Sequential multidisciplinary minimally invasive therapeutic strategy for heart failure caused by four diseases: A case report.

BACKGROUND: The coexistence with patent ductus arteriosus (PDA), mitral valve prolapse (MVP), atrial fibrillation (AF) and hyperthyroidism is extremely rare and complex. The optimal therapeutic strategy is difficult to develop. CASE SUMMARY: A 27-year-old female with PDA, MVP, AF and hyperthyroidism presented with severe dyspnea. Given that a one-stage operation for PDA, MVP and AF is high risk, we preferred a sequential multidisciplinary minimally invasive therapeutic strategy. First, PDA transcatheter closure was performed. Hyperthyroidism and heart failure were simultaneously controlled via medical treatment. Video-assisted thoracoscopic mitral valve repair and left atrial appendage occlusion were performed when heart failure was controlled. Under this therapeutic strategy, the patient's sinus rhythm was restored and maintained. Two years after the treatment, the symptoms of heart failure were relieved, and the enlarged heart was reversed. CONCLUSION: Sequential multidisciplinary therapeutic strategies, which take advantage of both internal medicine and surgical approaches, might be reasonable for this type of disease.

[Professor FANG Jian-qiao's clinical experiences in the identification and treatment of cranial tinnitus].

On the base of the relevant theories on disease identification of western medicine and traditional Chinese medicine, professor FANG Jian-qiao has made the differentiation of cranial tinnitus and proposes the intervention measures. The location of disease is identified firstly. Secondly, the deficiency is distinguished from the excess, and the involved zangfu organs are determined as well. In view of the holistic idea and in combination of meridian differentiation of acupuncture-moxibustion, the principle of treatment is proposed, named "regulating qi, harmonizing blood circulation, clearing office and tranquilizing the mind". In treatment, the disease is treated individually. According to the involved location of onset and the related meridian running course, acupuncture-moxibustion therapy is exerted, in which, the local acupoints are combined with the distal ones. Additionally, electroacupuncture is used flexibly. The appropriate electric wave and frequency are selected in consideration of the syndromes/patterns of disease so as to optimize the regimen of acupuncture-moxibustion therapy. All of the approaches aforementioned provide the reference to clinical treatment of traditional Chinese medicine.

Left ventricular end-diastolic strain rate recovered in hypothyroidism following levothyroxine replacement therapy: A strain rate imaging study.

BACKGROUND: This study aimed to explore the impact of overt hypothyroidism on diastolic left ventricular (LV) deformation and the effect of levothyroxine therapy using 2-dimensional speckle-tracking echocardiography (STE) strain rate (SR) imaging. METHODS: Forty-seven newly diagnosed hypothyroidic patients and 51 controls were prospectively enrolled. All participants underwent comprehensive 2-dimensional echocardiography. Besides the recently recommended parameters of LV diastolic function, strain imaging for LV systolic global longitudinal strain (GLS), and diastolic SR imaging at isovolumic relaxation period (SRivr), early (SRe) and late (SRa) diastole were assessed. Repeated echocardiography in hypothyroidic patients was made 6 months after the euthyroidic state was achieved. RESULTS: Hypothyroidic patients had a lower ejection fraction (EF) than the controls (68.6 ± 5.2% vs 71.5 ± 4.0%, P = 0.002) but all within normal range (57%-80% and 64%-79%, respectively). No difference in the ratio of early mitral flow (E) to early diastolic septal or lateral myocardial motion velocity (e') was found (both P > 0.05), but significant difference was identified for SRa (0.85 ± 0.17 [/s] vs 1.00 ± 0.17 [/s], P = 0.000) and GLS (-20.8 ± 3.2% vs -23.6 ± 2.3%, P = 0.000). Upon follow-up, LV SRa (1.01 ± 0.20 [/s], P = 0.99 vs control) normalized when GLS (-21.6 ± 3.1%, P = 0.004 vs control) remained worse than the controls. CONCLUSION: This study demonstrates subtle LV diastolic impairment in untreated hypothyroidic patients using SR imaging, which normalizes with short-term therapy and predates GLS.

Impaired Right Ventricular Mechanics at Rest and During Exercise Are Associated With Exercise Capacity in Patients With Hypertrophic Cardiomyopathy.

