Risk stratification of best medical therapy for acute uncomplicated type B intramural hematoma.

OBJECTIVES: Best medical therapy (BMT) for acute uncomplicated type B intramural hematoma (TBIMH) is the current treatment guideline, but there is considerable controversy about subsequent clinical course and outcome, which may be associated with a significant failure rate. The purpose of this study was to identify potential risk factors for BMT failure and to develop a risk score to guide clinical decision making. METHODS: Patients with acute uncomplicated TBIMH between 2011 January and 2020 December were retrospectively studied. Logistic regression was applied to univariately assess potential risk predictors, and multivariable model results were then used to formulate a simplified predictive model for BMT failure. RESULTS: In a total of 61 patients, the overall rate of BMT failure was 57.4% (35/61), of which 48.6% (17/35) occurred within 28 days of onset. Logistic regression identified maximum descending aortic diameter (HR â€‹= â€‹1.99 CI â€‹= â€‹1.16-3.40, p â€‹= â€‹0.012), initial IMH thickness (HR â€‹= â€‹3.29, CI â€‹= â€‹1.28-8.46, p â€‹= â€‹0.013) and presence of focal contrast enhancement (HR â€‹= â€‹3.12, CI â€‹= â€‹1.49-6.54, p â€‹= â€‹0.003) as potential risk predictors of BMT failure. A risk score was calculated as follows: [Max DTA diameter (mm)∗0.6876 â€‹+ â€‹Max IMH thickness (mm)∗1.1918 â€‹+ â€‹PAU/ULP ∗1.1369]. Freedom from BMT failure at 1 year was 72% in patients with a risk score â€‹< â€‹4.12, compared with only 35.1% in those with a risk score â€‹â‰§ â€‹4.12. CONCLUSIONS: In a substantial proportion of patients with acute uncomplicated TBIMH, initial BMT failed. Based on the three initial computed tomographic imaging variables, this risk score could help stratify patients at high or low risk for BMT failure and provided additional information for early intervention.

Myocardial Flow Assessment After Heart Transplantation Using Dynamic Cadmium-Zinc-Telluride Single-Photon Emission Computed Tomography With 201Tl and 99mTc Tracers and Validated by 13N-NH3 Positron Emission Tomography.

BACKGROUND: Cardiac allograft vasculopathy (CAV) is an obliterative and diffuse form of vasculopathy and is the most common cause of long-term cardiovascular mortality in heart transplant patients. This study aimed to investigate the diagnostic performance of 99mTc and 201Tl tracers in the assessment of CAV using cadmium-zinc-telluride (CZT) single-photon emission computed tomography (SPECT) for myocardial blood flow (MBF) and myocardial flow reserve (MFR) quantification, which was further validated using 13 N-NH3 positron emission tomography (PET). METHODS: Thirty-eight patients with prior heart transplantation who underwent CZT SPECT and 13 N-NH3 PET dynamic scans were included in this study. CZT SPECT with 99mTc-sestamibi was used in the first 19 patients and 201Tl-chloride for the remaining patients. To determine the diagnostic accuracy of angiographically defined moderate-to-severe CAV, the analysis included patients who underwent angiographic examinations within 1 year of their second scan. RESULTS: There were no significant differences in the patient characteristics between the 201Tl and 99mTc tracer groups. Both 201Tl and 99mTc CZT SPECT-derived stress MBF and MFR values globally and in 3 coronary territories showed good correlations with 13 N-NH3 PET. The 201Tl and 99mTc cohorts did not differ significantly in the correlation coefficients of CZT SPECT versus PET for MBF and MFR, except for stress MBF (201Tl:0.95 versus 99mTc:0.80, P=0.03). 201Tl and 99mTc CZT SPECT were satisfactory for detecting PET MFR <2.0 (201Tl area under the curve, 0.92 [0.71-0.99], 99mTc area under the curve, 0.87 [0.64-0.97]) and angiographically defined moderate-to-severe CAV, and CZT SPECT results were comparable to that of 13 N-NH3 PET (CZT area under the curve, 0.90 [0.70-0.99], PET area under the curve, 0.86 [0.64-0.97]). CONCLUSIONS: This small study suggests that CZT SPECT using 201Tl and 99mTc tracers showed comparable MBF and MFR, and the results correlated well with those of 13 N-NH3 PET. Hence, CZT SPECT with 201Tl or 99mTc tracers can be used to detect moderate-to-severe CAV in patients with prior heart transplantation. However, validation using larger studies is warranted.

