A programmable protease-based protein secretion platform for therapeutic applications.

Cell-based therapies represent potent enabling technologies in biomedical science. However, current genetic control systems for engineered-cell therapies are predominantly based on the transcription or translation of therapeutic outputs. Here we report a protease-based rapid protein secretion system (PASS) that regulates the secretion of pretranslated proteins retained in the endoplasmic reticulum (ER) owing to an ER-retrieval signal. Upon cleavage by inducible proteases, these proteins are secreted. Three PASS variants (chemPASS, antigenPASS and optoPASS) are developed. With chemPASS, we demonstrate the reversal of hyperglycemia in diabetic mice within minutes via drug-induced insulin secretion. AntigenPASS-equipped cells recognize the tumor antigen and secrete granzyme B and perforin, inducing targeted cell apoptosis. Finally, results from mouse models of diabetes, hypertension and inflammatory pain demonstrate light-induced, optoPASS-mediated therapeutic peptide secretion within minutes, conferring anticipated therapeutic benefits. PASS is a flexible platform for rapid delivery of therapeutic proteins that can facilitate the development and adoption of cell-based precision therapies.

Genetic-code-expanded cell-based therapy for treating diabetes in mice.

Inducer-triggered therapeutic protein expression from designer cells is a promising strategy for disease treatment. However, as most inducer systems harness transcriptional machineries, protein expression timeframes are unsuitable for many therapeutic applications. Here, we engineered a genetic code expansion-based therapeutic system, termed noncanonical amino acids (ncAAs)-triggered therapeutic switch (NATS), to achieve fast therapeutic protein expression in response to cognate ncAAs at the translational level. The NATS system showed response within 2 hours of triggering, whereas no signal was detected in a transcription-machinery-based system. Moreover, NATS system is compatible with transcriptional switches for multi-regulatory-layer control. Diabetic mice with microencapsulated cell implants harboring the NATS system could alleviate hyperglycemia within 90 min on oral delivery of ncAA. We also prepared ncAA-containing 'cookies' and achieved long-term glycemic control in diabetic mice implanted with NATS cells. Our proof-of-concept study demonstrates the use of NATS system for the design of next-generation cell-based therapies to achieve fast orally induced protein expression.

Far-red light-activated human islet-like designer cells enable sustained fine-tuned secretion of insulin for glucose control.

Diabetes affects almost half a billion people, and all individuals with type 1 diabetes (T1D) and a large portion of individuals with type 2 diabetes rely on self-administration of the peptide hormone insulin to achieve glucose control. However, this treatment modality has cumbersome storage and equipment requirements and is susceptible to fatal user error. Here, reasoning that a cell-based therapy could be coupled to an external induction circuit for blood glucose control, as a proof of concept we developed far-red light (FRL)-activated human islet-like designer (FAID) cells and demonstrated how FAID cell implants achieved safe and sustained glucose control in diabetic model mice. Specifically, by introducing a FRL-triggered optogenetic device into human mesenchymal stem cells (hMSCs), which we encapsulated in poly-(l-lysine)-alginate and implanted subcutaneously under the dorsum of T1D model mice, we achieved FRL illumination-inducible secretion of insulin that yielded improvements in glucose tolerance and sustained blood glucose control over traditional insulin glargine treatment. Moreover, the FAID cell implants attenuated both oxidative stress and development of multiple diabetes-related complications in kidneys. This optogenetics-controlled "living cell factory" platform could be harnessed to develop multiple synthetic designer therapeutic cells to achieve long-term yet precisely controllable drug delivery.

Synthetic far-red light-mediated CRISPR-dCas9 device for inducing functional neuronal differentiation.

The ability to control the activity of CRISPR-dCas9 with precise spatiotemporal resolution will enable tight genome regulation of user-defined endogenous genes for studying the dynamics of transcriptional regulation. Optogenetic devices with minimal phototoxicity and the capacity for deep tissue penetration are extremely useful for precise spatiotemporal control of cellular behavior and for future clinic translational research. Therefore, capitalizing on synthetic biology and optogenetic design principles, we engineered a far-red light (FRL)-activated CRISPR-dCas9 effector (FACE) device that induces transcription of exogenous or endogenous genes in the presence of FRL stimulation. This versatile system provides a robust and convenient method for precise spatiotemporal control of endogenous gene expression and also has been demonstrated to mediate targeted epigenetic modulation, which can be utilized to efficiently promote differentiation of induced pluripotent stem cells into functional neurons by up-regulating a single neural transcription factor, NEUROG2 This FACE system might facilitate genetic/epigenetic reprogramming in basic biological research and regenerative medicine for future biomedical applications.