Background Impaired right ventricular ( RV ) function indicates RV involvement in patients with hypertrophic cardiomyopathy ( HCM ). We aimed to assess RV function at rest and during exercise in HCM patients and to examine the association between impaired RV mechanics and exercise capacity. Methods and Results A total of 76 HCM patients (48 without and 28 with RV hypertrophy) and 30 age- and sex-matched controls were prospectively recruited. RV function was evaluated at rest and during semisupine bicycle exercise by conventional echocardiography and 2-dimensional speckle-tracking imaging. Exercise capacity was measured by metabolic equivalents. RV functional reserve was calculated as the difference of functional parameters between peak exercise and rest. Compared with controls, HCM patients had significantly higher RV free wall thickness, lower RV global longitudinal strain and RV free wall longitudinal strain at rest and during exercise, and reduced RV systolic functional reserve. Compared with those with HCM without RV hypertrophy, patients with HCM with RV hypertrophy had lower metabolic equivalents. Among HCM patients, an effective correlation was seen between exercise capacity and peak exercise RV global longitudinal strain and peak exercise RV free wall longitudinal strain. A binary logistic regression model revealed several independent predictors of exercise intolerance in HCM patients, but receiver operating characteristic curve analysis indicated exercise RV global longitudinal strain had the highest area under the curve for the prediction of exercise intolerance in HCM patients. Conclusions HCM patients have RV dysfunction and reduced contractile reserve. Exercise RV global longitudinal strain correlates with exercise capacity and can independently predict exercise intolerance. In addition, patients with HCM with RV hypertrophy exhibit more reduced exercise capacity, suggesting more severe disease and poorer prognosis.

Decreased biventricular mechanics and functional reserve in nonobstructive hypertrophic cardiomyopathy patients: implications for exercise capacity.

The present study investigated the changes of biventricular mechanics at rest and during exercise and examined the association between exercise capacity and biventricular mechanics and functional reserve in nonobstructive hypertrophic cardiomyopathy (NHCM) patients. A total of 50 NHCM patients and 25 controls were consecutively recruited for this study. Using echocardiography and two-dimensional speckle-tracking imaging, an experienced echocardiographer determined the following indices: RV free wall longitudinal strain (RVFWLS), LV global longitudinal strain (LVGLS), strain rate (SR), and functional reserve of strain values. We also investigated the relationships between biventricular mechanics and exercise capacity using metabolic equivalents (METs). NHCM patients had lower RVFWLS, LVGLS, systolic SR, early diastolic SR, and systolic and diastolic reserve during exercise compared to controls. An association of biventricular mechanics (LVGLS, RVFWLS) with exercise capacity at rest and during exercise was established. Multivariable logistic regression revealed that RVFWLS and LVE/e' during exercise (RVFWLS-exe, E/e'-exe) were independent predictors of exercise intolerance. Receiver operating characteristic curve analysis indicated that LVE/e'-exe had a higher area under the curve for predicting exercise intolerance in NHCM patients. In hierarchical analysis, RVFWLS-exe provided an incremental predictive value of exercise intolerance over LVGLS during exercise (LVGLS-exe) and LVE/e'-exe. LVE/e'-exe also changed incrementally compared to LVGLS-exe and RVFWLS-exe. NHCM patients have decreased biventricular mechanics at rest and during exercise and impaired biventricular functional reserve, and biventricular mechanics are associated with functional capacity. We propose that simultaneous evaluation of biventricular function should provide incremental predictive value for exercise intolerance.

Impaired left ventricular mechanics and functional reserve are associated with reduced exercise capacity in patients with hypertrophic cardiomyopathy.

BACKGROUND: Reduced metabolic equivalents (METs) are an indicator of exercise intolerance, which predicts poor prognosis in hypertrophic cardiomyopathy (HCM) patients. We sought to evaluate the changes in left ventricular (LV) mechanics and functional reserves, as well as their association with functional capacity in HCM patients. METHODS: Seventy HCM patients and thirty controls were included in this study. LV mechanics were evaluated at rest and during exercise by echocardiography and two-dimensional speckle-tracking imaging to obtain parameters of functional reserve, LV global longitudinal strain (LVGLS), strain rate (SR), and circumferential strain. RESULTS: Hypertrophic cardiomyopathy (HCM) patients had lower LVGLS, systolic SR, early and late diastolic SR at rest and during exercise, and reduced absolute and relative systolic and diastolic reserve compared to controls. LV circumferential strain was significantly higher at rest but lower during exercise in HCM patients. Exercise capacity was markedly reduced in HCM patients, and peak exercise LVGLS (LVGLS-exe) significantly correlated with exercise capacity. Multivariate regression analyses showed that LVGLS-exe, LV filling pressure during exercise (E/e'-exe), and LV mass index (LVMI) were independent predictors of exercise capacity. Moreover, LVGLS-exe displayed incremental predictive value over E/e'-exe and LVMI for exercise intolerance. Receiver operating characteristic curve analysis showed LVGLS-exe had optimal accuracy for predicting exercise intolerance in HCM patients. CONCLUSIONS: Hypertrophic cardiomyopathy (HCM) patients have reduced LV mechanics at rest and during exercise and impaired mechanical reserve. LVGLS-exe is associated with exercise capacity and is an optimal predictive value for reduced exercise capacity in HCM patients.

