Does the "obesity paradox" exist after transcatheter aortic valve implantation?

BACKGROUND: Transcatheter aortic valve implantation (TAVI) for symptomatic aortic stenosis is considered a minimally invasive procedure. Body mass index (BMI) has been rarely evaluated for pulmonary complications after TAVI. This study aimed to assess the influence of BMI on pulmonary complications and other related outcomes after TAVI. METHODS: The clinical data of 109 patients who underwent TAVI in our hospital from May 2018 to April 2021 were retrospectively analyzed. Patients were divided into three groups according to BMI: low weight (BMI < 21.9 kg/m2, n = 27), middle weight (BMI 21.9-27.0 kg/m2, n = 55), and high weight (BMI > 27.0 kg/m2, n = 27); and two groups according to vascular access: through the femoral artery (TF-TAVI, n = 94) and through the transapical route (TA-TAVI, n = 15). Procedure endpoints, procedure success, and adverse outcomes were evaluated according to the Valve Academic Research Consortium (VARC)-2 definitions. RESULTS: High-weight patients had a higher proportion of older (p < 0.001) and previous percutaneous coronary interventions (p = 0.026), a higher percentage of diabetes mellitus (p = 0.026) and frailty (p = 0.032), and lower glomerular filtration rate (p = 0.024). Procedure success was similar among the three groups. The 30-day all-cause mortality of patients with low-, middle-, and high weights was 3.7% (1/27), 5.5% (3/55), and 3.7% (1/27), respectively. In the multivariable analysis, middle- and high-weight patients exhibited similar overall mortality (middle weight vs. low weight, p = 0.500; high weight vs. low weight, p = 0.738) and similar intubation time compared with low-weight patients (9.1 ± 7.3 h vs. 8.9 ± 6.0 h vs. 8.7 ± 4.2 h in high-, middle-, and low-weight patients, respectively, p = 0.872). Although high-weight patients had a lower PaO2/FiO2 ratio than low-weight patients at baseline, transitional extubation, and post extubation 12th hour (p = 0.038, 0.030, 0.043, respectively), there were no differences for post extubation 24th hour, post extubation 48th hour, and post extubation 72nd hour (p = 0.856, 0.896, 0.873, respectively). Chronic lung disease [odds ratio (OR) 8.038, p = 0.001] rather than high weight (OR 2.768, p = 0.235) or middle weight (OR 2.226, p = 0.157) affected postoperative PaO2/FiO2 after TAVI. CONCLUSIONS: We did not find the existence of an obesity paradox after TAVI. BMI had no effect on postoperative intubation time. Patients with a higher BMI should be treated similarly without the need to deliberately extend the intubation time for TAVI.

Effects of seasonal and climate variations on in-hospital mortality and length of stay in patients with type A aortic dissection.

OBJECTIVE: To investigate the effects of seasonal and climatic changes on postoperative in-hospital mortality and length of stay (LOS) in patients with type A acute aortic dissection (AAD). METHODS: Patients undergoing implantation of the modified triple-branched stent graft to replace the descending aorta in addition to aortic root reconstruction for type A AAD in our hospital from January 2016 to December 2019 were included. Relevant data were retrospectively collected and analyzed. RESULTS: A total of 404 patients were included in our analyses. The multivariate unconditional logistic regression analysis showed that patients admitted in autumn (OR 4.027, 95% CI 1.023-17.301, P = 0.039) or with coronary heart disease (OR 8.938, 95% CI 1.991-29.560, P = 0.049) were independently associated with an increased risk of postoperative in-hospital mortality. Furthermore, patients admitted in autumn (OR 5.956, 95% CI 2.719-7.921, P = 0.041) or with hypertension (OR 3.486, 95% CI 1.192-5.106, P = 0.035) were independently associated with an increased risk of longer LOS. CONCLUSION: Patients admitted in autumn or with coronary heart disease are at higher risk of in-hospital mortality following surgery for type A AAD. Also, patients admitted in autumn or with hypertension have a longer hospital LOS. In the autumn of the temperature transition, we may need to strengthen the management of medical quality after surgery for type A AAD.

