Curva de Aprendizagem da Mortalidade Hospitalar da Substituição da Válvula Aórtica Transcateter: Insights do Registro Nacional Brasileiro / Learning Curve for In-Hospital Mortality of Transcatheter Aortic Valve Replacement: Insights from the Brazilian National Registry

Resumo Fundamento Dados robustos sobre a curva de aprendizagem (LC) da substituição da válvula aórtica transcateter (TAVR) são escassos nos países em desenvolvimento. Objetivo Avaliar a LC da TAVR no Brasil ao longo do tempo. Métodos Analisamos dados do registro brasileiro de TAVR de 2008 a 2023. Pacientes de cada centro foram numerados cronologicamente em número sequencial de caso (NSC). A LC foi realizada usando um spline cúbico restrito ajustado para o EuroSCORE-II e o uso de próteses de nova geração. Ainda, os desfechos hospitalares foram comparados entre grupos definidos de acordo com o nível de experiência, com base no NSC: 1º ao 40º caso (experiência inicial), 41º ao 80º caso (experiência básica), 81º ao 120º caso (experiência intermediária) e 121º caso em diante (experiência alta). Análises adicionais foram conduzidas de acordo com o número de casos tratados antes de 2014 (>40 e ≤40 procedimentos). O nível de significância adotado foi p <0,05. Resultados Foram incluídos 3194 pacientes de 25 centros. A idade média foi 80,7±8,1 anos e o EuroSCORE II médio foi 7±7,1. A análise da LC demonstrou uma queda na mortalidade hospitalar ajustada após o tratamento de 40 pacientes. Um patamar de nivelamento na curva foi observado após o caso 118. A mortalidade hospitalar entre os grupos foi 8,6%, 7,7%, 5,9%, e 3,7% para experiência inicial, básica, intermediária e alta, respectivamente (p<0,001). A experiência alta foi preditora independente de mortalidade mais baixa (OR 0,57, p=0,013 vs. experiência inicial). Centros com baixo volume de casos antes de 2014 não mostraram uma redução significativa na probabilidade de morte com o ganho de experiência, enquanto centros com alto volume de casos antes de 2014 apresentaram uma melhora contínua após o caso de número 10. Conclusão Observou-se um fenômeno de LC para a mortalidade hospitalar do TAVR no Brasil. Esse efeito foi mais pronunciado em centros que trataram seus 40 primeiros casos antes de 2014 que naqueles que o fizeram após 2014.

Abstract Background Robust data on the learning curve (LC) of transcatheter aortic valve replacement (TAVR) are lacking in developing countries. Objective To assess TAVR's LC in Brazil over time. Methods We analyzed data from the Brazilian TAVR registry from 2008 to 2023. Patients from each center were numbered chronologically in case sequence numbers (CSNs). LC was performed using restricted cubic splines adjusted for EuroSCORE-II and the use of new-generation prostheses. Also, in-hospital outcomes were compared between groups defined according to the level of experience based on the CSN: 1st to 40th (initial-experience), 41st to 80th (early-experience), 81st to 120th (intermediate-experience), and over 121st (high-experience). Additional analysis was performed grouping hospitals according to the number of cases treated before 2014 (>40 and ≤40 procedures). The level of significance adopted was <0.05. Results A total of 3,194 patients from 25 centers were included. Mean age and EuroSCORE II were 80.7±8.1 years and 7±7.1, respectively. LC analysis demonstrated a drop in adjusted in-hospital mortality after treating 40 patients. A leveling off of the curve was observed after case #118. In-hospital mortality across the groups was 8.6%, 7.7%, 5.9%, and 3.7% for initial-, early-, intermediate-, and high-experience, respectively (p<0.001). High experience independently predicted lower mortality (OR 0.57, p=0.013 vs. initial experience). Low-volume centers before 2014 showed no significant decrease in the likelihood of death with gained experience, whereas high-volume centers had a continuous improvement after case #10. Conclusion A TAVR LC phenomenon was observed for in-hospital mortality in Brazil. This effect was more pronounced in centers that treated their first 40 cases before 2014 than those that reached this milestone after 2014.

Comparison of Vertebral Artery Ultrasound, Magnetic Resonance Angiography and Digital Subtraction Angiography in the Diagnosis of Vertebral Artery Stenosis in Patients with Posterior Circulation Ischemia

SUMMARY: The aim of this study was to compare the clinical value of vertebral artery ultrasound (VAU), Magnetic Resonance Angiography (MRA) and Digital Subtraction Angiography (DSA) on vertebral artery stenosis in patients with posterior circulation ischemia. Seventy-three patients with posterior circulation ischemia underwent vertebral artery ultrasound and magnetic resonance angiography as well as digital subtraction angiography, and the diagnosis of vertebral artery stenosis (VAS) and the degree of stenosis (normal, mild stenosis, moderate stenosis, severe stenosis, and occlusion) were recorded and compared between digital subtraction angiogram and vertebral artery ultrasound and magnetic resonance angiography. The vertebral artery stenosis rates on digital subtraction angiography and vertebral artery ultrasound were 87.30 % (55/63) and 49.20 % (31/63), respectively, and the difference was statistically significant. The rates of vertebral artery stenosis on digital subtraction angiography and, magnetic resonance angiography was 90.38 % (47/52) and 88.46 % (46/ 52), respectively, and the differences was not statistically significant. The sensitivity, accuracy, negative predictive value, and positive predictive value of vertebral artery ultrasound in diagnosing vertebral artery stenosis were 51.35 %, 54.76 %, 18.18 %, and 95.00 %, respectively, lower than those of magnetic resonance angiography, which were 91.89 %, 90.48 %, 57.14 %, and 97.14 %, respectively. Of the noninvasive imaging techniques, vertebral artery ultrasound does not accurately characterize vertebral artery stenosis and its degree of stenosis. Magnetic resonance angiography effectively screens for vertebral artery stenosis and its degree of stenosis, and can be used as a reliable tool for vertebral artery stenosis in posterior circulation cerebral infarction, and can be used in conjunction with digital subtraction angiogram in order to improve diagnostic convenience and accuracy.

