[Preliminary evaluation on the efficacy of emergency transcatheter aortic valve replacement: a multicenter study]

Objectives: To explore the efficacy and safety of emergency transcatheter aortic valve replacement (TAVR). Methods: Data of patients who underwent emergency TAVR in eight centers, namely Fuwai Hospital, Wuhan Asia Heart Hospital, Xijing Hospital, Union Hospital Affiliated to Tongji Medical College of Huazhong University of Science and Technology, Guangdong Provincial People's Hospital, Zhongshan Hospital Affiliated to Fudan University, the First Affiliated Hospital of Zhengzhou University, the Second Xiangya Hospital of Central South University, between May 2017 and December 2020 were retrospectively analyzed. The use of mechanical circulatory support system (MCS) and the results of laboratory tests (N-terminal B-type natriuretic peptide (NT-proBNP)) and echocardiography (mean aortic valve cross valve pressure difference and left ventricular ejection fraction) before and after operation were collected. The primary endpoint was all-cause death, and the secondary endpoints were stroke, major bleeding, major vascular complications, myocardial infarction, permanent pacemaker implantation, and acute renal injury. Device success was caculated, which refered to absence of procedural mortality and correct positioning of a single prosthetic heart valve into the proper anatomical location and intended performance of the prosthetic heart valve (mean aortic valve gradient<20 mmHg(1 mmHg=0.133 kPa) or peak velocity<3 m/s, with no moderate or severe prosthetic valve regurgitation). Kaplan-Meier survival curve was used to estimate the survival rate of patients during follow-up. Results: This study included 48 patients. The age was (72.5±8.1) years, and 34 patients were males (70.8%). Device success rate was 91.7% (44/48). The mean aortic valve transvalvular pressure was significantly decreased after operation ((12.3±6.4)mmHg vs. (60.2±23.8)mmHg, P<0.000 1). Left ventricular ejection fraction was significantly increased ((41.5±11.7)% vs. (31.0±11.3)%, P<0.000 1). NT-proBNP significantly decreased (3 492.0 (1 638.8, 7 165.5) ng/L vs. 12 418.5 (6 693.8, 35 000.0) ng/L, P<0.000 1). In-hospital all-cause mortality was 8.3% (4/48). During hospitalization, the rate of stroke was 2.1% (1/48), major bleeding was 6.3% (3/48), major vascular complications was 10.4% (5/48), myocardial infarction was 4.2% (2/48), permanent pacemaker implantation was 6.3% (3/48), and the rate of acute renal injury was 12.5% (6/48). MCS was used in 20 patients (41.7%). The median follow-up time was 196 days. During the follow-up, one patient died (due to systemic metastasis of pancreatic cancer), two cases suffered new myocardial infarction and one case received permanent pacemaker implantation. The survival rate of 30 days, 1 year and 2 years after the operation were 91.7% (44/48), 89.6% (43/48), 89.6% (43/48), respectively. Conclusion: Emergency TAVR may be a safe and effective treatment for patients with severe decompensated aortic valve stenosis.

[Efficacy of fenestrated atrial septal defect occulders on pulmonary hypertension dogs]