Transcatheter and intraoperative device closure and surgical repair for atrial septal defect.

BACKGROUND: Transcatheter and intraoperative device closure for atrial septal defect (ASD) are widely applied to reduce the incision size and the potential for injury during cardiopulmonary bypass (CPB) in conventional surgical repair. No studies had been conducted to compare the safety and efficiency of these three treatments. METHODS: From January 2018 to April 2018, 87 patients with an isolated ASD who had undergone transcatheter device closure (n = 45), intraoperative device closure (n = 22) and surgical repair (n = 20) were retrospectively reviewed and further analyzed to compare these three treatments. RESULTS: The successful closure rate was similar in the three groups. There was a significant difference in aortic cross-clamping time, CPB duration and operative time between the surgical group and the device groups. The length of intensive care unit stay, postoperative mechanical ventilation time and length of hospital stay were shorter in the two device groups than in the surgical group. The incision was the most extended in the surgical group. Regarding major adverse events, no significant differences were found among the three groups. CONCLUSIONS: Transcatheter and intraoperative device closure and surgical repair for ASD are all safe and effective. Considering their respective disadvantages and advantages, the transcatheter approach may be the first choice for an isolated secundum ASD, the intraoperative approach may be the second choice, and surgical repair may be the last resort.

Intraoperative Device Closure of a Perimembranous Ventricular Septal Defect Using the Right Thoracic Ventricle Approach.

BACKGROUND: This study compared the safety and effectiveness of intraoperative device closure of a perimembranous ventricular septal defect (pmVSD) using the right thoracic minimal incision to right ventricle and lower midline sternotomy to right ventricle approaches. METHODS: We retrospectively analyzed the clinical data of 46 patients who underwent intraoperative device closure of a pmVSD through the right thoracic minimal incision to right ventricle route (group 1) and 52 patients who underwent intraoperative device closure of a pmVSD through a minimal incision in the lower sternum (group 2) at our hospital from March 2016 to March 2017. In group 1, a right thoracic minimal incision to the fourth intercostal space was used to establish a delivery system through the right ventricle to complete pmVSD closure. RESULTS: In group 1, intraoperative device closure of the pmVSD was successful in 44 patients and was converted to open surgery in 2 patients (a delivery system could not be established in the one, and a significant residual shunt was present in the other). In group 2, the corresponding numbers of patients were 50 and 2, respectively. Neither group exhibited serious adverse effects, including dislocation of the occluder, third-degree atrioventricular block, or new onset of aortic valve regurgitation during the perioperative period or during a median follow-up period of 1 to 2 years. CONCLUSIONS: Intraoperative device closure of a pmVSD through the right thoracic minimal incision to right ventricle approach is safe and effective. This procedure can avoid some of the shortcomings caused by sternotomy, uses an incision with an improved cosmetic appearance, and is worth recommendation.

Transthoracic Balloon Pulmonary Valvuloplasty for Treatment of Congenial Pulmonary Atresia Patients with Intact Ventricular Septum.

BACKGROUND To summarize our clinical experience in performing transthoracic balloon pulmonary valvuloplasty for the treatment of patients suffering from congenial pulmonary atresia with intact ventricular septum (PA/IVS). MATERIAL AND METHODS Between April 2009 and April 2016, 38 patients with PA/IVS underwent transthoracic balloon pulmonary valvuloplasty in our hospital. All of them were combined with patent ductus arteriosus, tricuspid insufficiency, and atrial septal defect or patent foramen ovale. The valvuloplasty was performed from the right ventricular outflow tract through a median sternotomy incision under TEE guidance for all cases. RESULTS Thirty-five patients were successfully discharged, and 3 patients died after the operation. The 35 surviving patients were followed up. Spo2 in the 35 patients was 88-96% after the operation. The transpulmonary valvular gradient pressure was less than or equal to 30 mmHg in 31 patients and between 36 and 52 mmHg in the other 4 patients. After the surgery, tricuspid regurgitation was significantly reduced. We found only 4 patients with moderate regurgitation, 5 patients with mild to moderate regurgitation, and mild regurgitation in the remaining 26 patients. Five patients underwent a second-stage operation, including biventricular repair in 4 patients and ligation of ductus arteriosus in 1 patient. CONCLUSIONS The application of transthoracic balloon pulmonary valvuloplasty for the treatment of PA/IVS is minimally invasive and safe, which has great significance for improving the curative effect for this condition and reducing operation mortality.