Aortic remodeling after endovascular aortic repair and tailored distal entry tears exclusion in Crawford type III or IV dissection aneurysm.

BACKGROUND: Thoracic endovascular aortic repair (TEVAR) can only promote 55-80% false lumen (FL) thrombosis when only the proximal primary tear is covered during the repair of type B aortic dissection (TBAD). This study evaluated the effectiveness and clinical outcome of tailored exclusion of the primary entry tear with TEVAR and distal fenestrations with ancillary devices in patients with subacute or chronic Crawford type III and IV aortic dissection aneurysm. METHODS: All patients underwent either TEVAR for primary entry tear; subsequently, various ancillary devices were applied on each distal fenestration. These techniques included covered stent occlusion of detached visceral artery entry tears, TL stenting and FL occlusion with vascular plugs in the common iliac artery dissection, or TEVAR coverage for multiple fenestrations from segmental arteries. This case series included nine patients (seven men and two women; mean age: 63.4 years) during January 2013 to May 2019. Outcome analysis included the rates of technical success and procedure-related complications, completeness of FL occlusion, aortic remodeling, and midterm mortality at 2 years. RESULTS: The mean follow-up duration was 37.7 months without in-hospital mortality. One patient was lost to follow-up at the second month, the rest of patients were all alive during the follow-up period. All patients achieved complete FL thrombosis, and six patients exhibited aneurysm diameter shrinkage. CONCLUSION: Tailored exclusion of visceral and iliac distal fenestrations with proximal primary tear coverage can promote FL thrombosis and aortic remodeling in the visceral aortic segment in patients with Crawford type III or IV aortic dissection aneurysm.

Outcome Comparison Between Open and Endovascular Aortic Repair for Retrograde Type A Intramural Hematoma With Intimal Tear in the Descending Thoracic Aorta: A Retrospective Observational Study.

Objective: The optimal treatment modality for retrograde type A intramural hematoma (IMH) remains debatable. This study evaluated and compared surgical outcomes and aortic remodeling after open aortic repair and thoracic endovascular aortic repair (TEVAR) in patients with retrograde type A IMH with a primary intimal tear or ulcer like projection in the descending aorta. Methods: A single center, retrospective observational study was performed on patients with retrograde type A IMH undergoing either open aortic repair and TEVAR. From June 2009 and November 2019, 46 patients with retrograde type A IMH who received either open aortic repair or TEVAR at our institution were reviewed for clinical outcomes, including post-operative mortality/morbidity, re-intervention rate and aortic remodeling. Results: 33 patients underwent open aortic repair and 13 underwent TEVAR. Median age was 68 years (interquartile range [IQR] 15.2 years) and 63 years (IQR 22.5 years) for the open repair group and TEVAR group, respectively. The median duration of follow-up for TEVAR patients was 37.6 months and 40.3 months for open aortic repair. No difference in the 5-year estimated freedom from all-cause mortality (82.1 vs. 87.8%, p = 0.34), re-intervention (82.5 vs. 93.8%, p = 0.08), and aortic-related mortality (88.9 vs. 90.9%, p = 0.88) were observed between the TEVAR and open repair group, respectively; however, the open repair group had a significantly higher 30-day composite morbidity (39.4 vs. 7.7%, p = 0.037). All patients from both treatment groups had complete resolution of the IMH in the ascending aorta. With regard to the descending thoracic aorta, TEVAR group had a significantly greater regression in the diameter of the false lumen or IMH thickness when compared to the open repair group [median 14mm (IQR 10.1) vs. 5mm (IQR 9.5), p < 0.001]. Conclusion: TEVAR and open aortic repair were both effective treatments for retrograde type A IMH, in which no residual ascending aortic IMH was observed during follow-up. TEVAR was also associated with lower post-operative composite morbidities and better descending aortic remodeling. In selected patients with retrograde type A IMH, TEVAR might be a safe, effective alternative treatment modality.

Long-Term Outcomes and Prognosticators of Pediatric Primary Dilated Cardiomyopathy in an Asian Cohort.