The effect of resistance training on sleep in Chinese older adults: A randomized controlled trial.

Sleep disturbances affect approximately half of the older adult population and add additional risks of developing Alzheimer's disease. This study is to test the effects of a 12-week resistance training (RT) program on sleep in older adults residing in an assisted living facility in China. A total of 62 eligible participants were randomly assigned to RT (n = 31) or control group (n = 31). Participants in RT group participated in three 1-hour moderate intensity RT sessions per week for 12 weeks (at least 48 h between sessions). In the overall sample, sleep efficiency increased (P < 0.01), wake after sleep onset (P < 0.01) decreased in participants in RT group at post-intervention, compared to control group. Similar results were found in participants with mild cognitive impairment (MCI). The findings support that RT improves sleep efficiency and decreases sleep fragmentation in older adults in general and in those with MCI.

Antidiabetic Close Loop Based on Wearable DNA-Hydrogel Glucometer and Implantable Optogenetic Cells.

Diabetes mellitus and its associated secondary complications have become a pressing global healthcare issue. The current integrated theranostic plan involves a glucometer-tandem pump. However, external condition-responsive insulin delivery systems utilizing rigid glucose sensors pose challenges in on-demand, long-term insulin administration. To overcome these challenges, we present a novel model of antidiabetic management based on printable metallo-nucleotide hydrogels and optogenetic engineering. The conductive hydrogels were self-assembled by bioorthogonal chemistry using oligonucleotides, carbon nanotubes, and glucose oxidase, enabling continuous glucose monitoring in a broad range (0.5-40 mM). The optogenetically engineered cells were enabled glucose regulation in type I diabetic mice via a far-red light-induced transgenic expression of insulin with a month-long avidity. Combining with a microchip-integrated microneedle patch, a prototyped close-loop system was constructed. The glucose levels detected by the sensor were received and converted by a wireless controller to modulate far-infrared light, thereby achieving on-demand insulin expression for several weeks. This study sheds new light on developing next-generation diagnostic and therapy systems for personalized and digitalized precision medicine.

Exploring plant-derived phytochrome chaperone proteins for light-switchable transcriptional regulation in mammals.

Synthetic biology applications require finely tuned gene expression, often mediated by synthetic transcription factors (sTFs) compatible with the human genome and transcriptional regulation mechanisms. While various DNA-binding and activation domains have been developed for different applications, advanced artificially controllable sTFs with improved regulatory capabilities are required for increasingly sophisticated applications. Here, in mammalian cells and mice, we validate the transactivator function and homo-/heterodimerization activity of the plant-derived phytochrome chaperone proteins, FHY1 and FHL. Our results demonstrate that FHY1/FHL form a photosensing transcriptional regulation complex (PTRC) through interaction with the phytochrome, ΔPhyA, that can toggle between active and inactive states through exposure to red or far-red light, respectively. Exploiting this capability, we develop a light-switchable platform that allows for orthogonal, modular, and tunable control of gene transcription, and incorporate it into a PTRC-controlled CRISPRa system (PTRCdcas) to modulate endogenous gene expression. We then integrate the PTRC with small molecule- or blue light-inducible regulatory modules to construct a variety of highly tunable systems that allow rapid and reversible control of transcriptional regulation in vitro and in vivo. Validation and deployment of these plant-derived phytochrome chaperone proteins in a PTRC platform have produced a versatile, powerful tool for advanced research and biomedical engineering applications.

Relationships between parental responsive feeding and infant appetitive traits: The moderating role of infant temperament.

Introduction: Between the ages of 6 and 12 months is a crucial stage for children to develop appetitive self-regulation. Evidence suggests that a combination of parental responsive feeding and infant temperament (surgency, effortful control, negative affect) shapes infant appetitive traits (food approach, food avoidance). There is a need for research to explore these relationships, in order to provide guidance for the design of an effective intervention to improve appetitive traits. The objective of the current study was to explore the moderating role of infant temperament in the relationship between parental responsive feeding and infant appetitive traits. Methods: A total of 616 questionnaires, measuring parental responsive feeding, infant appetitive traits, and infant temperament, were collected from parents with infants aged 6-12 months. Results: Results revealed that responsive feeding was associated with both food approach and food avoidance. Furthermore, only lower levels of surgency significantly moderated the relationship between responsive feeding and food approach, while responsive feeding was associated with food avoidance irrespective of infant temperament. Discussion: These findings suggest that a strategy embedding responsive feeding interventions should be adopted to reduce infant food avoidance and low-surgent infant food approach, and interventions that are tailored toward food approach for infants with effortful control, negative affect, or higher levels of surgency should be further sought.