Objective: To explore the short-term efficacy of fenestrated atrial septal defect (ASD) occulders in the treatment of pulmonary arterial hypertension (PAH). Methods: Thirty-six healthy dogs were divided into the balloon atrial septostomy (BAS)+fenestrated ASD occulders group (n=12), BAS group (n=12) and non-septostomy group (n=12). PAH was induced by intra-atrial injection of dehydrogenized monocrotaline (1.5 mg/kg) in all dogs. Animals in the BAS+fenestrated ASD occulders group underwent atrial septal puncture and fenestrated ASD occulders implantation. Animals in the BAS group underwent balloon atrial septostomy. The non-septostomy group received no surgical intervention. The hemodynamic indexes and blood N-terminal pro-B-type natriuretic peptide (NT-proBNP) of dogs were measured before modeling, 2 months after modeling, 1, 3, and 6 months after surgery, respectively. Echocardiography was performed to observe the patency of the shunt and atrial septostomy of the dogs in the BAS+fenestrated ASD occulders group and BAS group at 1, 3, and 6 months after surgery. Three dogs were sacrificed in each group at 1, 3, and 6 months after surgery, respectively. Atrial septal tissue and fenestrated ASD occulders were removed to observe the patency and endothelialization of the device. Lung tissues were obtained for hematoxylin-eosin (HE) staining to observe the inflammatory cells infiltration and the thickening and narrowing of the pulmonary arterials. Results: Among 36 dogs, 2 dogs died within 24 hours after modeling, and 34 dogs were assigned to BAS+fenestrated ASD occulders group (n=12), BAS group (n=11), and non-septostomy group (n=11). Compared with BAS group, the average right atrial pressure (mRAP) and NT-proBNP of dogs in the BAS+fenestrated ASD occulders group were significantly reduced at 3 months after surgery (P<0.05), and the cardiac output (CO) was significantly increased at 6 months after surgery, arterial oxygen saturation (SaO₂) was also significantly reduced (P<0.05). Compared with non-septostomy group, dogs in the BAS+fenestrated ASD occulders group had significantly lower mRAP and NT-proBNP at 1, 3, and 6 months after surgery (P<0.05), and higher CO and lower SaO₂ at 6 months after surgery (P<0.05). Compared with the non-septostomy group, the dogs in the BAS group had significantly lower mRAP and NT-proBNP at 1 month after surgery (P<0.05), and there was no significant difference on mRAP and NT-proBNP at 3 and 6 months after surgery (P>0.05). Echocardiography showed that there was a minimal right-to-left shunt in the atrial septum in the BAS group at 1 month after the surgery, and the ostomy was closed in all the dogs in the BAS group at 3 months after the surgery. There was still a clear right-to-left shunt in the dogs of BAS+fenestrated ASD occulders group. The shunt was well formed and satisfactory endothelialization was observed at 1, 3 and 6 months after surgery. The results of HE staining showed that the pulmonary arterials were significantly thickened, stenosis and collapse occurred in the non-septostomy group. Pulmonary microvascular stenosis and inflammatory cell infiltration in the pulmonary arterials were observed in the non-septostomy group. Pulmonary arterial histological results were comparable between BAS+fenestrated ASD occulders group and non-septostomy group at 6 months after surgery. Conclusions: The fenestrated ASD occulder has the advantage of maintaining the open fistula hole for a longer time compared with simple balloon dilation. The fenestrated ASD occulder can improve cardiac function, and it is safe and feasible to treat PAH in this animal model.

[Impact of transcatheter aortic valve replacement on renal function in patients with severe aortic stenosis]

Objective: To explore the impact of transcatheter aortic valve replacement (TAVR) on renal function in patients with severe aortic stenosis. Methods: This is a single-center retrospective study. Consecutive patients with severe aortic valve stenosis and received TAVR in Zhongshan Hospital from December 2014 to December 2019 were included. The patients were divided into four groups according to the estimate glomerular filtration rate (eGFR) measured at one day before TAVR, namely eGFR>90 ml·min-1·1.73m-2 group, 6090 ml·min-1·1.73m-2 group, 60 Collapse

Key Words

• Acute kidney recovery
• Aortic valve stenosis
• Renal function
• Transcatheter aortic valve implantation

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Affiliation(s)