El objetivo de este estudio fue comparar el valor clínico de la ecografía de la arteria vertebral (VAU), la angiografía por resonancia magnética (ARM) y la angiografía por sustracción digital (DSA) en la estenosis de la arteria vertebral en pacientes con isquemia de la circulación posterior. A 73 pacientes con isquemia de la circulación posterior se les realizó una ecografía de la arteria vertebral y una angiografía por resonancia magnética, así como una angiografía por sustracción digital, y se les diagnosticó estenosis de la arteria vertebral (EVA) y el grado de estenosis (normal, estenosis leve, estenosis moderada, estenosis grave, y oclusión) se registraron y compararon la angiografía por sustracción digital y la ecografía de la arteria vertebral y la angiografía por resonancia magnética. Las tasas de estenosis de la arteria vertebral en la angiografía por sustracción digital y la ecografía de la arteria vertebral fueron del 87,30 % (55/63) y del 49,20 % (31/63), respectivamente, y la diferencia fue estadísticamente significativa. Las tasas de estenosis de la arteria vertebral en la angiografía por sustracción digital y la angiografía por resonancia magnética fueron del 90,38 % (47/52) y del 88,46 % (46/52), respectivamente, y las diferencias no fueron estadísticamente significativas. La sensibilidad, precisión, valor predictivo negativo y valor predictivo positivo de la ecografía de la arteria vertebral en el diagnóstico de estenosis de la arteria vertebral fueron 51,35 %, 54,76 %, 18,18 % y 95,00 %, respectivamente, inferiores a los de la angiografía por resonancia magnética, que fueron 91,89 %, 90,48 %, 57,14 % y 97,14 %, respectivamente. De las técnicas de imagen no invasivas, la ecografía de la arteria vertebral no caracteriza con precisión la estenosis de la arteria vertebral y su grado de estenosis. La angiografía por resonancia magnética detecta eficazmente la estenosis de la arteria vertebral y su grado de estenosis, y puede usarse como una herramienta confiable para la estenosis de la arteria vertebral en el infarto cerebral de circulación posterior, y puede ser utilizada junto con la angiografía por sustracción digital para mejorar el diagnóstico y la exactitud.

Endarterectomía carotídea, resultados a corto plazo

Objetivo: Analizar los factores de riesgo y resultados de la endarterectomía carotídea (EC) en el hospital Metropolitano de la Florida Dra. Eloísa Díaz Insunza. Materiales y métodos: Se trata de un estudio observacional, retrospectivo y descriptivo, donde se analizan 89 endarterectomías carotídea, en un período de 8 años (enero del 2015 a enero de 2023) realizadas en 85 pacientes, los pacientes fueron divididos en 2 grupos, sintomáticos y asintomáticos, con respecto a las complicaciones fueron clasificadas en mayores y menores. Resultados: Se realizaron 89 endarterectomías carotídeas desde enero del 2015 hasta enero del 2023. El grupo sintomático corresponde a 78 (87,64%) pacientes, el grupo asintomático 11 (12,35%). 62 en hombres (69,66%) y 27 en mujeres (30,33%). Hubo muerte en 1 (1,12%) solo paciente, perteneciendo éste al grupo sintomático. Accidentes vasculares perioperatorios en 3 (3,37%) pacientes, todos con secuelas neurológicas presentes a 30 días post-operatorios (uno de estos fallecido en post-operatorio inmediato). Hematomas en 5 (5,61%) casos, 4 (3,56%) que requirieron intervención quirúrgica para drenaje del mismo. Lesión neurológica periférica en 1 (1,12%) solo paciente que corresponde a lesión del laríngeo recurrente. 1 (1,12%) caso de infección superficial de herida operatoria. 1 (1,12%) caso de síndrome de reperfusión cerebral Discusión: Todas las grandes series y guías internacionales demuestran el amplio beneficio de la endarterectomía carotídea en la prevención de eventos neurológicos. Conclusión: La endarterectomía carotídea sigue siendo el tratamiento de elección en la estenosis carotídea sintomática, realizada en centros con experiencia presenta resultados excelentes en cuanto a la prevención de nuevos eventos neurológicos.

Objective: To analyze the risk factors and short-term results of the carotid endarterectomy in our hospital. Materials and method: The present is an observational, retrospective and descriptive study, where 89 carotid endarterectomies are analyzed in a period of 8 years (January 2015 to January 2023) performed in 85 patients, the patients were divided in to two groups, symptomatic and asymptomatics, as for the complications there were divided in minor and mayor. Results: 89 carotid endarterectomies where perform between January 2015 to January 2023. In the symptomatic group are 78 (87.64%) patients, in the asymptomatic group there are 11 patients (12.35%). 62 where male (69.66%) and 27 where women (30.33%). Only 1 (1.12%) patient died, this one from the symptomatic group. Perioperatory stroke in 3 (3.37%) patients, all of them with neurologic secuela at 30 days of post operatory. 5 (5.61%) cases of post operatory hematomas 4 of them requiring reintervention. There was 1 (1.12%) patient with neurologic affection. 1 (1.12%) case of superficial wound infection. Conclusion: The carotid endarterectomy remains as the gold standard to prevent strokes in symptomatic patients. Performed in high volume centers it has excellent results as for the prevention of new strokes.

Manejo del tracto de salida del ventrículo derecho con implante percutáneo de válvula Melody en pacientes pediátricos: experiencia en un centro de alta complejidad en Colombia / Management of right ventricular outflow tract with percutaneous Melody valve implantation in pediatric patients: experience in a high complexity center in Colombia

