Aortic valve replacement with Y-incision/rectangular patch aortic annular enlargement.

A small aortic root and annulus would need extensive aortic annular enlargement during valve replacement in adult patients to avoid patient-prosthesis mismatch. This report describes a technique that enlarges the aortic annulus by 4-5 valve sizes as well as a modification of the aortotomy with the roof technique to make the aortotomy closure easier and more hemostatic while enlarging the sinotubular junction and proximal ascending aorta effectively for future transcatheter valve-in-valve replacement. Supplementary Information: The online version contains supplementary material available at 10.1007/s12055-023-01606-4.

Subtalar Joint Arthroscopy.

Subtalar arthroscopy is being more commonly utilized by surgeons who perform foot and ankle arthroscopy. The joint can be entered from an anterior lateral or posterior approach. There is unique pathology in the joint that can be repaired through an arthroscopic approach.

Aortic Sinus Contrast Retention During TAVR: A Warning Sign Preceding a Potential Thrombotic Complication.

Sinus contrast material retention after transcatheter aortic valve replacement (TAVR) is a rare phenomenon that may reflect an increased risk for thrombotic complications. We present 3 cases of persistent contrast agent retention in the sinus of Valsalva during the TAVR procedure that portend the occurrence of embolic stroke or bioprosthetic valve thrombosis. (Level of Difficulty: Advanced.).

Mass Spectrometry of Au10(4-tert-butylbenzenethiolate)10 Nanoclusters Using Superconducting Tunnel Junction Cryodetection Reveals Distinct Metastable Fragmentation.

Cryodetection mass spectrometry (MS) was used to study the Au10(TBBT)10 (TBBT = 4-tert-butylbenzenethiolate) catenane nanocluster. The matrix-assisted laser desorption ionization (MALDI) process generates distinct fragments that can be arranged into two distinct regimes: (i) in-source fragmentation, which occurs rapidly in a relatively short (<170 ns) time frame, and (ii) metastable fragmentation, which occurs postacceleration during a time-of-flight (TOF) mass analysis over a longer time frame (>170 ns-250 µs). Using MALDI-TOF MS with superconducting tunnel junction (STJ) cryodetection, distinct metastable nanocluster fragments were resolved at lower energies deposited into the detector. The results also demonstrated that STJ cryodetection MS can be used to acquire multiple (>10), simultaneous tandem mass spectra in a single experiment. Simulated fragmentation of the Au10 nanocluster using ab initio molecular dynamics (AIMD) revealed the different fragmentation processes and confirmed the MS results. Using both the empirical MS data and AIMD calculations, fragmentation pathways are proposed for Au10(TBBT)10, which terminate with two small, stable ringed species.

Snare-Assisted Valve Positioning of Self-Expanding Valves for Transcatheter Aortic Valve Replacement.

We describe 4 cases in which technical challenges were anticipated in delivering a self-expanding TAVR valve due to challenging aortic anatomy or a previous placed surgical aortic valve. An upfront snare strategy is described which facilitates valve centralization and atraumatic valve delivery. (Level of Difficulty: Advanced.).

Bailout From Sinus Jailing: In-Series TAVR-in-TAVR to Avoid Coronary Flow Obstruction.

Redo transcatheter aortic valve replacement (TAVR) may pose the risk of coronary flow obstruction. We report 2 cases of severe TAVR regurgitation due to different physiopathological mechanisms in which TAVR-in-TAVR could be at high risk for sinus sequestration. Both cases were successfully treated by in-series implantation of a second transcatheter heart valve, thus avoiding sinus sequestration. (Level of Difficulty: Intermediate.).

Follow-up aortic dilatation in patients with repaired tetralogy of Fallot using cardiovascular magnetic resonance.

PURPOSE: The study sought to determine the rate of aortic expansion and correlation with somatic growth in patients with repaired tetralogy of Fallot (rTOF), and predictors for determining the annual growth rate of the aorta (Ao-AGR). METHODS: Ninety-four rTOF patients (mean age 14.5 ± 4.4 years) with two cardiac magnetic resonance tests (CMR) (median duration 52 months, interquartile range, IQR 24-71) were analyzed for aortic diameter (AoD) at the annulus, the sinus of Valsalva (SoV), the sinotubular junction, and the ascending aorta (AAo), and compared with the normal limit AoD (NL-AoD) values. The median age-at-repair was 60 months (IQR 36-84). Ao-AGR and its index (Ao-AGRI) were derived from changes of the AoD and AoD-index, respectively, divided by the duration between the two studies. Three potential predictors (baseline AoD, sex, and age-at-repair) for the progression of Ao-AGR were analyzed. RESULTS: There was a significant larger AoD than NL-AoD (p < 0.001). Slow aortic growth was encountered in 78-85 % of patients. The Ao-AGR was slow, the median AGR ranged from 0.37 mm (IQR 0.13-0.72) at annulus to 0.56 mm (IQR 0.22-0.91) at AAo. There was a regression in Ao-AGRI, ranged from -1.41 mm (IQR -1.94, -0.87) at annulus to -2.36 mm (IQR -3.09, -1.63) at SoV. The three predictors were not correlated with severity of Ao-AGR. CONCLUSION: Most adolescents with rTOF show significant aortic dilatation. There is a slow Ao-AGR with regression of Ao-AGRI, which may suggest that the rate of aortic growth is slower than the somatic growth. There are no significant predictors of the progression of Ao-AGR.