Background: Dilated cardiomyopathy (DCM) is the most common childhood cardiomyopathy. The epidemiological profiles and prognosticators of clinical outcomes in Asian populations are not well elucidated. Methods: Data of 104 children aged <18 years with a diagnosis of primary DCM from January 1990 to December 2019 in our institutional database were retrospectively investigated. Relevant demographic, echocardiographic, and clinical variables were recorded for analysis. A P <0.05 was considered statistically significant. Results: The median age at diagnosis was 1.4 years (interquartile range = 0.3-9.1 years), and 52.9% were males. During a median follow-up duration of 4.8 years, 48 patients (46.2%) were placed on the transplantation waitlist, and 52.1% of them eventually received heart transplants. An exceptionally high overall waitlist mortality rate was noted (27.1%), which was even higher (43.5%) if the diagnostic age was <3 years. The 1-, 5-, and 10-year transplant-free were 61.1, 48.0, and 42.8%. Age at diagnosis >3 years and severe mitral regurgitation at initial diagnosis were independent risk factors for death or transplantation (hazard ratios = 2.93 and 3.31, respectively; for both, P <0.001). In total, 11 patients (10.6%) experienced ventricular function recovery after a median follow-up of 2.5 (interquartile range = 1.65-5) years. Younger age at diagnosis was associated a higher probability of ventricular function recovery. Conclusions: Despite donor shortage for heart transplantation and subsequently high waitlist mortality, our data from an Asian cohort indicated that transplant-free long-term survival was comparable with that noted in reports from Western populations. Although younger patients had exceptionally higher waitlist mortality, lower diagnostic age was associated with better long-term survival and higher likelihood of ventricular function recovery.

Effects of Slowness, Frailty, Insufficient Intake, and Delirium in Patients Following Cardiac Surgery: A Cohort Study.

BACKGROUND: Slow gait, frailty, insufficient postoperative caloric intake, and delirium, although seemingly distinct, can appear simultaneously in patients who underwent cardiac surgery. OBJECTIVES: The aim of this study was to evaluate how these 4 factors overlap and how they individually and cumulatively affect cardiac surgery outcomes. METHODS: The effects of slowness (gait speed <0.83 m/s), frailty (≥3/5 Fried criteria), insufficient postoperative intake (<800 kcal/d), and delirium (defined by the Confusion Assessment Method) on hospital length of stay (LOS) and 3-month mortality were analyzed in 308 adult patients. RESULTS: Slowness, frailty, insufficient intake, and delirium affected 27.5%, 29.5%, 31.5%, and 13.3% of participants, respectively; only 42.2% (130/308) were free from these risks. Risk overlap was prevalent, as 26.3% (n = 81) had 2 or more risk factors. The most obvious overlap was in delirium (80% of delirious participants had other risks), suggesting that delirium cannot be managed in isolation. Individually, whereas slowness was associated only with longer LOS, frailty, insufficient intake, and delirium all led to longer LOS and higher mortality. When equally weighting each risk factor to analyze their cumulative effects, LOS increased by 4.4 days (95% confidence interval, 3.0-5.7) and 3-month mortality increased by 2.6-fold (95% confidence interval, 1.4-4.6), with each risk factor added, independent of participants' educational level, body mass index, and risk for cardiac surgery (EuroSCORE II ≥6). CONCLUSIONS: Because a clinical overlap of slowness, frailty, insufficient postoperative intake, and delirium was evident in patients who underwent cardiac surgery, and risk of death and longer hospital stay increased with each factor added, care should be revised to consider these overlapping factors to maximize patient outcomes.

Surviving and Thriving 1 Year After Cardiac Surgery: Frailty and Delirium Matter.