Resumen Antecedentes: Las cardiopatías congénitas plantean un desafío terapéutico, específicamente la estenosis de la válvula pulmonar. Esta ha sido tratada durante muchos años con procedimientos invasivos e inserción de bioprótesis, que con el tiempo se vuelven disfuncionales y pueden reestenosarse por acumulación de tejido fibroso y calcificación. Debido a las complicaciones generadas por la injuria quirúrgica, se han descrito medidas menos invasivas para el manejo de la estenosis residual e inicial por medios endovasculares en adultos y más recientemente en población pediátrica. Objetivo: El objetivo de este reporte es describir la misma en el manejo endovascular del tracto de salida del ventrículo derecho, como el inicio de un trabajo continuo para la mejoría de los resultados pediátricos en países en vía de desarrollo. Métodos: Se presentan siete casos pediátricos de manejo endovascular del tracto de salida derecho; tres de ellos sometidos a valvuloplastia quirúrgica con persistencia de la estenosis pulmonar, por lo cual se decidió inserción percutánea de una válvula pulmonar (IVPP) transcatéter con válvula Melody utilizando la técnica valve-in-valve, con lo que se consiguió una resolución del 100% de la estenosis y no se presentó ningún tipo de complicación asociada al procedimiento. Resultados: En cuatro pacientes se logró una implantación exitosa de la válvula por vía percutánea en diferentes cardiopatías congénitas, siendo uno de ellos en tracto nativo; además, destaca el caso de un paciente en quien se realizó fractura intencional de la válvula pulmonar, procedimiento innovador en el manejo endovascular pediátrico en Colombia. Conclusiones: En estos pacientes el procedimiento resultó ser poco invasivo, seguro y efectivo. La técnica IVPP podría ser considerada una opción viable en Colombia (y en otros países en desarrollo) para el manejo de implantes valvulares primarios fallidos o incluso en tractos nativos.

Abstract Background: Congenital heart disease poses a therapeutic challenge, specifically pulmonary valve stenosis. This has been treated for many years with invasive procedures and bioprostheses, which over time, become dysfunctional due to the accumulation of fibrous tissue and calcification. Objective: The aim of this study is to describe the use of endovascular management in the right ventricular outflow tract, as the beginning of an ongoing effot to improve pediatric outcomes in developing countries. Methods: Seven pediatric patients with endovascular management of the right outflow tract are presented. Three of them underwent surgical valvuloplasty with persistent pulmonary stenosis. They decided to insert a percutaneous transcatheter pulmonary valve (PPVI) with a Melody valve using the valve-in-valve technique, with 100% stenosis and no complications associated with the procedure. Results: Four patients with successful percutaneous valve implantation had different congenital heart diseases. In addition, the case of a patient in whom an intentional pulmonary valve fracture was performed, an innovative procedure in pediatric endovascular management in the country, is highlighted. Conclusions: The procedure was minimally invasive, safe, and effective. The IVPP technique could be a viable option in our country for managing failed primary valve implantations or even in native tracts.

Prevalencia de estenosis aórtica moderada-grave en pacientes con amiloidosis cardiaca en un centro de referencia / Prevalence of moderate-severe aortic stenosis in patients with cardiac amyloidosis in a referral center

Resumen Antecedentes: La estenosis aórtica (EA) es actualmente la enfermedad valvular más frecuente, con una prevalencia estimada de más del 4 % en octogenarios. Objetivo: Describir la prevalencia de estenosis aórtica (EA) moderada-grave en pacientes con amiloidosis por transtiretina wild type (ATTRwt). Además, describir las características clínicas, ecocardiográficas y la evolución en este grupo de pacientes. Método: Estudio de cohorte retrospectiva de pacientes con diagnóstico de ATTRwt, pertenecientes al Registro Institucional de Amiloidosis del Hospital Italiano de Buenos Aires, en el periodo del 30/11/2007 al 31/05/2021. El seguimiento de los pacientes se realizó a través de la historia clínica electrónica de la institución. Se estimó la prevalencia de EA moderada-grave, que se presenta como porcentaje con su intervalo de confianza del 95% (IC 95%). Se compararon las características por grupos según tuvieran o no EA moderada-grave. Resultados: Se incluyeron 104 pacientes con diagnóstico de ATTRwt. La mediana de seguimiento fue de 476 días [rango intercuartílico: 192-749]. La prevalencia de EA moderada-grave al momento del diagnóstico de ATTRwt fue del 10.5% (n = 11; IC95%: 5-18%). La mediana de edad de los pacientes con EA fue de 86 años [78-91] y predominó el sexo masculino (81.8%). La mayoría de los pacientes tenían el antecedente de insuficiencia cardiaca (n = 8) y fibrilación auricular (n = 8). Predominaron los pacientes con EA grave de bajo flujo y bajo gradiente (n = 7). Cuatro pacientes fueron sometidos a alguna intervención en la válvula aórtica. Durante el seguimiento, 5 pacientes (46%) tuvieron internaciones por insuficiencia cardiaca descompensada y 4 (36%) fallecieron. Conclusiones: En nuestra cohorte, la coexistencia de ambas patologías tuvo una prevalencia similar a la reportada en la literatura internacional. Se trató de una población añosa con alto porcentaje de fibrilación auricular y antecedente de insuficiencia cardiaca. La mayoría presentaron EA grave de bajo flujo y bajo gradiente.

Abstract Background: Aortic stenosis (AS) is currently the most common valvular disease, with an estimated prevalence of over 4% in octogenarians. Objective: To describe the prevalence of moderate-severe aortic stenosis (AS) in patients with wild type transthyretin amyloidosis (ATTRwt). Also, describe the clinical features, echocardiographic characteristics and clinical evolution. Method: Retrospective cohort of patients with diagnosis of ATTRwt, belonging to Hospital Italiano de Buenos Aires Institutional Amyloidosis Registry, from 30/11/2007 to 31/05/2021. Patients follow up was carried out through the institution clinical history. The prevalence of moderate-severe AE was estimated and presented as a percentage with its 95% confidence interval (95% CI). The characteristics were compared by groups according to whether or not they had moderate-severe AS. Results: 104 patients with ATTRwt were included. Median follow up was 476 days [interquartile range: 192-749]. Moderate-severe AS prevalence at the ATTRwt time of diagnosis was 10.5% (n = 11; 95% CI: 5-18%). The median age of patients with AS moderate-severe at the time of diagnosis of ATTRwt was 86 years [78-91] and the male sex predominated (82%). Most of the patients had a history of heart failure (n = 8) and atrial fibrillation (n = 8) prior to the diagnosis of ATTRwt. Most of the patients were subclassified as low flow low gradient severe AS group (n = 7). Four patients underwent some intervention on the aortic valve. During follow-up, 5 patients (46%) were hospitalized for decompensated heart failure and 4 (36%) died. Conclusions: In our cohort, the coexistence of both pathologies had a similar prevalence as reported in the international literature. It was an elderly population with a high percentage of atrial fibrillation and history of heart failure. Most of the patients presented with severe AS with low flow low gradient.