L F Yang Department of Cardiology, Shanghai Institute of Cardiovascular Disease, Zhongshan Hospital, Fudan University, Shanghai 200032, China
X C Zhang Department of Cardiology, Shanghai Institute of Cardiovascular Disease, Zhongshan Hospital, Fudan University, Shanghai 200032, China
Y Zhang Department of Cardiology, Shanghai Institute of Cardiovascular Disease, Zhongshan Hospital, Fudan University, Shanghai 200032, China
S S Chen Department of Cardiology, Shanghai Institute of Cardiovascular Disease, Zhongshan Hospital, Fudan University, Shanghai 200032, China
L H Guan Department of Cardiology, Shanghai Institute of Cardiovascular Disease, Zhongshan Hospital, Fudan University, Shanghai 200032, China
W Z Pan Department of Cardiology, Shanghai Institute of Cardiovascular Disease, Zhongshan Hospital, Fudan University, Shanghai 200032, China
D X Zhou Department of Cardiology, Shanghai Institute of Cardiovascular Disease, Zhongshan Hospital, Fudan University, Shanghai 200032, China
J B Ge Department of Cardiology, Shanghai Institute of Cardiovascular Disease, Zhongshan Hospital, Fudan University, Shanghai 200032, China

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Small balloon strategy associated with low pacemaker implantation rate after self-expanding transcatheter valve implantation

BACKGROUND

This study aims to investigate whether small balloon aortic valvuloplasty (BAV) reduces the need for permanent pacemaker implantation (PPMI) after transcatheter aortic valve implantation (TAVI).

METHODS

This was a retrospective analysis using data from our local TAVI database. Small BAV was defined as a small balloon size (=18 mm) pre-dilatation. Normal BAV was defined as a balloon size >18 mm. The primary endpoint was the incidence of new PPMI.

RESULTS

Of 99 consecutive TAVI patients, five patients were excluded due to pre-existing permanent pacemaker. Patients in the small BAV group (n=57) had a significantly lower PPMI rate compared with the normal BAV group (n=37) (3.5% vs. 18.9%, P=0.026). Moderate or severe aortic valve regurgitation post-procedure was similar between the small BAV and normal BAV groups (5.3% vs. 8.1%, P=0.480); likewise, the mean aortic gradient post-procedure did not differ significantly (11.5±5.2 mmHg vs. 12.2±7.3 mmHg, 1 mmHg=0.133 kPa, P=0.580) between the groups. Device success rates were also similar (94.7% vs. 91.8%, P=0.680). In multivariable analysis, small BAV (P=0.027), the ratio of prosthesis diameter to annulus diameter (P=0.048), and mean aortic gradient by echo in the basement (P=0.021) were independent predictors of PPMI.

CONCLUSIONS

The small BAV strategy is associated with a low rate of permanent pacemaker implantation after transcatheter self-expanding valve implantation in this single-center observational study.

[Effects of transcatheter aortic valve replacement in patients with severe aortic valve stenosis]

Objective: To investigate the effects of transcatheter aortic valve replacement (TAVR) in patients with severe aortic valve stenosis. Methods: The clinical data of 130 patients with severe aortic valve stenosis, who underwent TAVR in our hospital with self-expanding valve between January 1,2010 and October 30, 2016, were analyzed retrospectively. The patients were divided into calcific aortic valve stenosis (CAS) group (112 cases) and non-calcific aortic valve stenosis (NCAS) group (18 cases) according to 3D volume-rendering reconstruction under multiple detector computed tomography before TAVR. The baseline clinical features, imageology results, procedural details, and clinical prognosis were compared between the 2 groups. Results: (1) Compared with CAS group, the patients in NCAS group were younger, had higher proportion of rheumatic heart disease, and less proportion of bicuspid aortic valve morphology (P<0.01 or 0.05). Except for minimum value of sinotubular junction (P=0.017), there were no significant differences in multiple detector computed tomography measurements of aortic valve annulus and aortic root structure between the 2 groups (all P>0.05). (2) Compared with CAS group, the proportions of valve release under rapid pacing and oversized valve release were larger than pre-procedural evaluation, and the proportion of post-dilation was lower in NCAS group (P<0.01 or 0.05). (3) Post-procedural transthoracic echocardiography revealed that left ventricular ejection fraction was higher than baseline level in CAS group (P<0.001), while which was similar in NCAS group (P=0.552). Compared with before TAVR, mean pressure gradient and maximum transvalvular velocity were significantly reduced, aortic valve orifice area was significantly increased, and proportion of moderate to severe aortic regurgitation was significantly reduced after the procedure in both groups (all P<0.01). There were no significant differences in left ventricular ejection fraction, mean pressure gradient, maximum transvalvular velocity, aortic valve orifice area, and proportion of moderate to severe aortic regurgitation after TAVR between the 2 groups (all P>0.05). (4) There were no significant differences in successful rate of device placement and cardiovascular related death within 30 days after TAVR between the 2 groups (105/112 vs. 17/18, P=0.909; 3/112 vs. 1/18, P=0.453, respectively). Conclusion: TAVR is safe and effective for patients with severe aortic valve stenosis.