BACKGROUND: We compared 1-year functional outcomes for 4 cardiac surgery patient groups: comparison (without preoperative frailty or postoperative delirium [POD]), frailty only (with preoperative frailty only), POD only (with POD only), and frailty-POD (combined frailty and POD). METHODS: Consecutive cardiac surgery patients (n = 298) at a university hospital were assessed for preoperative frailty using Fried's phenotype, and POD was assessed daily for 10 days after surgery using the Confusion Assessment Method. Functional outcomes (Barthel Index for activities of daily living [ADL]) and all-cause mortality were evaluated 1-year after surgery. RESULTS: Preoperative frailty presented in 85 of participants (28.5%) and POD in 38 (12.8%). Frail participants were at increased risk for POD (odds ratio = 4.9; P < .001). Overall, 1-year mortality was 4.0% (n = 12) and functional change was 0.4 ± 11.0 Barthel points. Controlling for age, cardiac risk, and baseline ADL, frailty-only and comparison participants had comparable 1-year functional outcomes. The POD-only group had greater mortality (adjusted hazard ratio = 23.9; P = .01), whereas the combined frailty-POD group had the greatest ADL decline (ß = -23.7; P = .01) and the highest mortality (adjusted hazard ratio = 30.2; P = .006) compared with the comparison group. CONCLUSIONS: Preoperative frailty alone did not negatively affect cardiac surgery patients' functional outcomes up to 1 year, but coexisting frailty and POD led to substantial loss of independence on 3 to 4 ADLs and a 30.2-fold higher likelihood of dying 1 year after surgery. Because frailty led to a 4.9-fold increase in POD risk, frailty may serve as a presurgical screen to identify patients who would likely benefit from delirium prevention and functional recovery programs to maximize 1-year postsurgical outcomes.

Endovascular Repair for Retrograde Type A Intramural Haematoma with Intimal Tear in the Descending Thoracic Aorta.

OBJECTIVE: The current treatment for acute retrograde type A intramural haematoma (IMH) remains challenging. Aortic remodelling in both the ascending aorta (AA) and descending thoracic aorta (DTA) was evaluated and the 30 day and mid term outcomes were determined in patients who underwent thoracic endovascular aneurysm repair (TEVAR) for retrograde type A IMH with a primary intimal tear or ulcer like projection in the DTA METHODS: This was a retrospective, multicentre observational study. Clinical data, including post-operative mortality and adverse event, aorta related re-intervention, aortic remodelling, and the survival rate of 18 non-consecutive patients with acute retrograde type A IMH undergoing TEVAR between June 2006 and March 2018 were reviewed. RESULTS: The median age at repair was 58.1 years (range 38-86) and 14 (78%) were men. Eight patients (44%) presented with haemopericardium, and 10 (56%) underwent TEVAR within 24 h. The mean IMH thickness and AA diameter were 10.4 ± 3.6 and 45.7 ± 4.6 mm, respectively. Among all patients with acute retrograde type A IMH, 11 patients presented with classical type B aortic dissection and seven with type B IMH. All procedures were technically successful. The median follow up was 28.7 months (range 7-78). No 30 day mortality was observed. Three patients developed post-procedure adverse events. Of these, two patients had neurological events, with one each having cerebrovascular and spinal cord infarction individually, and the third patient required long term haemodialysis with ventilator support. The overall survival rate was 100%. The maximum diameter of the AA and the IMH in the AA significantly decreased after TEVAR. Aortic remodelling was also observed in the DTA along the length of TEVAR coverage. CONCLUSION: In selected patients with acute retrograde type A IMH, TEVAR offered a treatment alternative to open surgical grafting and medical follow up.

The Difficulties and Needs of Organ Transplant Recipients during Postoperative Care at Home: A Systematic Review.

With recent advances in surgery and immunosuppressive drugs, organ transplantation has become a major treatment for irreversible organ failure. However, organ transplant recipients returning home after operation may face ongoing physiological, psychological, and social difficulties. To increase recipients' quality of life, postoperative care at home is critical. Thus, the aim of this systematic literature review was to explore recipients' difficulties and needs during postoperative care at home. Our search conformed to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and returned 23 relevant articles published from 1997-2020 in PubMed, MEDLINE, EBSCO, Cochrane, ProQuest, and CEPS, which were assessed using the Modified Jadad Scale or the 32 Consolidated Criteria for Reporting Qualitative Research (COREQ) appraisal indices and then synthesized through narration. The most common difficulties faced were psychological difficulties, followed by physiological, social, and other difficulties; the most common needs were psychological needs, followed by education and information training, social, and other needs. These results demonstrated that healthcare professionals can do more to provide patients with comprehensive care and promote successful self-management and quality of life at home. They also confirmed that collaboration between transplant teams, caregivers, and patients is necessary to optimize postoperative outcomes. We suggest that customized care may promote postoperative patients' self-management and quality of life at home.

Adaptation Process of Male Kidney Transplant Recipients During the Difficult Postoperative Recovery Stage at Home.

