Accurate and Rapid Diagnosis of Complex Mitral Valve Aneurysm with Neoplasm via Real-time 3D Transesophageal Echocardiography.

Mitral valve leaflet aneurysm (MVA) is a rare and potentially devastating complication of infective endocarditis. Here, we report the case of a 49-year-old man with mitral endocarditis who had an anterior MVA without aortic morphologic change and only mild regurgitation. By real-time 3D transesophageal echocardiography (TOE), we found two perforations and a hard mass in the aneurysm accompanied with severe regurgitation. The patient underwent valve replacement surgery combined with anti-infection treatment and was successfully discharged. In addition to the case report and literature review related to MVA, we also summarize the application value of RT-3D TOE in these cases.

Thyroid dose-volume thresholds for the risk of radiation-related hypothyroidism in nasopharyngeal carcinoma treated with intensity-modulated radiotherapy-A single-institution study.

BACKGROUND: To identify thyroid dose-volume thresholds for radiotherapy (RT)-related hypothyroidism (HT) in patients with nasopharyngeal carcinoma (NPC) treated with intensity-modulated RT (IMRT). In this way, we desired to guide the design of treatment plans and, finally, lower HT prevalence. METHODS: In total, 345 NPC patients treated with IMRT were evaluated retrospectively during a median follow-up of 45.2 (range, 11.3-64.9) months. Serum-based assessments of thyroid function before and after IMRT were monitored periodically. Thyroid dose-volume parameters were analyzed for their association with HT risk. RESULTS: In total, 44.1% of patients (152/345) developed primary HT. Analyses of thyroid dose-volume parameters identified a stringent dose-volume histogram (DVH) threshold defined by V25Gy (the percentage thyroid volume that receives >25 Gy, not the absolute volume) ≤60%, V35Gy  ≤ 55%, and V45Gy  ≤ 45%. Patients whose thyroid DVHs satisfied these constraints had a lower prevalence of 2-year HT compared with the overall prevalence (13.2% vs 25.8%, P < .001). Another DVH was defined by V25Gy  > 95%, V35Gy  > 90%, and V45Gy  > 75%, and patients whose thyroid DVHs satisfied with these constraints had a higher prevalence of 2-year HT than the overall incidence (36.0% vs 25.8%, P < .001). CONCLUSION: We recommend V25Gy  ≤ 60%, V35Gy  ≤ 55%, and V45Gy  ≤ 45% as the "stringent" DVH line, and V25Gy  > 95%, V35Gy  > 90%, and V45Gy  > 75% as the "inhibition" DVH line, under the precondition of not compromising the target coverage. These findings could help in the design of individual treatment plans and, eventually, to lowering of HT prevalence.

Efficacy and safety of clopidogrel only vs. clopidogrel added proton pump inhibitors in the treatment of patients with coronary heart disease after percutaneous coronary intervention: A systematic review and meta-analysis.

BACKGROUND: Controversy still exists that whether clopidogrel should add proton pump inhibitors (PPIs) in patients with coronary heart disease after percutaneous coronary intervention (PCI). The aim of this study was to evaluate the efficacy and safety of clopidogrel added proton pump inhibitors (PPIs) vs. clopidogrel for the treatment of patients with coronary heart disease after percutaneous coronary intervention (PCI). METHODS AND RESULTS: We systematically searched PubMed, EMBASE, Web of Science, the Chinese Biomedical Medical Literature database, and the Cochrane Library for all clinical trials that were published on this topic through October 2018. We specifically selected the clinical trials that evaluated the efficacy and safety of clopidogrel added proton pump inhibitors vs. clopidogrel in the treatment of patients with coronary heart disease after PCI. RevMan 5.0 software was used for quantitative data analyses.15 randomized controlled trials including 50,366 patients were included. The meta-analysis results showed that compared with the clopidogrel added PPI group, the non-PPI group had significantly less risk of MACE[RR = 0.82,95%CI:0.77-0.88], myocardial infarction recurrence[RR = 0.72,95%CI:0.57-0.90], stent thrombosis[RR = 0.71,95%CI:0.56-0.92], Target vessel revascularization (TVR)[RR = 0.77,95%CI:0.63-0.93] and stroke [RR = 0.72,95%CI:0.67-0.76]. The risks of all cause death [RR = 1.14,95%CI:0.85-1.51], cardiovascular death [RR = 1.14, 95% CI: 0.85-1.52], bleedings events [RR = 1.60,95%CI:0.53-4.81] were similar in the two groups. CONCLUSIONS: The patients in the non-PPI group were observed to be associated with less risk of MACE, myocardial infarction recurrence, stent thrombosis, target vessel revascularization (TVR) and stroke. And the two groups had similar all cause death, cardiovascular death, bleedings events.