Association of Estimated Glucose Disposal Rate With the Stenosis Severity of Coronary Artery Disease： A Cross-sectional Study / 中山大学学报(医学科学版)

ObjectiveTo investigate the association between estimated glucose disposal rate （eGDR） and the severity of coronary heart disease. MethodsWe conducted a hospital-based cross-sectional study that included 1258 patients （mean age： 62（53-68） years） who underwent coronary angiography for suspected coronary artery disease （53.9% were male）. Insulin resistance level （IR） was calculated according to eGDR formula： eGDR = 21.158 - （0.09 × WC） - （3.407 × hypertension） - （0.551 × HbA1c） ［hypertension （yes = 1 / no = 0）， HbA1c = HbA1c （%）］. Subjects were grouped according to the eGDR quantile. CAD severity was determined by the number of narrowed vessels： no-obstructive CAD group （all coronary stenosis were<50%， n=704）， Single-vessel CAD group （only one involved major coronary artery stenosis≥50%， n=205）， Multi-vessel CAD group （two or more involved major coronary arteries stenosis≥50%， n=349）； Multivariate logistic regression model was used to analyze the association between eGDR and CAD severity. The linear relationship between eGDR and CAD in the whole range of eGDR was analyzed using restricted cubic spline. Subgroup analyses were used to assess the association between eGDR and CAD severity in different diabetic states. Receiver operating characteristic （ROC） curve analysis were used to evaluate the value of eGDR in improving CAD recognition. ResultsA decrease in the eGDR index was significantly associated with an increased risk of CAD severity （OR： 2.79； 95%CI： 1.72~4.55； P<0.001）. In multivariate logistic regression models， individuals with the lowest quantile of eGDR （T1） were 2.79 times more likely to develop multi-vessel CAD than those with the highest quantile of eGDR （T3） （OR： 2.79； 95%CI： 1.72~4.55； P<0.001）. Multivariate restricted cubic spline analysis showed that eGDR was negatively associated with CAD and multi-vessel CAD （P-nonlinear>0.05）. In non-diabetic patients， compared with the reference group （T3）， the T1 group had a significantly increased risk of CAD （OR： 1.42； 95% CI： 1.00~2.01； P<0.05） and multi-vessel CAD （OR： 1.86； 95%CI： 1.21~2.86； P<0.05）. No statistical association was found between eGDR and CAD in diabetic patients. In ROC curve analysis， when eGDR was added to traditional model for CAD， significant improvements were observed in the model's recognition of CAD and multi-vessel CAD. ConclusionOur study shows eGDR levels are inversely associated with CAD and CAD severity. eGDR， as a non-insulin measure to assess IR， could be a valuable indicator of CAD severity for population.

Correlation between Triglyceride Glucose Product Index and Coronary Heart Disease / 医学研究杂志

Objective To investigate the correlation of triglyceride glucose product index(TyG index)with the diagnosis of coronary heart disease(CHD)and the severity of coronary stenosis.Methods A total of 404 patients who received coronary angiography for the first time in Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine with unexplained chest pain from December 2021 to October 2022 were included.All subjects were divided into CHD group(n=216)and non-CHD group(n=188).General clin-ical data,laboratory information and coronary angiography results of all participants were collected.The CHD group(n=123)and the non-CHD group(n=123)were obtained after the propensity score matching(PSM).Patients in CHD group were further divided into low Gensini score(Gensini score＜35,n=59)group and high Gensini score(Gensini score ≥ 35,n=64)group according to the me-dian Gensini score.The differences among groups were compared and the relation between TyG index and the severity of coronary artery stenosis was analyzed.Then the predictive value of TyG index for CHD and the severity of coronary lesion was evaluated by Logistic regres-sion and receiver operating characteristic(ROC)curve.Results After PSM,the differences in TyG index,TG,FPG,HDL-C in CHD group were statistically significant compared with the non-CHD group(P＜0.05).Multivariate Logistic regression analysis showed that the TyG index was an independent risk factor for CHD.Spearman correlation analysis showed that the TyG index was positively correlated with the Gensini score(r=0.618,P＜0.001).The ROC curve analysis showed that the area under the curve(AUC)of the TyG index predicting a high Gensini score was 0.873(95％CI:0.802-0.943,P＜0.001).A cut-off value was 7.08,and the sensitivity and specificity were 95.2％and 67.3％,respectively.Conclusion TyG index can be used as an independent risk factor for CHD,and has certain predictive value for the severity of coronary stenosis.

New advances in stroke and cerebral embolism protection devices in transcatheter aortic valve replacement / 中国介入心脏病学杂志

Stroke is one of the most serious complications of transcatheter aortic valve replacement(TAVR),tremendously increasing mortality and the loss of neurocognitive function.Since TAVR is expected to further spread into lower-risk patient groups,there will be greater emphasis to obviate such serious complications.One possible technique for preventing stroke is using cerebral embolic protection devices(CEPDs).CEPDs are designed for capturing or deflecting emboli that are enter route to the brain and hence to protect the brain from embolism.Since this is a rapidly growing field with recent advances,and the impact of CEPD on preventing neurological events is still limited,there is an urgent need for understanding the role of CEPD in preventing clinically significant strokes.Although their clinical utilization is increasing,the risk factors for stroke related to TAVR and evidence for using CEPDs are not yet clear.In this review,we present an overview of the available literature on TAVR related stroke and CEPD,and outline recent advances within this field.

Application of 3D printing in the preoperative evaluation of transcatheter aortic valve replacement for patients at risk of coronary artery obstruction:two case reports / 中国介入心脏病学杂志

Transcatheter aortic valve replacement(TAVR)is currently one of the main therapeutic strategies for aortic valve disease.Preoperative imaging assessment is crucial for operation project planning and prevention of procedure-associated complications.Different from planar image reconstruction,3D printing technology can accurately depict the anatomical structure of the aortic root.It enables further assessment of operative risk and therapeutic strategy through in vitro simulation,especially for assessing the risk of coronary artery obstruction and planning interventional procedures.Here,we report on two patients who underwent a 3D printing aortic root anatomical simulation model,followed an by in vitro balloon dilatation/valve implantation test,to evaluate the risk of coronary artery obstruction suggested by CT angiography planar image reconstruction before TAVR.