BACKGROUND: Kidney transplantation is the main treatment for irreversible organ failure. It helps patients regain hope, prolongs their lives, and improves their quality of life. Because of cultural barriers, male kidney-transplant recipients in Taiwan may face a difficult adaptation process during postoperative care at home. METHODS: In this qualitative exploratory study, we employed purposive sampling of male kidney-transplant recipients that was obtained from a leading medical center in Taiwan. Semi-structured, face-to-face interviews were used to collect data, which were further content analyzed. RESULTS: All 30 qualified patients were approached and agreed to participate (age range = 29-67 years). Participants' post-kidney transplant time frame ranged from 2 to 22 years. We revealed several difficulties that participants experienced during their postoperative recovery: (1) physical and mental exhaustion and treatment side effects; (2) worry and uncertainty about rejection, graft failure, and the future; (3) fear of losing one's job and putting the family in financial trouble; and (4) impaired self-image and social barriers. Corresponding adaptation processes included (1) experiencing shock during the early post-transplantation stage, (2) re-identification of the transition period of self-value, (3) seeking support and thinking positively, (4) accepting one's new self-image, and (5) regaining autonomy. CONCLUSION: The current results can be used to improve the quality of care at home for male kidney-transplant recipients. Health care providers should assist patients in the adaptation process to reduce discomfort and relieve stress. This study can also serve as a reference for future research.

Difficulties and Coping Strategies of Kidney-transplant Recipients During Their Dark Postoperative Recovery Stage After Returning Home.

INTRODUCTION: Kidney Transplantation (KT) is the best treatment for end-stage renal disease to prolong patients' lives. To improve patients' postoperative survival rate and quality of life, postoperative care at home is vital. We explored the difficulties faced and coping strategies used by KT recipients during their dark postoperative recovery stage at home. METHODS: This qualitative, exploratory study used a purposive sample, which was obtained from a leading medical center in Taiwan. We used a semi-structured interview guide to collect data through in-depth, face-to-face interviews. Data were content analyzed. RESULTS: Fifty individuals were approached and agreed to participate (30 men, 20 women). Participants' post-KT timeframe ranged from 2 to 28 years. Seven difficulties were reported: 1. physical discomfort and treatment side-effects; 2. concern about the impact of transplant failure; 3. uncertainty about the future; 4. unbearable economic pressure; 5. concerns about becoming a family burden; 6. feeling that life lacks a purpose; and 7. feeling isolated. Coping strategies included 1. seeking assistance from health care professionals, 2. thinking positively, 3. changing one's lifestyle, 4. setting goals to divert attention, 5. seeking psychological, and 6. seeking spiritual support. CONCLUSIONS: By elucidating KT recipients' adaptability and coping strategies, we hope to improve their quality of life at home. Health care professionals should be aware of the difficulties faced by patients during their dark postoperative recovery stage and promote effective coping strategies. This study informs future research and has implications concerning the effective coordination of transplant medical teams.

Effects of sarcopenia on functional improvement over the first year after cardiac surgery: a cohort study.

BACKGROUND: Sarcopenia is linked with poor postoperative outcomes. AIMS: To evaluate the effects of sarcopenia on first-year functional changes after cardiac surgery. METHODS: In this prospective cohort study, functional changes (physical activity levels in metabolic equivalent hours/week, 6-minute walking distance in metres, and grip strength in kg) from preoperative baseline to 1, 3, 6 and 12 months postoperatively were compared in adult patients with and without sarcopenia undergoing cardiac surgery at a tertiary medical centre. Presurgical sarcopenia was defined as low muscle mass plus either low strength or poor physical performance (i.e. reduced gait speed). Secondary outcomes (length of hospital stay and 1-year mortality) were compared between sarcopenia and non-sarcopenia groups. RESULTS: Sarcopenia presented in 27.7% ( n=67) of 242 participants. Participants with sarcopenia were significantly older, predominantly women, and had lower body mass index and higher cardiac surgery risk (measured by the EuroSCORE II) than those without sarcopenia. For both groups, physical activity levels, walking distance and grip strength steadily improved over the year following cardiac surgery. Independent of EuroSCORE II, changes in physical activity levels, walking distance and grip strength did not differ significantly between the sarcopenia and non-sarcopenia groups 1, 3, 6 and 12 months after surgery. Nevertheless, the sarcopenia group had a significantly longer length of hospital stay than the non-sarcopenia group (19.4 vs. 15.3 days; ß=2.9, P=0.02) but 1-year mortality (3.4 vs. 3.9% for non-sarcopenia group) was comparable. CONCLUSIONS: Despite a longer length of hospital stay for the sarcopenia group, sarcopenia was not a restriction for cardiac surgery given their comparable functional improvement and mortality 1 year following surgery.