Comparison of transvenous versus transthoracic catheter-based device closure of patent ductus arteriosus with amplatzer duct occluder.

OBJECTIVE: This study compared the clinical outcome of the transvenous versus transthoracic approach for closure of patent ductus arteriosus (PDA). BACKGROUND: There are no data regarding the results of transvenous versus transthoracic catheter-based device closure of PDA with Amplatzer duct occluder (ADO) despite their increasing use as alternatives to conventional surgery. METHODS: In this observational study, a total of 150 consecutive patients with PDA were allocated either to the transvenous approach (group A, n = 108) and the transthoracic approach (group B, n = 42) by using ADO between January 2010 and April 2012. Echocardiography was performed to evaluate the prespecified initial and 6-month success of PDA closure. The technical indices and procedure-related major acute and chronic complications were documented. RESULTS: There were similar initial success rates (98.2% vs 100%; P>.05) and 6-month success rates (99.1% vs 100%; P>.05) between groups, and group A had fewer major acute complications (3.7% vs 85.7%; P<.001), shorter operating time (1.3 hours vs 2.1 hours; P<.001), Intensive Care Unit stay (0 hours vs 23.0 hours; P<.001), and recovery time (3.8 days vs 9.5 days; P<.001), and lower rates of general anesthesia (36.1% vs 100%; P<.001), blood transfusion (0.9% vs 71.4%; P<.001), and extra use of antibiotics (27.8% vs 78.6%; P<.001), and lower total cost of hospitalization ($3815.78 vs $5730.21; P<.001). CONCLUSIONS: Despite similar efficacy for duct closure with ADO, transvenous approach was associated with fewer acute complications, more periprocedural comfort, and lower cost; thus, transthoracic approach should not be a reasonable choice for duct closure except for particular indications.

[Validation and comparison of pharmacogenetics-based warfarin dosing algorithms in Han Chinese patients].

OBJECTIVE: To assess whether the existing three types of pharmacogenetics-based Warfarin dosing algorithms appropriately predict the actual maintenance dose in Han Chinese mechanical heart valve replacement patients (n = 130). METHODS: The patients' CYP2C9 and VKORC1 genetic polymorphisms were detected by PCR-RFLP. The genotype of CYP2C9, VKORC1 and other information were used to calculate predicted doses. Accuracy of the models was assessed using the absolute value of the difference between predicted dose and actual dose, calculated on both an absolute and percentage basis. Actual weekly dose was also regressed on predicted weekly dose, from which we obtained R(2) values. Clinical accuracy of the predictions was assessed by computing the proportion in which the predicted dose was 20% or more below the actual dose (under dosed), within 20% of the actual dose (ideally dosed), or 20% or greater above the actual dose (over dosed). RESULTS: The average absolute error is the smallest for the predictions made by the Wen model (3.74 mg/wk), followed by the Ohno model (4.07 mg/wk) and IWPC model (5.05 mg/wk). R(2) was 40.2% in the Wen model, 38.2% in the Ohno model and 26.7% in the IWPC model. When comparing the percentage of patients for whom the predicted doses were ideal, the Wen model works the best (50.0%) in low-dose group (≤ 21 mg/wk), but the Ohno model works the best (85.29%) in middle-dose group (21 - 49 mg/wk), followed by the Wen model. CONCLUSION: The best accuracy is achieved by the Wen model and the best clinical accuracy is obtained by the Ohno model for predicting the actual maintenance dose in Han Chinese mechanical heart valve replacement patients.