Clinical outcome of lateral lumbar interbody fusion in the treatment of lumbar spinal stenosis with redundant nerve roots / 中国脊柱脊髓杂志

Objectives:To investigate the clinical efficacy and outcome of lateral lumbar interbody fusion in the treatment of lumbar spinal stenosis(LSS)with redundant nerve roots(RNRs).Methods:The data of 48 LSS patients with RNRs(23 males and 25 females,aged 45-81 years,on average 65.4±7.5 years)treated with lat-eral lumbar interbody fusion between January 2018 and July 2022 in our hospital were analyzed retrospec-tively.Among the patients,17 cases received single-level surgery and 31 cases received multi-level surgery.On the basis of the postoperative supine MRI scans,the patients were divided into RNRs relieved group(group A)and RNRs unrelieved group(group B).Radiographic assessments included disc heights,segmental angle and cross-sectional area of the spinal canal at the RNRs segment before and after operation were per-formed.The visual analogue scale(VAS),Oswestry disability index(ODI)and Japanese Orthopaedic Association(JOA)score were used to evaluate the clinical outcomes at preoperation and 1 month after surgery.Results:All patients underwent surgery successfully.The preoperative cross-sectional area of the spinal canal was 65.2±21.5mm2 in group A and 35.9±11.5mm2 in group B,with a significant difference(P＜0.05).The posterior disk height and cross-sectional area of the spinal canal was 8.3±1.7mm and 92.6±25.8mm2 respectively in group A,and that of group B was 6.0±2.3mm and 45.4±12.1mm2 respectively,the differences were significant-ly statistical(P＜0.05).Furthermore,in 1 month after operation the VAS leg pain,ODI and JOA scores was 2.4±0.8,(24.1±3.0)%and 22.8±1.9 respectively in group A,and that of group B was 3.3±0.8,(30.2±4.4)%and 17.7±2.5 respectively,the differences were significantly statistical(P＜0.05).The total incidence of complications was 10.4%,including anterolateral thigh pain in 4 cases and hip flexor weakness in 1 case,which were released at 3 months of follow-up.Conclusions:Lateral lumbar interbody fusion can eliminate RNRs by restoring postoperative posterior disc height and enlarging the cross-sectional area of spinal canal,which provides an effective treatment for most LSS patients with RNRs.

Clinical efficacy of percutaneous endoscopic decompression in treating lumbar spinal stenosis combined with degenerative scoliosis in geriatric patients / 中国脊柱脊髓杂志

Objectives:To evaluate the clinical efficacy of percutaneous endoscopic decompression in the treatment of lumbar spinal stenosis(LSS)with degenerative scoliosis in geriatric patients.Methods:A retro-spective analysis was conducted on the LSS patients combined with degenerative scoliosis underwent percuta-neous endoscopic decompression between January 2020 and June 2021.18 patients(11 males and 7 females)aged 65-90(78.9±7.1)years old were included in the study.Percutaneous endoscopic unilateral or bilateral decompression was performed according to the clinical symptoms,comorbidities and imaging characteristics of the patients.The operative time,intraoperative blood loss and fluoroscopy times were recorded.Visual ana-logue scale(VAS)was used to evaluate back and leg pain before and immediately after operation,and at 6 months after surgery and final follow-up.Oswestry disability index(ODI)and Japanese Orthopaedic Association(JOA)score were applied to evaluate lumbar function before and after operation,and the Macnab criteria were adopted to assess the efficacy at final follow-up.The sagittal vertical axis(SVA),C7-CSVL,Cobb angle,lum-bar lordosis(LL),pelvic incidence(PI),pelvic tilt(PT),sacral slope(SS),PI-LL,and cross-sectional area of spinal canal before and after surgery were measured and analyzed.Results:All the patients underwent the surgery successfully,and 14 cases were treated with bilateral decompression and 4 cases with unilateral decompression.There were no serious complications during the perioperative period.The patients completed more than 12 months of follow-up.The operative time was 69.72±12.66min,intraoperative blood loss was 39.72±10.21mL,and the number of preoperative and intraoperative fluoroscopy was 5.11±1.49 times.The VAS scores of low back and leg pain immediately after operation,at 6 months after operation and final follow-up were significantly lower than those before operation(P＜0.05).The ODI and JOA score at final follow-up were significantly improved compared with those before operation(P＜0.05).The postoperative SVA,C7-CSVL,Cobb angle,PI-LL,and cross-sectional areas of spinal canal were improved compared with the preoperative values,respectively(P＜0.05).There were 7 excellent cases(38.90％),9 good cases(50.00％)and 2 acceptable cases(11.11％)at the final follow-up,and the total excellent and good rate was 88.89％.Conclusions:Percutaneous endoscopic decompression has the clinical efficacies of relieving back and leg pain,improving lumbar function and spino-pelvic alignment,and enlarging intraspinal cross-sectional area in treating old LSS patients with degenerative scoliosis,and it is small in wound,little in bleeding,and short in operative time.

Short-term clinical of oblique lateral interbody fusion in the treatment of mild-to-moderate of de-generative lumbar spinal stenosis / 中国脊柱脊髓杂志