Correlation between the expression of Drp1 in vascular endothelial cells and inflammatory factors in hypertension rats.

The objective of this study was to investigate the expression level of dynamin-related protein 1 (Drp1) in vascular endothelium of hypertension rats and its correlation with expression of inflammatory factors. Twenty spontaneous hypertension rats (SHR) were randomly divided into SHR group (n=10) and inhibition group (MD group, n=10), and the Sprague Dawley rats were enrolled as the control group (C group, n=10). For rats in the MD group, Mdivi-1, a mitochondrial division inhibitor, was given in dosage of 25 mg/kg. After 4 weeks of administration, blood pressure was measured via tail-artery blood pressure measurement. The blood samples collected from the abdominal aorta of rats were used to assay the C-reaction protein (CRP) concentration in serum through radioimmunoassay. Hematoxylin and eosin (H&E) staining was performed for sections of thoracic aorta for morphological observation and measurement of medial thickness. Enzyme-linked immunosorbant assay (ELISA), semi-quantitative real-time polymerase chain reaction (RT-PCR) and western blotting was carried out for detecting the expression levels of interleukin-6 (IL-6) and tumor necrosis factor-α (TNF-α). Drp1 and monocyte chemotactic protein 1 (MCP-1). After 4 weeks of drug administration, the blood pressure in the MD group was significantly higher (P<0.01). The medial thickness of the thoracic aorta in the MD group was significantly decreased in comparison with the SHR group (P<0.01). The results of ELISA showed that compared with the SHR group, the expression levels of IL-6 and TNF-α in the MD group were remarkably decreased (P<0.01). Semi-quantitative RT-PCR results indicated that the mRNA expression levels of Drp1 and MCP-1 in the MD group were significantly lower than those in the SHR group (P<0.05). In the SHR rats, after administration of Mdivi-1, the expression of Drp1 is decreased, which contributes to the alleviation in inflammatory reactions and protects the vessels in SHR rats.

Improved transcatheter aortic valve implantation for aortic regurgitation using a snare loop-assisted device: the first preclinical experience.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) is an effective percutaneous treatment for high-risk patients with severe symptomatic aortic stenosis. However, TAVI is rendered less effective in patients with noncalcified aortic valve disease because noncalcified aortic valves lack an anchor site for the implanted stent, causing the stent to relocate to an unexpected position. In this study, we developed an improved TAVI with a snare loop-assisted device, and evaluated the feasibility and safety of this strategy in noncalcified aortic valve disease. MATERIALS AND METHODS: The balloon-expandable valve stent made of cobalt-chromium alloy was cut into a cylindrically shaped mesh configuration. The prosthetic valve was made of bovine pericardium. Ten healthy sheep (six males and four females with an average weight of 27·8 ± 1·18 kg) were selected to undergo transcatheter implantation of valved stents using the snare loop-assisted device. Aortic angiography and colour Doppler echocardiography were applied to assess the function of artificial valves immediately and 3 months after the operation. RESULTS: The snare loop-assisted TAVI was successfully implanted in all 10 sheep. The aortogram showed that the valve stent was fixed in the expected position. Among these 10 sheep, nine sheep survived for more than 3 months normally and one sheep died of infective endocarditis 1 week after the operation. Ultrasound and aortogram in the 3 months after operation showed proper positions of the prosthetic valves without stenosis and other apparent complications, and normal coronary artery openings. CONCLUSIONS: The snare loop-assisted TAVI approach can reduce stent shifting during valve stent implantation and improve the success rate of the TAVI in those with noncalcified aortic valves.

Transcatheter closure of medium and large congenital coronary artery fistula using wire-maintaining technique.