A Responsive Feeding Questionnaire Based on Self-Determination Theory for Caregivers of Chinese Toddlers.

OBJECTIVE: To develop and test the psychometric properties of a responsive feeding questionnaire (RFQ) on the basis of Self-Determination Theory for caregivers of toddlers aged 12-24 months in China. DESIGN: Item generation, preliminary evaluation items, refinement questionnaire, and psychometric properties testing. SETTING: Toddlers' caregivers from Shandong Province, China, were surveyed online between June 2021 and February 2022 (n = 616). MAIN OUTCOME MEASURE: Content, face, and construct validity and reliability of the RFQ. ANALYSIS: Content validity was performed on the basis of expert panel feedback and cognitive interviews among caregivers. Construct validity was evaluated using principal component analysis with varimax rotation. Test-retest reliability was conducted with a sample of 105 caregivers. RESULTS: Over 3 phases of testing, a new instrument was developed to measure responsive feeding in toddler caregivers. The instrument was reliable, with an internal consistency of 0.87 and an intraclass correlation of 0.92. The principal component analysis identified a 3-factor solution (autonomy support, positive involvement, appropriate response) aligning with a theoretical framework from Self-Determination Theory. The final version of the instrument included 23 items. CONCLUSIONS AND IMPLICATIONS: The 23-item RFQ has been validated in a Chinese population. Future research needs to validate this instrument in other countries and with children of different ages.

A small and highly sensitive red/far-red optogenetic switch for applications in mammals.

Optogenetic technologies have transformed our ability to precisely control biological processes in time and space. Yet, current eukaryotic optogenetic systems are limited by large or complex optogenetic modules, long illumination times, low tissue penetration or slow activation and deactivation kinetics. Here, we report a red/far-red light-mediated and miniaturized Δphytochrome A (ΔPhyA)-based photoswitch (REDMAP) system based on the plant photoreceptor PhyA, which rapidly binds the shuttle protein far-red elongated hypocotyl 1 (FHY1) under illumination with 660-nm light with dissociation occurring at 730 nm. We demonstrate multiple applications of REDMAP, including dynamic on/off control of the endogenous Ras/Erk mitogen-activated protein kinase (MAPK) cascade and control of epigenetic remodeling using a REDMAP-mediated CRISPR-nuclease-deactivated Cas9 (CRISPR-dCas9) (REDMAPcas) system in mice. We also demonstrate the utility of REDMAP tools for in vivo applications by activating the expression of transgenes delivered by adeno-associated viruses (AAVs) or incorporated into cells in microcapsules implanted into mice, rats and rabbits illuminated by light-emitting diodes (LEDs). Further, we controlled glucose homeostasis in type 1 diabetic (T1D) mice and rats using REDMAP to trigger insulin expression. REDMAP is a compact and sensitive tool for the precise spatiotemporal control of biological activities in animals with applications in basic biology and potentially therapy.

Constructing Smartphone-Controlled Optogenetic Switches in Mammalian Cells.

With the increasing indispensable role of smartphones in our daily lives, the mobile health care system coupled with embedded physical sensors and modern communication technologies make it an attractive technology for enabling the remote monitoring of an individual's health. Using a multidisciplinary design principle coupled with smart electronics, software, and optogenetics, the investigators constructed smartphone-controlled optogenetic switches to enable the ultraremote-control transgene expression. A custom-designed SmartController system was programmed to process wireless signals from smartphones, enabling the regulation of therapeutic outputs production by optically engineered cells via a far-red light (FRL)-responsive optogenetic interface. In the present study, the investigators describe the details of the protocols for constructing smartphone-controlled optogenetic switches, including the rational design of an FRL-triggered transgene expression circuit, the procedure for cell culture and transfection, the implementation of the smartphone-controlled far-red light-emitting diode (LED) module, and the reporter detection assay.