Using an informatics education strategy to resolve the dilemma of teaching transplantation in medical institutions: Multidisciplinary medical team perspectives.

In Taiwan, the current survival rate 1 year after transplantation exceeds 80%. However, the number of organ/tissue donors per year in Taiwan is extremely low, resulting in increased mortality. This is also true in Europe and in the United States. Recently, data from the Taiwan Organ Registry and Sharing Center showed that, although fundraising for organs/tissues slightly increased, the number of donors did not exhibit a corresponding growth trend. Identifying appropriate donors and the provision of good quality transplantation care by medical team members are current challenges. Hence, the application of information technology to in-service education for organ transplantation professionals has been suggested.This was a qualitative study that employed qualitative content analysis with purposive and snowball sampling. The study participants (n = 8, mean age 39.88 ±â€Š3.06 years) included medical staff involved in tissue/organ transplantation from 4 leading medical centers and 3 regional teaching hospitals, and those who participated in the informatics education system.The interviewees from multidisciplinary medical teams showed the status of and dilemma in organ fundraising/donation/transplantation, noting 6 core themes. Regarding relevant education and training, 4 core themes were identified.Current educational courses for organ fundraising/donation/transplantation are inadequate and seem to provide insufficient information to multidisciplinary medical teams. Hence, it is necessary to develop a theoretical construct to create a complete curriculum framework and to establish complete fit-in professional and ethical organ transplantation learning programs based on informatics technology to increase the interdisciplinary exchange of experience.

Long-term outcomes of surgical treatment for intravascular leiomyomatosis.

BACKGROUND: Intravascular leiomyomatosis (IVL) is relatively rare. The optimal surgical method and long-term outcomes are not completely understood. METHODS: Medical records between 2007 and 2017 in our hospital were analyzed to identify IVL cases with surgical intervention. Their medical records, operative details, and follow-up were collected by chart review and telephone communication. RESULTS: Eight patients with IVL were included in the study, accounting for 0.26% of all uterine leiomyoma cases. Primary IVL was confined to pelvic cavity in three patients, extended to the inferior vena cava (IVC) below renal vein in one, reached IVC and right atrium in three, and reached main pulmonary artery in one. One-stage operation was performed for seven patients. Cardiopulmonary bypass was done in four patients, and aortic cross-clamp and temporary circulatory arrest was performed in two patients. None of the four patients with intrapulmonary tumors received concomitant pulmonary tumor resection. There was no operative mortality and four morbidities, including ureter injury (2), bladder injury (1), and femoral vein thrombosis (1). During follow-up, two patients exhibited local recurrence of the tumor in the pelvis, and one patient had rapidly growing intrapulmonary tumor three months post-operatively. Intrapulmonary tumors in the other three patients remained stationary at 6, 84, and 120 months post-operatively. CONCLUSION: One-stage operation to completely remove IVL is feasible and with good long-term outcomes, which is recommended if the patient can tolerate the operation. Concomitant intrapulmonary tumors can be followed up watchfully except when associated with pleural effusion or the pathology indicating trend of increasing malignancy.

Comparisons of aortic remodelling and outcomes after endovascular repair of acute and chronic complicated Type B aortic dissections.