BACKGROUND: For medium and large coronary artery fistula (CAF), the initially selected device sometimes has to be exchanged by reconstruction of track wire loop due to the complexity of CAF. OBJECTIVES: We sought to evaluate the feasibility and safety of transcatheter closure of medium and large CAF by using the wire-maintaining technique (WMT). METHODS: A total of 18 patients aged 15-56 years with congenital CAF underwent percutaneous transcatheter closure by WMT between April 2006 and October 2012. The immediate and long-term outcomes were evaluated. RESULTS: Of the 18 patients (11 females), 16 (88%) underwent successful transcatheter closure of fistula using WMT. The CAFs originated from the right coronary artery (67%), the left circumflex coronary artery (28%), and the left anterior descending coronary artery (5%). The drainage sites were the right ventricle (56%), right atrium (22%), left ventricle (11%), and coronary sinus (11%). The mean diameter of fistulas was 9.5±1.71mm and mean size of the devices was 13.6±3.03mm. An angiogram following device deployment showed complete occlusion in 11 patients, mild residual shunt in 2 patients, and trivial residual shunt in 3 patients. One patient had transient ST-T wave changes, and one patient had hemolysis after the procedure. Follow-up ranged from 1 month to 54 months (median 39 months). Echocardiogram showed trivial residual shunt in 3 patients at 6-month follow-up and in 1 patient at 12-month follow-up. Coronary artery thrombosis was observed in 1 patient by multislice computed tomography at 12-month follow-up. CONCLUSION: For those patients with medium and large complex fistula, transcatheter closure of CAF can be performed by using the wire-maintaining technique.

Balloon-expanding stent and delivery system for transcatheter aortic valve implantation: An animal study.

OBJECTIVE: To evaluate the feasibility and satefy of transcatheter aortic valve implantation in animals by using a new balloon-expanding valved stent. METHODS: The balloon-expandable stent is made from cobalt-based alloy material and designed with a tubular, slotted structure. Fresh bovine pericardium was treated, sutured and fixed on the balloon-expandable stent. Ten healthy sheep (five males and five females), weighing an average of (25.16 ± 1.83) kg, were selected to undergo transcatheter implantation of the valve stents. The function of the valve stent was evaluated by angiography, echocardiography, and histology six months after the procedure. RESULTS: Of the ten experimental sheep, two sheep died during the operation because the higher position of the artificial valve affected the opening of the coronary artery. We successfully implanted the aortic valve stent in other eight sheep; however, one sheep died of heart failure two weeks after the operation due to the lower position of the valve stent. The valve stents were implanted in the desired position in seven sheep. Ascending aortic angiographic and autoptic findings immediately after the operation confirmed the satisfactory location and function of the valved stent. Echocardiography, angiography, and histology at six postoperative months confirmed the satisfactory location and function of the valve stent. CONCLUSION: We successfully implanted our new valve stent as a replacement of native aortic valve via the transcatheter route with satisfactory outcome.

[Experimental study of transcatheter aortic valve implantation assisted with snare to fix the delivery system].

OBJECTIVE: To evaluate the feasibility and effectiveness of transcatheter aortic valve implantation assisted with snare to fix the delivery system. METHODS: This study was made in 5 healthy goats. After the abdomen was opened and the abdominal aorta was exposed, a stiff guide wire was advanced into the apex of the left ventricle through abdominal arterial puncture points. The delivery catheter equipped with valved stent was inserted into the descending aorta under fluoroscopy along the stiff guide wire. A minimal thoracic surgery approach was used to access the apex of the heart. A J-type guidewire and 5 F multifunction catheter were placed transapically and across the aortic valve down to the descending aorta. The snare was introduced through the 5 F catheter into the ascending aorta and was controlled to seize the head of stent delivery catheter. Then the delivery catheter was advanced into the left ventricle. The valved stent was positioned in the desired position under aortography and then the balloon was dilated and the valved stent was deployed into the aortic annulus assisted with snare to fix the catheter to prevent stent dispositions. Aortic angiography and echocardiography were performed to evaluate of valve performance post procedure. RESULTS: The interventional procedure was completed successfully in all 5 goats. The mean aortic annulus diameter was (23.8 ± 2.6) mm, two valved stent of 23 mm diameter and three valved stent of 26 mm in diameter were implanted. The operation duration and X-ray exposure time were (112.3 ± 19.5) min and (16.8 ± 5.2) min, respectively. Immediate observation after procedure showed that the valved stents were in the desired position after implantation by angiography and echocardiography. No moderate to severe aortic regurgitation was observed. All goats were alive at 1 month post procedure. CONCLUSIONS: The procedure of transcatheter implantation of a balloon-expandable valved stent into the aortic valve position of goats assisted with snare to fix the delivery catheter is feasible and effective. This procedure might be suitable also for patients with noncalcified aortic stenosis.

[An experiment study of transcatheter transapical aortic valve implantation with a new domestic balloon-expandable bioprosthetic aortic valve in goats].