17ß-estradiol preserves right ventricular function in rats with pulmonary arterial hypertension: an echocardiographic and histochemical study.

Pulmonary arterial hypertension (PAH) is more prevalent in females. Paradoxically, female patients have better right ventricular (RV) function and higher survival rates than males. However, the effects of 17ß-estradiol (E2) on RV function in PAH has not been studied. Twenty-four male rats were exposed to monocrotaline (MCT) to induce experimental PAH, while treated with E2 or vehicle respectively. Together with eight control rats, thirty-two rats were examined by echocardiography 4 weeks after drug administration. Echocardiographic measurement of RV function included: tricuspid annular plane systolic excursion (TAPSE), RV index of myocardial performance (RIMP), RV fractional area change (RVFAC) and tricuspid annular systolic velocity (s'). RV free wall longitudinal strain (RVLSFW) and RV longitudinal shortening fraction (RVLSF) were also used to quantify RV function. RV morphology was determined by echocardiographic and histological analysis. TAPSE, RVFAC and s' were reduced, and RIMP was elevated in the MCT-treated group and vehicle-treated group, when compared with control group (P < 0.01). TAPSE, RVFAC and s' in the E2 group were higher, while RIMP was lower than those in the MCT-treated group and vehicle-treated group (P < 0.01). Myocardial functional parameters (RVLSFW and RVLSF) were also higher in the E2 group. Enhanced serum E2 levels were closely correlated with the improvement in RV functional parameters and enhancement of serum BNP levels (P < 0.01 for all groups). RV function decreased significantly in male rats with MCT-induced PAH, while E2 exhibited a protective effect on RV function, suggesting that E2 is a critical modulator of sex differences in PAH.

Involvement of Oct4 in the pathogenesis of thoracic aortic dissection via inducing the dedifferentiated phenotype of human aortic smooth muscle cells by directly upregulating KLF5.

OBJECTIVE: To investigate the expression of Oct4 in human thoracic aortic dissection (TAD) and the regulation mechanisms of Oct4 on phenotype transition of human aortic smooth muscle cells (HASMCs). METHODS: Aortic samples from TAD patients (n = 12) and organ donors (n = 6) were collected. qRT-PCR, western blot, and immunohistochemistry were performed to identify Oct4 expression in aortic media. Immunofluorescence was performed to analyze Oct4 expression in primary HASMCs. Oct4A and Oct4B isoforms were detected. Gain-of-function experiments were performed to determine the effects of Oct4 on HASMC phenotype transition. Chromatin immunoprecipitation, luciferase assay, and rescue experiments were performed to analyze mechanisms of Oct4 on HASMC phenotype transition. RESULTS: Oct4 expression levels, especially the Oct4A isoform, were significantly higher in TAD patients compared with normal controls. Notably, Oct4 presented a strong and strict nuclear localization in primary HASMCs of TAD patients but a mild and diffuse distribution in both cytoplasm and nucleus in the control group. Overexpression of Oct4 induced dedifferentiation of HASMCs characterized by decreased contractile proteins and elevated migration capability. Krüppel-like factor 5 (KLF5) was found to be a directly regulated target gene of Oct4 in HASMCs. Furthermore, downregulation of KLF5 significantly alleviated the effects of Oct4 on phenotype transition of HASMCs. CONCLUSIONS: Oct4 expression was significantly upregulated in aortic tissues and primary HASMCs of TAD patients. The increased Oct4 induced phenotype transition of HASMCs from the contractile type to the synthetic type by directly upregulating KLF5.

Proximal aortic repair versus extensive aortic repair in the treatment of acute type A aortic dissection: a meta-analysis.