OBJECTIVES: Patients with acute (ACTBAD) or chronic complicated Type B aortic dissection (CCTBAD) undergoing thoracic endovascular aortic repair (TEVAR) remain at high risk for late aorta-related events. Few data exist on the comparison of aortic remodelling and outcomes after TEVAR between both groups. METHODS: Forty-nine patients of TEVAR for CCTBAD (n = 26) and ACTBAD (n = 23) were retrospectively reviewed at our centre. RESULTS: The overall 30-day mortality was 4%. Cumulative freedom from all-cause mortality (ACTBAD: 77.6%, CCTBAD: 68.8%; P = 0.76), aneurysmal-related mortality (ACTBAD: 88.2%, CCTBAD: 95.0%; P = 0.63) and the 3-year reintervention rate (ACTBAD: 92.3%, CCTBAD: 95.6%; P = 0.94) were the same in both groups. Aortic remodelling was significant (P < 0.001) above the coeliac level after TEVAR. Thirty-five (75.5%) patients still experienced false lumen flow in the abdominal aorta below the coeliac artery (ACTBAD: 16, CCTBAD: 19, P = 0.10). No difference was found in aortic remodelling between the ACTBAD and CCTBAD groups, and the length of endograft coverage had no impact on the aortic remodelling. CONCLUSIONS: The early and 3-year follow-up in our study showed that endovascular repair for both ACTBAD and CCTBAD was safe and effective. Aortic remodelling was favourable above the coeliac artery after TEVAR, and no difference was found between ACTBAD and CCTBAD. The length of endograft coverage had no impact on aortic remodelling. The low rate of false lumen thrombosis in the abdominal aorta warranted continuous imaging surveillance.

Morphological transformation of hBMSC from 2D monolayer to 3D microtissue on low-crystallinity SF-PCL patch with promotion of cardiomyogenesis.

The effects of the stiffness of substrates on the cell behaviours of human bone marrow-derived mesenchymal stem cells (hBMSC) have been investigated, but the effects of the secondary structures of proteins in the substrates on the morphological transformation and differentiation of hBMSC have yet been elucidated. To investigate these issues, silk fibroin-poly(ε-caprolactone) SP cardiac patches of poly(ε-caprolactone; P), on which is grafted by silk fibroin (SF) with various ß-sheet contents (or crystallinity) to provide various degrees of stiffness, were produced to examine the in vitro behaviours of hBMSC during proliferation, and cardiomyogenesis on the SP patches. ß-sheet contents of SF from 20% to 44% (SP20 to SP44, respectively) were induced on patches, which were examined by attenuated total reflection Fourier-transform infrared (ATR-FTIR) spectroscopy, and analysed using the Fourier self-deconvolution method. The stiffness of the SP patches, quantified by their Young's moduli and elasticities, increased with the crystallinity of the SF. During 3 days of proliferation, hBMSC migrated and morphologically transformed into 3D microtissues with diameters of approximately 150-200 µm on low-stiffness SP20 and SP30 patches, whereas 2D monolayers were observed on the SP37 and SP44 patches. The 3D microtissues/patch yielded more extensive in vitro cardiomyogenesis of hBMSC than the 2D cell monolayer with significantly higher expressions of all examined cardiac-specific proteins after induction by 5-aza. Notably, in vivo subcutaneously growing 3D microtissues on SP20 patches and a 2D monolayer on SP44 patches were preliminarily demonstrated in a rat model. Morphological transformations of hBMSC from a 2D monolayer to a 3D microtissue by low-stiffness SP cardiac patches, promoting cardiomyogenesis, provide a new opportunity for cardiac tissue engineering.

Subcellular Localization of Survivin Determines Its Function in Cardiomyocytes.

Rationale: Reducing cardiomyocyte death and enhancing their proliferation after myocardial infarction is perhaps the single largest challenge for cardiac tissue regeneration. Survivin (SVV) is the smallest member of the inhibitor of apoptosis (IAP) family but plays two important roles; inhibiting caspase-9 activation in the intrinsic apoptosis pathway, and regulating microtubule dynamics and chromosome segregation during cell division. Genetic depletion of cardiac SVV leads to incomplete cardiomyocyte division and abnormal heart development. However, the function of SVV in adult hearts after myocardial infarction remains unclear. Methods: A homozygous inducible cardiomyocyte-specific SVV knockout transgenic mouse model was established through crossbreeding SVVflox/flox and αMHC-MCM transgenic mice. Adult mice received consecutive intraperitoneal injection of tamoxifen to induce genetic removal of SVV in cardiomyocytes. A SVV overexpressing model was established via local delivery of SVV in wild-type mouse hearts. Results: We found that 30.82% of cardiomyocytes in the peri-infarct region of SVV knockout mice were apoptotic, significantly higher than the 22.18% in control mice. In addition, ejection fraction was 29.00±0.40% in knockout mice compared to 38.04±0.50% in control mice 21 days after myocardial infarction. On the contrary, locally overexpressing SVV in the heart improved cardiac functions. Unexpectedly, we found that altering the subcellular localization of SVV overexpression produced different outcomes. Overexpression of SVV in the cytoplasm decreased cardiomyocyte apoptosis, whereas overexpression of SVV in the nucleus enhanced cardiac regeneration. The ejection fraction of mice overexpressing SVV was 36.58±0.91%, significantly higher than 28.18±1.70% in the GFP control group. Apoptotic cardiomyocytes were only 4.63% in mouse overexpressing cytosolic SVV, compared to 9.31% in the GFP group, and activation of caspase-3 was also reduced. Moreover, mice overexpressing NLS-SVV exhibited a better ejection fraction (36.19±1.02%,) than GFP controls (26.69±0.75%). NLS-SVV enhanced H3P-positive cardiomyocytes in the border zone to 0.28%, compared to only 0.08% in GFP group, through interacting with Aurora B. Conclusions: We demonstrate the importance of SVV subcellular localization in regulating post-MI cardiac repair and regeneration. We hope that this will open new translational approaches through targeted delivery of SVV.

