogrel (75 mg/day) for a 6-month period after the procedure. Enalapril (5-20 mg/day) was administered to the patients with heart failure and/or cardiac dilatation. Chest radiography, electrocardiogram, and transthoracic echocardiography were undertaken at intervals of 1, 6, 12, 24, 36, 48, and 60 months during the follow-up. RESULTS: The size of the duct occluder selected was up to 1-3 mm larger than the maximal diameter of the RSVA opening site. The devices were successfully deployed without any complications. On follow-up, no severe arrhythmia occurred; there was no device embolization, residual shunt, RVOT obstruction, new aortic regurgitation, or rupture site. Compared with the preoperative results, the cardiothoracic ratio and left ventricular were significantly decreased in the patients with cardiac dilatation (0.54 ± 0.05 vs 0.50 ± 0.04, P<.05 and 54.11 ± 2.32 vs 50.11 ± 2.47 mm, P<.01, respectively). CONCLUSIONS: Transcatheter closure is a safe and effective alternative in the treatment of RSVA. The mid-term follow-up outcomes are good.

Association between C-reactive protein and atrial fibrillation recurrence after catheter ablation: a meta-analysis.

BACKGROUND: Atrial fibrillation (AF) is associated with inflammation. Increased serum C-reactive protein (CRP) levels are important representatives of an inflammatory state of AF. A variety of studies have evaluated whether increased CRP levels have an association with AF recurrence after catheter ablation. However, the results remain inconsistent, therefore, this meta-analysis was conducted to offer suggestions. HYPOTHESIS: Increased baseline CRP have an association with AF recurrence after catheter ablation. METHODS: Electronic databases including PubMed, Embase, Medline, ISI Web of Knowledge, and ScienceDirect were searched until December 31, 2012 for any CRP-associated studies. Overall and subgroup analyses were performed. Standardized mean difference (SMD) and 95% confidence interval (CI) were used to evaluate the associations between CRP levels and postablation AF recurrence. Statistical analysis was performed with Review Manager 5.2 and Stata 11.0. RESULTS: Seven available studies were identified, which included 526 patients (179 recurrence vs 347 no recurrence). Overall, increased baseline CRP levels had significant positive association with postablation AF recurrence. The SMD in the CRP levels was 0.65 units (95% CI: 0.30-0.99), and the z-score for overall effect was 3.70 (P = 0.0002). The heterogeneity test showed that there were moderate differences between individual studies (P = 0.006, I(2) = 67%). Metaregression revealed that different sample sizes of studies possibly accounted for the heterogeneity. Positive associations were also found in subgroup analyses based on sample size. When stratifying for ethnicity, similarly significant associations were found in both European (Caucasian) and Asian populations. CONCLUSIONS: Investigations demonstrate that baseline CRP levels are greater in patients with postablation AF recurrence. Further studies with larger sample size and delicate design for CRP should be conducted.