OBJECTIVES: The optimal surgical strategy for acute type A aortic dissection (ATAAD) is still controversial because of the inconsistent or even conflicting results of proximal aortic repair (PR) versus extensive aortic repair (ER) on early and late prognostic outcomes. This meta-analysis pooled data from all available studies of PR versus ER to get a summarized conclusion. METHODS: Studies were identified by searching the Medline, EMBASE and Cochrane databases. Early and late prognostic outcomes of interest were evaluated with meta-analysis. Fixed- or random-effect models were used according to the significance of heterogeneity. Robustness of pooled estimates and the source of heterogeneity were assessed via sensitivity analyses and meta-regression, respectively. Publication bias was evaluated by the funnel plot and Egger's test. RESULTS: Nine studies with a total of 1872 patients were included for the meta-analysis. Pooled results indicated that, when compared with the ER procedure, PR was associated with lower early mortality [risk ratio (RR) = 0.69, 95% confidence interval (CI) 0.54-0.90, P = 0.005] but higher incidence of postoperative aortic events including reoperation of the distal aorta (RR = 3.14, 95% CI 1.74-5.67, P < 0.001). PR and ER demonstrated analogous prognosis on long-term mortality (HR = 1.02, 95% CI 0.51-2.06, P = 0.96) and the incidences of early postoperative renal failure (RR = 0.75, 95% CI 0.49-1.14, P = 0.17) and stroke (RR = 0.73, 95% CI 0.30-1.78, P = 0.50). All the pooled results were robust to sensitivity analysis. Heterogeneity was insignificant except for the meta-analysis of late mortality. CONCLUSIONS: Performing a less aggressive initial surgical procedure of PR in ATAAD patients would have lower early mortality but elevated incidence rates of late aortic reintervention, when compared with ER. Other prognostic results of the two surgical strategies including long-term mortality were similar for both.

Immediate- and medium-term effects of simultaneous percutaneous corrections of secundum type atrial septal defect combined with pulmonary valve stenosis in local anesthesia and without transesophageal echocardiography guidance.

BACKGROUND: The feasibility and efficacy of simultaneous percutaneous treatment of secundum type atrial septal defect (ASD) combined with pulmonary valve stenosis (PS) have not been proved. OBJECTIVE: To evaluate the safety and efficacy on the clinical benefit of simultaneous percutaneous correction of these two pathologies under local anesthesia and without transesophageal echocardiography guidance. METHODS: Transpulmonary gradient, functional status, pulmonary regurgitation (PR), and tricuspid regurgitation (TR) were studied in 35 patients undergoing percutaneous balloon pulmonary valvuloplasty and ASD closure from March 2004 to July 2012. All patients were followed up until January 2013, an average of 39 months. RESULTS: According to color Doppler transthoracic echocardiography (TTE) before the intervention, the ASD defect size and transpulmonary gradient were 17±8.4 mm and 88±37.8 mmHg, respectively. Post-interventionally, the peak-to-peak transpulmonary gradient decreased from 77±37.6 mmHg to 20±16.2 mmHg (p<0.001) and the ASD occluder size was 23±10.5 mm. In all those patients, there was no residual shunt detected, and moderate and severe TR decreased from 45.7% (16/35) and 20% (7/35) to 8.6% (3/35) and 5.7% (2/35) before and after intervention detected by TTE, respectively. Eight patients had mild PR after procedure and two of them recovered at 6 months and no patient encountered severe adverse events at the latest follow-up. CONCLUSION: Simultaneous percutaneous corrections of ASD combined with PS are feasible, safe, and effective with satisfactory results.

A rare cause of cyanosis: hepatopulmonary syndrome caused by congenital extrahepatic portosystemic shunt.

A 19-year-old male patient presented cyanosis and dyspnoea because of the presence of multiple pulmonary arteriovenous fistulas resulting in oxygen desaturation. The CTA revealed that intestinal and splenic venous blood bypasses the liver and drains into the inferior vena cava. This is the first reported case of hepatopulmonary syndrome caused by congenital extrahepatic portosystemic shunt in which intestinal and splenic venous blood bypasses the liver and drains into the inferior vena cava.

Effects of the dietary supplementation with fructooligosaccharides on the excretion of nitrogen and phosphorus in Miichthys miiuy fries.

Effects of dietary supplementation with fructooligosaccharides on the excretion of nitrogen and phosphorus in Miichthys miiuy fries were investigated. Nine hundred Miichthys miiuy fries were divided into 3 groups, each with triplicates. The basal diet and the basal diet supplemented with carnitine groups were considered as the negative and positive controls respectively. Results showed that the nitrogen concentration in excreted feces decreased significantly in fries fed the diet supplementation with 1000 x 10(-6) fructooligosaccharides and 200 x 10(-6) carnitine (P<0.05). The ammonic-nitrogen concentration decreased significantly in the carnitine group only (P<0.05), indicating the decreasing tendency caused by the supplementation with fructooligosaccharides. Supplementation with both did not have significant effects on the concentration of phosphorus in feces of Miichthys miiuy fries.