Impact of Fatigue Characteristics on Quality of Life in Patients After Heart Transplantation.

BACKGROUND: Fatigue has been identified as a major symptom in heart transplant (HTx) patients; however, researchers have not examined the role of fatigue characteristics (ie, intensity, interference, and duration) in the quality of life (QOL) of HTx patients. OBJECTIVE: The aim of this study was to explore differences in physical and mental aspects of QOL by patient characteristics, as well as the association between fatigue characteristics and QOL in HTx patients after considering other confounding factors (symptom distress and psychological distress). METHODS: A cross-sectional study was conducted in which patients completed the Transplant Symptom Frequency and Symptom Distress Scale, the Fatigue Symptom Inventory, the Hospital Anxiety and Depression Scale, and the 12-item Short-Form Health Survey. Multiple regressions were used to identify factors significantly related to QOL. RESULTS: A total of 126 patients reported moderate levels of fatigue intensity, mild fatigue interference, and low QOL scores in the physical and mental domains. Patients with better physical and cardiac function and lower symptom distress and fatigue interference had better scores on the physical aspect of QOL (explaining 30.7% of the variance); patients with lower fatigue interference, anxiety, and depression had better scores on the mental aspect of QOL (explaining 50% of the variance). CONCLUSIONS: Fatigue interference had a greater influence on QOL domains than fatigue intensity. The degree to which fatigue interferes with daily life should be assessed, and suitable interventions should be introduced in clinical settings to help patients manage their fatigue and improve their QOL.

The relationship between serum fibrosis markers and restrictive ventricular filling in patients with heart failure with reduced ejection fraction: A technetium-99m radionuclide ventriculography study.

Myocardial fibrosis leads to a restrictive diastolic filling pattern of the left ventricle which is associated with a poor prognosis in patients with heart failure. We investigated the relationship between cardiac fibrosis and restrictive filling pattern of the left ventricle measured by Tc99m left ventriculography in patients with chronic symptomatic heart failure. Serum cardiac extracellular matrix markers including type I and III aminoterminal propeptide of procollagen (PINP and PIIINP), matrix metalloproteinase-2,9 (MMP-2,9), and tissue inhibitor of MMP-1 (TIMP-1) were analyzed. Fifty-one (39 males) patients were enrolled. Their median age was 51.8 years, and median left ventricular ejection fraction was 31.9%. Time to peak filling rate of the left ventricle was significantly correlated with serum levels of the three cardiac extracellular matrix markers (TIMP-1, PIIINP, and MMP-2). The patients with a restrictive diastolic filling pattern of the left ventricle (time to peak filling rate ≤ 154 ms) had significantly higher levels of these extracellular matrix markers. In receiver operating characteristic curve analysis, areas under the curve of PIIINP, TIMP-1, and MMP-2 were 0.758, 0.695, and 0.751 to predict the presence of a restrictive pattern. In C-statistics, all three cardiac extracellular matrix markers significantly increased the area under the curve after adding creatinine. In net reclassification improvement and integrated discrimination improvement models, PIIINP and MMP-2 significantly improved the predictive power of age, creatinine and brain natriuretic peptide. In conclusion, serum extracellular matrix markers are significantly correlated with restrictive diastolic filling pattern of the left ventricle in patients with heart failure.