Objectives:To investigate the short-term efficacy of oblique lateral interbody fusion(OLIF)in treating mild-to-moderate lumbar spinal stenosis(LSS).Methods:35 patients with mild-o-moderate LSS treated with OLIF between May 2018 and May 2020 were analyzed retrospectively,including 25 males and 10 females,aged 50-74(60.3±10.7)years old.The patients were followed up for 12-28(18.3±3.7)months.The operative time,intraoperative bleeding,and complications were recorded;At preoperation,1 week,and 3,6 and 12 months after surgery,the visual analogue scale(VAS)for lumbar and leg pain and Oswestry disability index(ODI)were compared to evaluate clinical efficacy;And lumbar X-ray,CT,and MRI were performed at the same time to measure and evaluate the height of the intervertebral space,size of intervertebral foramen,area of dural sac and sagittal diameter,lordotic angle of intervertebral space,lordotic angle of lumbar spine,and their respective differences between before and after operation,as well as between each postoperative time point were analyzed;The complications and fusion conditions at each time point were also documented.Results:The operative time was 30-100(70.5±20.3)min,and intraoperative bleeding was 20-120(60.3±20.2)mL.The lumbar and leg pain VAS scores and ODI at postoperative 1 week,and 3,6 and 12 months were signif-icantly improved compared with those before operation,and the differences were statistically significant(P＜0.05),while there was no statistical significance when compared pairwisely between postoperative time points(P＞0.05).At postoperative 1 week,and 3,6 and 12 months,the intervertebral space height,intervertebral lor-dotic angle and lumbar lordotic angle,left and right intervertebral foramina sizes,dural sac areas,and sagittal diameters increased significantly compared with those before operation,with statistically significance(P＜0.05),and no statistical difference was found when compared pairwisely between postoperative time points for each imaging parameter(P＞0.05).According to the CT image evaluation 1 year after operation,the overall fusion rate was 94.2％(33/35 cases).No serious complications such as nerve and vascular injury occurred;3 cases of postoperative hip flexion weakness and anterior thigh numbness were relieved after 1 month of symptomatic treatment with conservative therapy;2 cases of fusion device sinking of end-plate cutting were revised in the second stage and underwent posterior muscular gap approach internal fixation.Conclusions:OLIF has satisfactory short-term clinical efficacy in the treatment of mild-to-moderate LSS.

Short-term curative effect evaluation of unilateral biportal endoscopy through Sublamina approach for lumbar intervertebral foramen stenosis combined with lumbar disc herniation / 中国内镜杂志

Objective To explore the efficacy of unilateral biportal endoscopy(UBE)for lumbar intervertebral foramen stenosis combined with lumbar disc herniation through Sublamina approach.Methods From October 2021 to June 2022,7 elderly patients with typical symptoms of lumbar disc herniation in the intervertebral foramen area accompanied by spinal stenosis were retrospectively analyzed.There were 6 patients with lumbar disc herniation and nerve root canal stenosis at L4/5 and 1 patient at L5/S1.The mean course of disease was(8.6±2.5)months.All the patients were treated by UBE through Sublamina approach.Results Postoperative limb radicular symptoms of 7 patients were relieved.The visual analogue scale(VAS)of limb pain was significantly decreased from preoperative(8.6±1.3)to(2.1±1.1)at 2 d after the surgery(P<0.05),the Japanese Orthopaedic Association(JOA)score was significantly increased from preoperative(10.1±2.4)to(17.3±1.8)at 2 d after the surgery(P<0.05).Conclusion UBE for lumbar intervertebral foramen stenosis combined with lumbar disc herniation through Sublamina approach has a satisfactory therapeutic effect,providing a new idea for the surgical treatment of this disease.

Application effect and safety analysis of unilateral laminectomy and bilateral decompression under unilateral biportal endoscopy and microendoscope in lumbar spinal stenosis / 中国内镜杂志

Objective To analyze the efficacy and safety of unilateral laminectomy and bilateral decompression under unilateral biportal endoscopy(UBE)and microendoscope(MED)in lumbar spinal stenosis.Methods 80 patients with lumbar spinal stenosis from January 2021 to December 2022 were selected and divided into two groups by numerical table method,the control group and the study group,and the number of cases was 40.The grouping method was random number table method.The control group was treated with unilateral laminectomy and bilateral decompression under MED,while the study group was treated with unilateral laminectomy and bilateral decompression under UBE.Operation time,intraoperative blood loss,Oswestry disability index(ODI)and visual analogue scale(VAS)of lumbago and leg pain were obtained before surgery,1,3 months after surgery and at the last follow-up,efficacy and complications were compared between the two groups.Result There were no significant differences in operative time and blood loss between the study group and the control group(P>0.05).1,3 months after surgery and at the last follow-up,ODI in both groups were lower than those before surgery(P<0.05),but there was no difference between the study group and the control group(P>0.05).The VAS of lumbago and leg pain in both groups were lower than those before surgery(P<0.05),at 1,3 months after surgery and the last follow-up,and the study group was significantly lower than the control group(P<0.05).The excellent and good rate of clinical treatment in the study group was 97.50%,and there was no difference compared with 92.50%in the control group(P>0.05).The complication rate of the study group was 2.50%,significantly lower than that of the control group(15.00%)(P<0.05).Conclusion Unilateral laminectomy and bilateral decompression under the UBE and MED have similar efficacy in the treatment of lumbar spinal stenosis,both of which can effectively promote functional recovery,but UBE can reduce pain more effectively and has fewer postoperative complications.

Special application of stone extractor balloon catheter in ERCP for anastomotic biliary stenosis after liver transplantation / 中国内镜杂志

Objective To discuss the application effect of using a stone extractor balloon catheter to assist in crossing the anastomotic stenosis in treatment of anastomotic biliary stenosis after liver transplantation using endoscopic retrograde cholangiopancreatography(ERCP).Methods Clinical data of 48 patients who developed anastomotic biliary stenosis after liver transplantation and underwent ERCP treatment were collected.Upon unsuccessful use of a dilation catheter to cross the stricture,attempts were made to cross the anastomotic biliary stenosis by using a stone extractor balloon catheter.The success rate of the procedure was recorded,intraoperative conditions were observed,treatment outcomes and complications were analyzed.Results The main presenting symptoms in the 48 patients on admission were abdominal discomfort(32 patients),fever(7 patients),pruritus(4 patients),jaundice(3 patients),and no obvious symptoms(2 patients).Preoperative magnetic resonance cholangiopancreatography(MRCP)examination revealed isolated stricture of the anastomotic site in 35 cases,and stricture associated with stones in 13 cases.Using the stone extractor balloon catheter as a guide,guidewire crossing of the anastomotic stenosis was successful in 26 cases,resulting in a success rate of 54.17%(26/48).Through statistical analysis of the successful group and the failed group,there was a significant difference in whether the distal biliary dilatation between the two groups,and the difference was statistically significant(χ2 = 8.39,P = 0.004).In the 26 successfully treated cases,alanine transaminase(ALT),aspartate transaminase(AST),γ-glutamyl transpeptidase(γ-GT),alkaline phosphatase(ALP),and total bilirubin(TBiL)levels decreased significantly 48 hours after the procedure(P<0.05),and no serious complications occurred.Conclusion The use of a stone extractor balloon catheter significantly increases the success rate of crossing anastomotic stenosis in the treatment of anastomotic biliary stenosis after liver transplantation,especially in cases with distal dilatation of the common bile duct.This approach is safe and worth promoting.