OBJECTIVE: To evaluate the feasibility and effectiveness of transcatheter transapical implantation of a new domestic balloon-expandable bioprosthetic aortic valve in goats. METHODS: We developed a new tube-like balloon-expandable bioprosthetic aortic valve which was made from cobalt-chromium alloy and bovine pericardium. Briefly, fresh bovine pericardium was trimmed into artificial leaflets and sutured into the cobalt-chromium alloy stent by hand post cell extracting and anti-calcification treatments. A left anterolateral mini-thoracotomy was performed in the 5(th) intercostal space of 5 goats. After opening the pericardium, the apex of the left ventricle was punctured, a stiff guidewire was positioned across the aortic arch and anchored in the descending aorta. The delivery catheter (22 F) was then introduced through the stiff guidewire into the aorta arch under fluoroscopic guidance. After correct valve position was confirmed by digital subtraction angiography, the valved stent was implanted after rapid inflation of the balloon. The immediate results of implanted valved stents were evaluated with angiography and echocardiography. RESULTS: Four devices were successfully implanted into aortic valve position of goats and one goat died of severe aortic valve regurgitation because the valved stent was implanted below the normal position.Immediate observation after procedure in 4 goats by angiography and echocardiography showed that the valved stents were in the desired position after implantation. Mild paravalvular leakage were found in 3 out of the 4 survived goats and there were no moderate to severe aortic regurgitation in survived goats. CONCLUSION: The procedure of transcatheter transapic aortic valve implantation with our new-type domestic balloon-expandable valved stent and delivery system is feasible and effective.

[The effects of different occluder selection on cardiac remodeling post transcatheter closure in patients with secundum atrial septal defect].

OBJECTIVE: To evaluate the effects on cardiac remodeling post transcatheter closure by Amplatzer septal occluder selected by oval circumference formula in patients with atrial septal defect (ASD). METHODS: A total of 146 patients with ASD (68 males,mean 33.5 years) treated by transcatheter closure with the Amplatzer occluder were enrolled in this study. The diameter of defects was corrected with the oval circumference formula (group A, 73 cases) or by echocardiography (group B, 73 cases). Cardiac remodeling was assessed by transthoracic echocardiography (TTE) before the procedure, 3 days, 3 months and 6 months after ASD closure. RESULTS: The mean ASD diameter was similar between the two groups [(20.16 +/- 4.98) mm vs. (21.36 +/- 5.69) mm, P > 0.05] and the mean diameter of the selected occluder of group A was significantly smaller than that in group B [(21.95 +/- 6.78) mm vs. (25.85 +/- 6.75) mm, P < 0.05]. Procedural success rate was identical between the two groups (97.3%) and the defects were completely occluded and there was no residual shunt during the 6 months follow up period, there were also no complications during and after the procedure. The lateral diameter of right atrial (RALD), the diastolic diameter of right ventricle (RVDD), RALD/LALD, RVDD/LVDD and pulmonary diameter (PD) were significantly decreased while the lateral diameter of left atrial (LALD) and left ventricle (LVDD) were significantly increased post ASD closure in both groups. At 6 months follow up, RALD decreased by (18.63 +/- 10.59)% in group A versus (10.14 +/- 6.59)% in group B, LALD increased by (13.42 +/- 8.38)% in group A versus (9.28 +/- 4.95)% in group B and RALD/LALD ratio decreased by (26.35 +/- 11.24)% in group A versus (13.98 +/- 8.96)% in groups B (all P < 0.05). CONCLUSION: ASD occluder selection based on the oval circumferen ce formula is superior to that made by echocardiography in terms of more favorable cardiac remodeling post ASD closure.

[Clinical observation on warming needle moxibustion plus exercise for treatment of temporomandibular joint dysfunction syndrome].

OBJECTIVE: To search for a better therapy for temporomandibular joint dysfunction syndrome. METHODS: Two hundred and ten cases of temporomandibular joint dysfunction syndrome were randomly divided into a treatment group, a control group I and a control group II, 70 cases in each group. The treatment group were treated with warming needle moxibustion plus exercise, with Hegu (LI 4), Xiaguan (ST 7), Yifeng (TE 17) and so on selected, in combination with opening and closing the mouth; the control group I were treated with simple filiform needle needling, and the control group II with local blocking therapy. The therapeutic effects of the 3 groups were compared. RESULTS: The total effective rate was 94.3% in the treatment group, 87.1% in the control group I and 85.7% in the control group II with a significant difference among the 3 groups, the treatment group being better than the two control groups (P < 0.05). CONCLUSION: Warming needle moxibustion plus exercise has a good therapeutic effect on temporomandibular joint dysfunction syndrome.