Intraoperative device closure of perimembranous ventricular septal defects: another safe and feasible alternative to surgical repair in infants.

OBJECTIVES: Conventional surgical closure has been considered the gold standard for the treatment of perimembranous ventricular septal defects (PVSDs) in infants for many years, but it requires a cardiopulmonary bypass and midline sternotomy which can lead to both physical and psychological trauma in the future. An intraoperative device closure can be performed with the advantages of reduced invasion, faster recovery and so on. We evaluate the safety and feasibility of intraoperative device closure of PVSDs in infants in comparison with surgical closure. METHODS: One hundred eighty-six infants with a PVSD were enrolled in our study. Among them, 97 patients were treated by surgical closure and 89 were treated by intraoperative device closure. The success rates, complications, length of hospital stay and costs were measured. RESULTS: The success rate was similar (P = 0.228) in the two groups: 87/89 patients (97.8%) in the device group versus 97/97 patients (100%) in the surgical group. Complication needs management was required in one patient of the device group (1.1%) and in two patients of the surgical group (2.0%) (P = 1.000). Minor complications were observed in 7/87 patients (8.0%) of the device group versus 15/99 patients (15.2%) of the surgical group (P < 0.001). Both groups were similarly effective in reducing the left ventricular end-diastolic dimension, pulmonary arterial pressure and cardiothoracic rate. The procedure time, inpatient stay and intensive care unit stay are shorter in the device group; the total cost was similar for both groups. CONCLUSIONS: Intraoperative device closure of PVSDs under real-time transoesophageal echocardiography guidance is safe and feasible without CPB. Under the right conditions, intraoperative device closure can be a good alternative to surgical closure for the treatment of PVSDs in infants.

[Outcome post orthotopic heart transplantation for patients with end-stage hypertrophic cardiomyopathy].

OBJECTIVE: To investigate the outcome of orthotopic heart transplantation for patient with end-stage hypertrophic cardiomyopathy. METHODS: This retrospective review analyzed the clinical data of nine patients (7 males) undergoing orthotopic heart transplantation for end-stage hypertrophic cardiomyopathy in our center. All patients received induced therapy protocols peri-operative and standard triple maintenance immunosuppressive therapy postoperative. RESULTS: One recipients developed acute renal failure due to renal artery embolism and allograft rejection in the early posttransplantive course, symptoms and signs were improved under continuous renal replacement therapy and steroid-pulse therapy, this patient died of sudden cardiac arrest at 32 months post transplantation. Another recipient developed demyelinating disease in frontal and parietal lobe and finally recovered with medical therapy. Eight patients survived the operation with good quality of life and there was no episode of rejection or infection or chronic graft arteriosclerosis during follow-up time. Three recipients developed left ventricular hypertrophy and there were no signs of grapg-vessel diseases in the survivals. CONCLUSION: Heart transplantation is the best therapeutic option for selected patients with end-stage hypertrophic cardiomyopathy.

[Analysis of surgical treatment for Standford type A aortic dissection].

OBJECTIVE: To summarize the surgical experience of type A aortic dissection. METHODS: From January 2001 to December 2006, 54 cases were admitted for Standford type A aortic dissection, including 36 cases of acute aortic dissection and 18 cases of chronic. Thirty-five cases underwent emergence operation and 11 cases underwent selective/limited operation, while 8 cases received medical treatment According to the modus operandi of root of aorta, 9 cases underwent ascending aorta replacement merely, 11 cases for Bentall operation, 12 cases for Wheat operation and ascending aorta replacement, 14 cases for David operation and ascending aorta replacement. According to the modus operandi of aortic arch and descendens, 6 cases underwent right hemiarch replacement, 25 cases for total arch replacement with four branches aortic graft, 24 cases for stent-graft elephant trunk technique. One patient of coronary heart disease and 1 patient of right coronary fracture underwent coronary artery bypass grafting. Deep hyperthermic circulatory arrest and antegrade selective cerebral perfusion were applied with aortic arch operation. Surface cooling was applied with selective/limited operation. RESULTS: Four patients died in operation group (8.7%) and 8 died in non-operation group (75.0%). Postoperative complication included 1 mental symptom, 3 pleural/pericardial effusion, 1 hoarseness, 1 sternal rupture and poor wound healing. All the complication were cured. The operative out-hospital patients were followed up (13.0 +/- 14.2) months and the quality of life was satisfied. CONCLUSIONS: Standford type A aortic dissection should be operated aggressively. Expected outcome could be acquired with optimum modus operandi, proper cerebral protection and dealing with postoperative complication timely.