Constructing a Smartphone-Controlled Semiautomatic Theranostic System for Glucose Homeostasis in Diabetic Mice.

With the development of mobile communication technology, smartphones have been used in point-of-care technologies (POCTs) as an important part of telemedicine. Using a multidisciplinary design principle coupling electrical engineering, software development, synthetic biology, and optogenetics, the investigators developed a smartphone-controlled semiautomatic theranostic system that regulates blood glucose homeostasis in diabetic mice in an ultraremote-control manner. The present chapter describes how the investigators tailor-designed the implant architecture "HydrogeLED," which is capable of coharboring a designer-cell-carrying alginate hydrogel and wirelessly powered far-red light LEDs. Using diabetes mellitus as a model disease, the in vivo expression of insulin or human glucagon-like peptide 1 (shGLP-1) from HydrogeLED implants could be controlled not only by pre-set ECNU-TeleMed programs, but also by a custom-engineered Bluetooth-active glucometer in a semiautomatic and glycemia-dependent manner. As a result, blood glucose homeostasis was semiautomatically maintained in diabetic mice through the smartphone-controlled semiautomatic theranostic system. By combining digital signals with optogenetically engineered cells, the present study provides a new method for the integrated diagnosis and treatment of diseases.

Resilience and Associated Factors Among Parents of Children with Orofacial Clefts.

This study aims to examine the associations among social support, coping styles, and resilience in parents of children with orofacial clefts (OFCs). We conducted a cross-sectional study. Through convenience sampling, 306 parents of children with OFCs completed questionnaires on social support, coping styles, and resilience. Pearson's correlations and hierarchical regression analyses were used to examine the relationships among the selected variables. The results showed that age, gender, educational level, diagnosis of children, severity of OFCs, social support, and positive coping style had significant associations with resilience, which jointly explained 69.1% of the total variance in resilience. The findings suggested that social support and a positive coping style may be instrumental in improving resilience. Further research is required to explore interventions to improve the resilience of parents of children with OFCs.

Promoting Breastfeeding and Lactation Among Mothers of Premature Newborns in a Hospital in China.

OBJECTIVE: To promote breastfeeding and lactation in mothers separated from their premature infants admitted to the NICU in a hospital in China. DESIGN: For this evidence-based practice project we used a mixed method of survey measures and interviews and were guided by the Joanna Briggs Institute Practical Application of Clinical Evidence System and Getting Research Into Practice framework. SETTING/LOCAL PROBLEM: Obstetric unit of a Women and Children's Hospital in China from September 2017 to August 2018. Before the project, the partial breastfeeding rate in the hospital was 17.9%, and the exclusive breastfeeding rate of premature infants was 1.8%; these rates were much lower than the national breastfeeding rate in the country. PARTICIPANTS: Seventeen nurses and 70 mothers of premature infants. INTERVENTION/MEASUREMENTS: The project included three phases: (a) finding the best evidence to promote breastfeeding in the literature and identifying the gaps between best practice and current practice, (b) implementing best practice strategies, and (c) comparing pre- and postintervention outcomes. Based on the evidence in the literature and the barriers, strategies were implemented in practice to promote breastfeeding and lactation among women separated from their preterm newborns. Chi-square and t tests were performed to compare the pre-/postintervention differences. RESULTS: Partial breastfeeding rates increased from 17.9% to 52.7%, and exclusive breastfeeding rates increased from 1.8% to 4.1%. Compliance with breastfeeding guidelines and measures of maternal lactation volume both improved significantly. CONCLUSION: Promoting breastfeeding and lactation among mothers of premature infants requires not only scientific knowledge but also a caring environment and family-centered practice.

Effects of a theory of planned behavior-based intervention on breastfeeding behaviors after cesarean section: A randomized controlled trial.