Efficacy analysis of the acute endovascular treatment in patients with symptomatic severe anterior intracranial atherosclerotic stenosis / 中国脑血管病杂志

Objective Observing the feasibility of acute endovascular treatment for patients with symptomatic anterior intracranial atherosclerotic severe stenosis.Method From Jun 2019 to Jun 2023,30 symptomatic anterior intracranial atherosclerotic severe stenosis cases were retrospectively collected in the Guangdong Hospital of Traditional Chinese Medicine to evaluate the risk stratification score and explore the safety and effectiveness of acute(≤72.0h)endovascular treatment.Endovascular treatment includes balloon dilation+self-expanding stent placement,balloon-mounted stent placement,and balloon dilation.From the clinical experience,the risk stratification score was based on the ABCD3-I score for transient ischemic attacks(TIA)and additional evaluation of cerebral watershed infarction to identify the risk of stroke progression or recurrence in acute stage of symptomatic intracranial artery stenosis.The score of 0-3 was defined as low-risk,4-7 as medium risk,and 8-13 as high-risk.The successful revascularization of blood flow is determined based on the residual stenosis≤50％and the extended thrombolysis in cerebral infarction(eTICI)＞2c.The information of patient receiving endovascular treatment was recorded,including age,sex,risk factors of cerebrovascular disease(hypertension,diabetes,hyperlipidemia,hyperhomocysteinemia,drinking history,smoking history),onset data(time from onset to endovascular treatment,symptoms,progression),diseased vessels,risk stratification score,National Institutes of Health Stroke Scale(NIHSS)score before and 90 days after surgery,modified Rankin scale(mRS)score 90 days after surgery,intraoperative cerebrovascular events(intracranial hemorrhage,occlusion of responsible vessels),and postoperative cerebrovascular events 90 days after surgery(intracranial hemorrhage,cerebral infarction,TIA and in-stent restenosis)and deaths.Results Among 30 patients with symptomatic anterior intracranial atherosclerotic severe stenosis,3 patients were excluded from the time interval between onset and endovascular treatment＞72.0 hours,1 patient needed long-term anticoagulant drugs due to other diseases,1 patient lost follow-up,3 patients coexisted with other cardiogenic cerebral embolism diseases,4 patients with non-atherosclerotic arterial stenosis,and 7 patients refused emergency endovascular treatment.11 patients were finally included.(1)All 11 patients were successfully treated with endovascular treatment,and 7 were males;age ranged from 52 to 76 years old,with a median age of 64 years old;there were 9 cases with hypertension,3 cases diabetes,7 cases hyperlipidemia,2 cases hyperhomocysteinemia(only 9cases performed the examination),2cases smoking history,1 case drinking history;time from onset to endovascular treatment is 4.0-72.0 h,with a median time of 12.0 h;there were 3 and 8 cases of infarction in the left and right hemispheres,respectively,with 4,3,and 2 cases accompanied with anterior-posterior watershed,medial watershed,and anlerior-medial-posterior watershed infarctions,and 1 case accompanied by posterior-medial,anterior-medial watershed infarctions.(2)Among the 1 1 patients,the risk stratification score was 10-13 points,with a median score of 11 points;preoperative NIHSS score ranged 0-11 points,with a median score of 7 points.(3)Among the 1 1 patients,10 lesions located in the middle cerebral artery and 1 in the C7 segment of the internal carotid artery;the preoperative stenosis rate was 70％to 99％,with a median stenosis rate of 86％;preoperative eTICI grading was 2a in 7 cases and 2b50 in 4 cases(with slow distal blood flow);9 cases received balloon dilation and self-expanding stent placement,1 case received balloon-mounted stent placement,and 1 case received balloon dilation treatment;the postoperative stenosis rate is 10％to 20％,with a median stenosis rate of 15％;there were 3 cases with postoperative eTICI grade 2c and 8 cases with grade 3.(4)Among the 11 patients,one experienced intracranial hemorrhage on the first day after surgery and one had a new cerebral infarction on the third day after surgery.Eight patients were followed up by imaging 90days after surgery,demonstrating 2 cases of in-stent restenosis;90 days post-surgery,NIHSS score was 0-20 points,with a median score of 2 points;after 90 days of surgery,the mRS score was 0-4 points,with a median score of 1 point.There were 8 patients with mRS score ≤ 2 and no death events occurred.Conclusions Preliminary analysis shows that acute endovascular treatment for symptomatic anterior intracranial atherosclerotic severe stenosis has certain effectiveness,but the safety needs to be further validated.The screening of high-risk patients using risk stratification scores still requires further exploration through large sample and multicenter studies.

Effect of adding tranexamic acid during surgery on blood loss and security during short segment lumbar spinal stenosis surgery / 中国输血杂志