[Postoperative monitor of hemodynamics of orthotopic heart transplantation and treatment of its disorders].

OBJECTIVE: To study the postoperative hemodynamics after heart transplantation and treatment for disorders due to denervated transplanted hearts in order to improve the short term outcome of heart transplantation. METHODS: Forty one patients with endstage cardiopathy underwent orthotopic cardiac transplantation. The changes in the graft function were closely monitored during the postoperative period in order to maintain the stability of hemodynamics of the allografts. RESULTS: All recipients received vasoactive drug therapy and 6 recipients died of acute dysfunction of the right ventricle of the allograft during the postoperative period. The remaining patients survived well and led a life with rather good quality. CONCLUSION: The hemodynamic characteristics of a denervated grafted heart are unique. Close monitoring and good nursing care with rational administration of vasoactive drugs are the key measures for the prevention of acute dysfunction of the allograft in the early postoperative period.

[Early outcome of orthotopic heart transplantation: a report of 21 cases].

OBJECTIVE: To report the preliminary experience of 21 orthotopic heart transplantations without early death. METHODS: Between April 2002 and June 2005, 21 patients underwent orthotopic heart transplantation. Recipients' pulmonary vascular resistance ranged from 3.0 to 5.9 wood units [mean (4.3 +/- 1.4) wood units]; Stanford myocardial protective solution or HTK solution was perfused for donor heart myocardial preservation, donor heart cold ischemic period ranged from 52 to 310 min [mean (81 +/- 23) min]; Three patients had previous cardiac operations under cardiopulmonary bypass, conventional Stanford orthotopic cardiac transplantation in 20 cases and total heart technique in 1 case; Recipients received simulect preoperatively and cyclosporine A, cellcept and prednisone postoperatively for prevention of acute allograft rejection; Patients received appropriate medical control of hypertension, hyperglycemia, hypercholesterolemia and uricacidemia. RESULTS: Acute right heart failure in 3 cases and pericardial effusion in 4 cases were observed at the early postoperative stage, but no any infection and acute rejection were found. All patients survived with good life quality. CONCLUSIONS: Heart transplantation may produce satisfying early results. Suitable selection of recipients with low pulmonary vascular resistance, excellent donor heart conservation, practised anastomotic technique, proper immunosuppression treatment and efficient postoperative management are key measures of orthotopic heart transplantation with excellent early outcome.

[Experience in donor-recipient gender mismatching heart transplantation: analysis of seven female patients receiving male donor hearts].

OBJECTIVE: To summarize the experience in donor-recipient gender mismatching heart transplantation. METHODS: Seven female patients with end-stage cardiopathy aged 13 approximately 44, underwent orthotopic transplantation of hearts from male donors. Fine-tuning immunosuppressive protocols were adopted: Stanford classic therapy was applied on 3 cases and immunosupression induction therapy was applied on 4 cases. The clinical outcomes were observed for an average of 20 months (5 approximately 54 months). RESULTS: No acute reject reaction was found in all 7 cases within 3 months postoperatively. The earliest 2 patients died of refractory rejection 38 and 34 months postoperatively due to immunosuppressive withdrawal because of financial difficulty. The other 5 cases resumed their normal work and daily life. No allograft dysfunction, severe opportunistic infection episodes, and injury of liver and kidney functions were found in all cases. CONCLUSION: Fine-tuning immunosuppressive protocols improve the short-term and long-term clinical effects of donor-recipient gender mismatching heart transplantation.