OBJECTIVES: To examine the efficacy of an intervention based on the theory of planned behavior (TPB) in improving breastfeeding behavior among women with cesarean sections (C-sections). METHODS: This research was a randomized controlled trial. Women with planned elective C-sections were recruited to participate in a randomized controlled trial between June and September 2020. One hundred thirty-two women were divided randomly into the intervention (n = 66) and control group (n = 66) by systematic random sampling. In the intervention group, an intervention project was implemented after the C-section to establish positive breastfeeding attitudes, cultivate supportive subjective norms, enhance perceived behavioral control, and strengthen breastfeeding intention to change behaviors. Those in the control group received routine pre-and post-delivery care. Exclusive breastfeeding rate and breast problem were collected at 5 days, 2 weeks, and 1 month after C-section. The modified Breastfeeding Attrition Prediction Tool (BAPT) on the first day in the hospital, two weeks, and one month after C-section and Numerical Rating Scale (NRS) 24 h postoperatively were used to compare the intervention effect between the two groups. RESULTS: After the intervention, the intervention group had significantly higher exclusive breastfeeding rates than the control group at five days (86.4% vs. 60.6%), two weeks (77.3% vs. 57.6%), and one month (74.2% vs. 50.0%) after the C-section. Besides, the intervention group was less likely to have sore nipples at five days (6.1% vs. 18.2% in the control group, P < 0.05) and two weeks (9.1% vs. 12.1% in the control group, P < 0.05). After two weeks of intervention, attitude scores (90.64 ± 8.31 vs. 87.20 ± 8.15, P < 0.05), subjective norm scores (88.07 ± 24.65 vs. 79.42 ± 19.47, P < 0.05）and behavior control scores in the intervention group were significantly higher than those in the control group. After one month of intervention, attitude scores (90.34 ± 10.35 vs. 84.22 ± 10.51, P < 0.05) and behavior control scores (43.13 ± 5.02 vs. 39.15 ± 4.69, P < 0.05）in the intervention group were significantly higher than those in the control group, which resulted in the higher breastfeeding intention in the intervention group. CONCLUSION: This study indicated that the TPB-based interventions effectively improved women's breastfeeding behaviors after C-sections.

An exploration of the breastfeeding behaviors of women after cesarean section: A qualitative study.

OBJECTIVES: To explore the factors affecting breastfeeding behaviors in women after cesarean section. METHODS: This is a qualitative study that used a phenomenological approach. This study used individual face-to-face interviews with 19 women who underwent a cesarean section in a Women and Children's Hospital in China between July to September 2019. Information saturation was used to determine sample size. Data were analyzed using a thematic content analysis method. Themes were developed based on the theory of planned behavior. RESULTS: Thirteen (68.42%) had a planned cesarean section, and six (31.58%) cesarean sections were unplanned or emergent. Three major themes emerged: ambivalent attitude about breastfeeding, motivation to comply with the traditional cultural norms, and barriers and challenges. The motivating factors for breastfeeding after cesarean sections included perceived benefits of human milk, support from healthcare professionals, and responsibility for breastfeeding. The challenges for breastfeeding after cesarean sections included physical discomfort, knowledge and skills deficit of breastfeeding, lactation deficiency, and lack of knowledge and coping skills in managing their depressive mood after cesarean sections. There were a couple of neutral factors, such as the influences of family and peers. These factors could influence women either positively as facilitators or negatively as barriers. CONCLUSIONS: The findings can offer valuable information for healthcare professionals to help women breastfeed after cesarean sections. To promote women's breastfeeding behaviors after cesarean sections, it is necessary to change women's attitudes, belief systems, and the external environments and help them become more confident.

Association between family management and asthma control in children with asthma.

PURPOSE: The purpose of this study is to investigate the association between family management and asthma control in children with asthma. DESIGN AND METHODS: This cross-sectional descriptive study recruited 142 children with asthma and their parents. We used the Family Management Measure (FaMM), the Childhood Asthma Control Test (C-ACT), and fractional exhaled nitric oxide (FeNO) detectors to assess family management and asthma control. The McNemar's test was used to determine the proportional difference between C-ACT and FeNO in evaluating asthma control. Pearson correlation analysis and multiple linear regression analysis were used to assess the relationship between family management and asthma control in children with asthma. RESULTS: There was no significant difference in the proportion of C-ACT and FeNO in evaluating asthma control (McNemar's test p = .593). Child's Daily Life, Condition Management Ability, and Parental Mutuality were positively correlated with C-ACT (r = 0.398 to 0.655; all p < .05) and negatively correlated with FeNO (r = -0.245 to -0.402; all p < .05); Condition Management Effort, Family Life Difficulty, and View of Condition Impact were negatively correlated with C-ACT (r = -0.416 to -0.672; all p < .05) and positively with FeNO (r = 0.248 to 0.427; all p < 0.05). Child's Daily Life, Condition Management Effort, and View of Condition Impact dimensions significantly predicted the C-ACT results, and the Condition Management Effort and View of Condition Impact dimensions significantly predicted the FeNO results (p < .05). PRACTICAL IMPLICATIONS: Pediatric nurses could provide family management education for parents to improve asthma control in children. In addition, pediatric nurses might assess asthma control condition of asthmatic children in combination with C-ACT and FeNO levels.