Causes of ozone pollution in summer in Wuhan, Central China

In August 2016, continuous measurements of volatile organic compounds (VOCs) and trace gases were conducted at an urban site in Wuhan. Four high-ozone (O₃) days and twenty-seven non-high-O₃ days were identified according to the China's National Standard Level II (∼100 ppbv). The occurrence of high-O₃ days was accompanied by tropical cyclones. Much higher concentrations of VOCs and carbon monoxide (CO) were observed on the high-O₃ days (p < 0.01). Model simulations revealed that vehicle exhausts were the dominant sources of VOCs, contributing 45.4 ± 5.2% and 37.3 ± 2.9% during high-O₃ and non-high-O₃ days, respectively. Both vehicle exhausts and stationary combustion made significantly larger contributions to O₃ production on high-O₃ days (p < 0.01). Analysis using a chemical transport model found that local photochemical formation accounted for 74.7 ± 5.8% of the daytime O₃, around twice the regional transport (32.2 ± 5.4%), while the nighttime O₃ was mainly attributable to regional transport (59.1 ± 9.9%). The local O₃ formation was generally limited by VOCs in urban Wuhan. To effectively control O₃ pollution, the reduction ratio of VOCs to NO_x concentrations should not be lower than 0.73, and the most efficient O₃ abatement could be achieved by reducing VOCs from vehicle exhausts. This study contributes to the worldwide database of O₃-VOC-NO_x sensitivity research. Its findings will be helpful in formulating and implementing emission control strategies for dealing with O₃ pollution in Wuhan.

[Safety and efficacy of transcatheter aortic valve replacement through transcarotid approach for patients with severe aortic valve stenosis]

Objective: To investigate the safety and efficacy of transcatheter aortic valve replacement(TAVR) through transcarotid approach for patients with severe aortic valve stenosis. Methods: The clinical data of 9 symptomatic severe aortic valve stenosis patients who had high or prohibitive risk for surgery and not suitable for TAVR through femoral artery access,and thus received TAVR through transcarotid approach in our hospital from November 2015 to February 2017 were retrospectively analyzed.The patients were followed up to observe the safety and efficacy of the procedure. Results: There were 4 male and 5 female patients in this cohort, and age was (75.7±8.7) years old. The Society of Thoracic Surgery (STS) scores were (7.9±1.6)%. All patients were treated by left carotid artery approach. One patient experienced valve dislodgement during the procedure and received surgery, and TAVR procedure was successful in the rest 8 patients. Two patients were implanted with permanent pacemaker because of third degree atrioventricular block during the procedure.One patient had cardiac arrest during the procedure and recovered after external chest compression.One patient developed severe carotid stenosis,and there was no clinical manifestation of nerve function deficit after the procedure. All patients were followed up at (30±3) days after the procedure, and there were no adverse events. The modified Rankin scale score was 0. Echocardiography examination showed that the tranvalvular mean gradient was reduced from (63.0±19.2)mmHg(1 mmHg=0.133 kPa) on baseline to (18.1±4.9)mmHg(P<0.001), 4 cases had mild paravalvular leakage, and there was no moderate or severe paravalvular leakage.The NYHA classes was significantly improved at 30 days when compared with before the procedure(2 cases class Ⅱ, 4 cases class Ⅲ,3 cases class Ⅳ before the procedure,and 5 cases classⅠ, 4 cases class Ⅱ after the procedure, P=0.006) , and left ventricular ejection fraction increased from (55.9±13.1)% to (60.4±10.0)% (P=0.030). Conclusion: Our initial experience indicates that transcarotid TAVR is safe and effective for patients with severe aortic valve stenosis.