【Objective】 To discuss the effect of adding tranexamic acid(TXA) during surgery on blood loss and security during short segment lumbar spinal stenosis surgery. 【Methods】 One hundred and eight patients with lumbar spinal stenosis who were to undergo lumbar posterior fusion surgery were randomly divided into control group, TXA group and adding TXA group, with 36 patients in each group. In the control group, TXA was not used during surgery.The TXA group received intravenous infusion of 100 mL normal saline mixture containing 1 g of TXA 15 minutes before surgery after anesthesia. In adding TXA group, after the same operation in TXA group, 10 mg/kg(body weight) of TXA was infused 3 hours later. Total perioperative blood loss, dominant blood loss, hidden blood loss, intraoperative blood loss, postoperative drainage volume, and transfusion rate were recorded in the two groups. Hemoglobin (Hb), hematocrit(HCT), prothrombin time international standardized ratio (PT-INR), prothrombin time(PT), activated partial thromboplastin time(APTT), blood platelet count (BPC), D-dimer (D-D), fibringen(FIB), C-reactive protein (CRP), alanine aminotransferase (ALT), blood urea nitrogen (BUN) were measured 3 days before and after the surgery in the three groups. Postoperative adverse events were followed up. 【Results】 The total blood loss(mL) [(968.7±209.6) vs (1 369.8±276.3), (968.7±209.6) vs (1 273.9±250.2)], dominant blood loss(mL) [(590.5±164.3) vs (876.4±235.9), (590.5±164.3) vs (789.3±221.7)], intraoperative blood loss(mL) [(318.7±120.7) vs (457.8±146.6), (318.7±120.7) vs (423.9±162.3)] and postoperative drainage volume(mL) [1 day after surgery: (164.6±25.0) vs (262.3±51.7), (164.6±25.0) vs (219.8±37.1); 3 days after surgery: (107.2±18.6) vs (156.3±37.6), (107.2±18.6) vs (145.3±22.3)] of the adding TXA group were lower than those of the control group and TXA group (P0.05). Compared with the preoperative results, Hb, Hct and BPC in the three groups decreased (P0.05), and all of them were within the normal range. No serious adverse events such as deep vein thrombosis, pulmonary embolism, epilepsy, liver and kidney damage were found in all patients after postoperative follow-up. 【Conclusion】 Intraoperative addition of TXA can effectively reduce the amount of blood lost during short segment lumbar spinal stenosis surgery without increasing the risk of complications such as coagulation disorders, thrombosis, liver and kidney function damage.

Analysis of the Impact of Different Low-density Lipoprotein Cholesterol Levels on the Progression of Intermediate Coronary Stenosis Based on Quantitative Flow Ratio Quantification / 中国循环杂志

Objectives:This study aims to investigate the impact of different Low-Density Lipoprotein cholesterol(LDL-C)levels on progression of intermediate coronary stenosis,and the associated risk factors leading to the progression of such lesions. Methods:Data were collected on 219 consecutive patients admitted at the Fuwai Central China Vascular Hospital from January 2020 to February 2021,underwent angiographic examinations and diagnosed with intermediate coronary stenosis,with at least one follow-up angiography after 11 months.Offline quantitative flow ratio(QFR)analysis was performed on these cases.Patients were divided into two groups:LDL-C controlled group(LDL-C<1.8 mmol/L,148 patients with 191 vessels)and LDL-C uncontrolled group(LDL-C≥1.8 mmol/L,71 patients with 98 vessels).Coronary artery QFR and anatomical indicators such as minimal lumen diameter,minimal lumen area,percentage diameter stenosis,percentage area stenosis were compared within and between the groups.Further analysis was performed to identify influencing factors leading to changes in coronary physiological parameters derived from QFR. Results:Within the LDL-C controlled group,there was no significant difference in the QFR values of the vessels compared to baseline(P>0.05),whereas in the LDL-C uncontrolled group(P<0.05),a notable decline in QFR was observed.Patients in the LDL-C controlled group had lower rates of maximum diameter and area stenosis and higher minimum lumen diameter and area(all P<0.05).Through multifactorial Logistic regression analysis,it was found that a body mass index＞28 kg/m2,LDL-C≥1.8 mmol/L,and a history of myocardial infarction were independent risk factors leading to the decline in QFR(all P<0.05). Conclusions:It was found that patients in the LDL-C controlled group had higher coronary artery QFR,minimum lumen diameter and area,lower rates of maximum diameter and area stenosis.

Single-center Learning Curve Analysis of Transcatheter Aortic Valve Replacement / 中国循环杂志

Objectives:To evaluate the learning curve of transcatheter aortic valve replacement(TAVR)in a single center by single operator using Venus A valve. Methods:A total of 150 patients with severe aortic stenosis who underwent TAVR using Venus A valve in Fujian Provincial Hospital from July 2018 to May 2022 were selected.According to the time order of TAVR,the 1st-50th patients were included in group A,the 51st-100th patients were included in group B and the 101st-150th patients were included in group C.The basic clinical data,perioperative parameters and postoperative follow-up data of the three groups were analyzed. Results:All high-risk patients with severe aortic stenosis had an average STS score(7.9±1.5)and were treated with Venus A valve.The total operation time of group A,group B and group C was(226.2±86.3)min,(115.2±47.1)min,(108.2±38.1)min;the peripheral path operation time was(45±10)min,(20±7)min,(18±6)min;the valve release time was(13.0±2.3)min,(5.0±2.1)min,(3.0±1.7)min;the X-ray fluoroscopy time was(24±8)min,(11±5)min,(10±3)min;the radiation dose was(1 266±227)mGy,(532±132)mGy,(519±108)mGy;and the total incidence of perioperative adverse events was 46%,18%,16%,respectively.The differences were statistically significant(all P<0.05).The total incidence of adverse events during follow-up within 6 months for patients in group A,group B,and group C were 6%,2%,and 0%(P>0.05).With the increase of TAVR cases,the correlation curve of each time node of TAVR and radiation dose tended to be stable after the 50th-60th cases. Conclusions:With the increase of procedural experience,the total operation time,operative time nodes,radiation dose and perioperative adverse events of TAVR with Venus A valve decreases gradually,and the operator usually needs 50-60 cases to cross the TAVR learning curve.

The First Application of Domestically Produced Self-expanding Transcatheter Aortic Valve Controllable Bending Delivery System in China / 中国循环杂志

A domestically produced self-expanding transcatheter aortic valve controllable bending delivery system(VitaFlow? Ⅲcontrollable bending retrievable delivery system)was first used to perform transcatheter aortic valve replacement(TAVR)in a symptomatic severe aortic valve stenosis patient with severe heart failure and high risk of surgery in China on September 22,2023.The patient successfully completed TAVR under general anesthesia,with good valve position and function after the operation.Before discharge and at one month of follow-up,the patient's symptoms and degree of heart failure were significantly improved.The follow-up results of this case showed that the VitaFlow? Ⅲ controllable bending retrievable delivery system for TAVR is safe and feasible,and future prospective,multicenter clinical trials are expected to evaluate its efficacy.