An assessment of a pediatric early warning system score in severe hand-foot-and-mouth disease children: To detect clinical deterioration in hospitalized children.

Identification of deteriorating severe hand, foot, and mouth disease (HFMD) children for referral to intensive care remains problematic.The medical records of 2382 hospitalized children with severe HFMD from May 2013 to September 2015 were retrospectively reviewed. A Pediatric Early Warning System (PEWS) score was designed based on study parameters on admission, evaluated in a logistic regression model, and subsequently validated with different cut-off scores, to predict the risk for clinical deterioration.After admission, 191 cases were transferred to the pediatric intensive care unit (PICU) and 2191 were admitted to the infectious disease department. Of which, 116 cases were subsequently transferred to PICU, with younger age, consciousness levels of sluggishness, lethargy or drowsiness, rashes with vesicles on the hands or feet, moderate or high fever, increased or disordered lung marking or pulmonary infiltration, abnormal heart rate, fasting plasma glucose, blood platelet, and C-reactive protein. A corresponding 10-component PEWS score >7 was significantly associated with subsequent transfer to PICU.A 10-component PEWS score >7 has good specificity but poor sensitivity for identifying severe HFMD children vulnerable to clinical deterioration.

Smartphone-controlled optogenetically engineered cells enable semiautomatic glucose homeostasis in diabetic mice.

With the increasingly dominant role of smartphones in our lives, mobile health care systems integrating advanced point-of-care technologies to manage chronic diseases are gaining attention. Using a multidisciplinary design principle coupling electrical engineering, software development, and synthetic biology, we have engineered a technological infrastructure enabling the smartphone-assisted semiautomatic treatment of diabetes in mice. A custom-designed home server SmartController was programmed to process wireless signals, enabling a smartphone to regulate hormone production by optically engineered cells implanted in diabetic mice via a far-red light (FRL)-responsive optogenetic interface. To develop this wireless controller network, we designed and implanted hydrogel capsules carrying both engineered cells and wirelessly powered FRL LEDs (light-emitting diodes). In vivo production of a short variant of human glucagon-like peptide 1 (shGLP-1) or mouse insulin by the engineered cells in the hydrogel could be remotely controlled by smartphone programs or a custom-engineered Bluetooth-active glucometer in a semiautomatic, glucose-dependent manner. By combining electronic device-generated digital signals with optogenetically engineered cells, this study provides a step toward translating cell-based therapies into the clinic.

Minimally invasive transthoracic device closure of isolated ventricular septal defects without cardiopulmonary bypass: long-term follow-up results.

OBJECTIVE: Minimally invasive transthoracic device closure (MITDC) of ventricular septal defects (VSD) under transesophageal echocardiography guidance is increasingly and successfully being performed with excellent results. We retrospectively reviewed 458 patients who received this treatment in our center and summarized the 6-year follow-up results. METHODS: From March 2007 to March 2013, 458 patients (mean age, 11.41 ± 6.73 months; body weight, 9.82 ± 5.88 kg) underwent MITDC. Patients were strictly followed up according to a standard protocol by 2 specially appointed doctors. Meanwhile, 283 cases with an isolated VSD who underwent traditional surgical repair during this period were also reviewed and several characteristics were compared between the 2 groups. RESULTS: A total of 441 cases were successfully closed (96.29%), and the other 17 patients were converted to surgical closure. There were no deaths or major complications. Concentric devices were used in 313 cases (70.98%), eccentric devices in 113 cases (25.62%), and special devices in 15 cases (3.40%). The mean intracardiac deployment time was 18.35 ± 17.13 minutes (3-48 minutes). Most of the patients were discharged within 5 days after surgery. Follow-up in 426 patients (96.60%) ranged from 6 to 78 months (47.31 ± 19.69 months) and revealed no severe complications. Fewer minor complications, such as device-related trace to mild tricuspid regurgitation, residual shunt, and right bundle branch block, occurred with MITDC than surgical closure. CONCLUSIONS: MITDC of a VSD on a beating heart is a safe and effective alternative to conventional treatments. The 6-year clinical outcomes are promising. Modification of occluders and the delivery set play an important role in good outcomes.