[Analysis of pulmonary valve function in patients with tetralogy of Fallot after radical surgery]

Objective: To analyze the pulmonary valve function in patients with tetralogy of Fallot after radical surgery. Methods: Clinical data of 263 patients (119 male, mean age (33.2±11.5) years old) with tetralogy of Fallot underwent radical surgery in our hospital from January 2010 to June 2016 were retrospectively analyzed. According to age, patients were divided into 14-17 years old group (14 cases), 18-29 years old group (100 cases), 30-39 years old group (61 cases) and above 40 years old group (87 cases). The patients were divided into pulmonary regurgitation group (87 cases) and control group (176 cases) according to weather they have moderate or severe pulmonary regurgitation. Echocardiographic data were compared among groups. Results: A total of 83 patients received re-operation. The median age of the primary radical operation was 9 (5, 13) years, and the median time from the primary radical operation to echocardiographic follow-up was 5 (1, 13) years. Among the 263 enrolled patients, prevalence of pulmonary regurgitation was 36.1% (95/263), and pulmonary stenosis was evidenced in 28 patients (10.6%). The ratio of moderate to severe tricuspid regurgitation was 14.3% (2/14), 27.0% (27/100), 32.8% (20/61) and 37.9% (33/87) in 14-17 years old group, 18-29 years old group, 30-39 years old group and above 40 years old group, respectively (P=0.029), while prevalence of moderate and severe pulmonary regurgitation, moderate and severe pulmonary valve stenosis, pulmonary valve transvalvular pressure >40 mmHg (1 mmHg=0.133 kPa), right atrial and right ventricular enlargement ratio were similar among groups (all P>0.05). The ratio of moderate and severe tricuspid regurgitation and right ventricular enlargement in the pulmonary regurgitation group was significantly higher than in the control group (40.2% (35/87) vs. 27.3% (48/176) and 96.6% (84/87) vs. 87.5% (154/176), all P<0.05), while left ventricular ejection fraction, right atrial enlargement, and right ventricular wall thickness were similar between the two groups (all P>0.05). Conclusion: Pulmonary regurgitation is a common clinical feature among survivors of tetralogy of Fallot patients after radical surgery, and moderate to severe pulmonary regurgitation increases the risk of tricuspid regurgitation and enlargement of the right ventricle.

Plasma N-terminal pro-brain natriuretic peptide levels are positively correlated with pulmonary arterial pressure in atrial septal defect patients

N-terminal pro-brain natriuretic peptide (NT-proBNP), a pro-hormone secreted by the myocardium in response to various stimuli, was found to be correlated with several hemodynamic parameters in pulmonary hypertension associated with systemic sclerosis. We investigated plasma NT-proBNP levels and the relationships between NT-proBNP and several hemodynamic parameters in atrial septal defect (ASD) patients with or without pulmonary arterial hypertension (PAH). We found that plasma NT-proBNP level was significantly higher in PAH group compared with the control group (5495.4±388.4 pg/ml vs 4005.1±260.5 pg/ml, P<0.05). In a multiple regression model analysis, only mean pulmonary arterial pressure was an independent predictor of NT-proBNP (standardized coefficient=0.663, P=0.002). In the PAH group, only right atrial systolic pressure was found to be positively correlated with NT-proBNP, whereas other parameters were not found to be correlated with NT-proBNP. Our data suggests that NT-proBNP might also be a predictor of the severity of pulmonary hypertension in the ASD patients.