First-in-Human Endo-Bentall Procedure for Simultaneous Treatment of the Ascending Aorta and Aortic Valve.

We describe the endovascular management of a middle-aged woman who developed a bleeding suprasternal fistula after conventional aortic valve replacement. The patient's condition was considered inoperable. A customized stent attached to a transcatheter valve was successfully used to treat the individual, this being the first-in-human case of the promising Endo-Bentall procedure. (Level of Difficulty: Advanced.).

Feasibility of Laboratory-Based EXAFS Spectroscopy with Cryogenic Detectors.

Extended X-ray Absorption Fine Structure (EXAFS) spectroscopy is a powerful technique that gives element-specific information about the structure of molecules. The development of a laboratory EXAFS spectrometer capable of measuring transmission spectra would be a significant advance as the technique is currently only available at synchrotron radiation lightsources. Here, we explore the potential of cryogenic detectors as the energy resolving component of a laboratory transmission EXAFS instrument. We examine the energy resolution, count-rate, and detector stability needed for good EXAFS spectra and compare these to the properties of cryogenic detectors and conventional X-ray optics. We find that superconducting tunnel junction (STJ) detectors are well-suited for this application.

Cardiogenic Shock Due to Late Chimney Stent Failure Following Valve-in-Valve Transcatheter Aortic Valve Replacement.

Although the safety of valve-in-valve transcatheter aortic valve replacement has improved, coronary ostium obstruction remains a significant complication, with chimney stenting a possible solution to circumvent this complication. In this case, we discuss the failure of a chimney stent in a case of valve-in-valve transcatheter aortic valve replacement resulting in cardiogenic shock. (Level of Difficulty: Advanced.).

Characterization of ZnO Nanoparticles using Superconducting Tunnel Junction Cryodetection Mass Spectrometry.

Zinc oxide (ZnO) nanoparticles coated with either n-octylamine (OA) or α-amino poly(styrene-co-acrylonitrile) (PSAN) ligands (L) have been analyzed using laser desorption/ionization and matrix assisted laser desorption/ionization (MALDI) time-of-flight (TOF) superconducting tunnel junction (STJ) cryodetection mass spectrometry. STJ cryodetection has the advantage of high m/z detection and allows for the determination of average molecular weights and dispersities for 500-600 kDa ZnO-L nanoparticles. The ability to detect the relative energies deposited into the STJs has allowed for investigation of ZnO-L metastable fragmentation. ZnO-L precursor ions gain enough internal energy during the MALDI process to undergo metastable fragmentation in the flight tube. These fragments produced a lower energy peak, which was assigned as ligand-stripped ZnO cores whereas the individual ligands were at too low of an energy to be observed. From these STJ energy resolved peaks, the average weight percentage of inorganic material making up the nanoparticle was determined, where ZnO-OA and ZnO-PSAN nanoparticles are comprised of ~62% and ~68% wt ZnO, respectively. In one example, grafting densities were calculated based on the metastable fragmentation of ligands from the core to be 16 and 1.1 nm-2 for ZnO-OA and ZnO-PSAN, respectively, and compared with values determined by thermogravimetric analysis (TGA) and transmission electron microscopy (TEM). Graphical Abstract ᅟ.

Sangtongjian Mixture ameliorates glucose and lipid metabolism in type 2 diabetic rats / 中成药

AIM To observe the effects of Sangtongjian Mixture (STJ) on glucose and lipid metabolism,insulin resistance and fat cytokines in type 2 diabetic rats,and their mechanisms of action.METHODS One hundred and forty rats fed on the combination of STZ and high fat diet were established as the type 2 diabetic models.Fasting blood glucose (FBG) level reached more than 16.7 mmol/L and then the rats were randomly divided into model group,metformin (180 mg/kg) group,STJ (73.5,147 and 294 mg/kg) groups.Ten rats were set as the blank group.Each treatment group was intragastrically given the corresponding agents for twelve weeks.The fasting blood glucose levels of rats were measured once every two weeks after the administration.After a 12-week administration period,glycosylated serum protein (GSP),glycosylated hemoglobin (GHb) and lipid profile indices (TC,TG,HDL-C and LDL-C) were determined.The serum insulin level was measured by radioimmunoassay,and homeostasis model assessment of insulin resistance (HOMA-IR) and insulin sensitivity index (ISI) were calculated.The levels of serum adiponectin and leptin were detected by ELISA.RESULTS STJ remarkably decreased the levels of FBG,GSP,GHb,TC,TG,LDL-C,leptin and HOMR-IR in type 2 diabetic rats.Furthermore,STJ also significantly increased the levels of HDL-C,adiponectin and ISI.CONCLUSION STJ can improve glucose and lipid metabolism in type 2 diabetic rats by ameliorating insulin resistance and regulating fat cytokine levels.

Morphometric study of left coronary artery trunk in adult human cadavers: a study on the eastern region population.

INTRODUCTION: The left coronary artery shows a wide range of morphological variations which has great clinical importance. Difficulties may occur during performance of diagnostic procedures, especially in patients who undergo evaluation of percutaneous coronary interventions or during coronary artery surgeries or prosthetic valve replacements. Even, it has been found that short length of main left coronary artery was one of the congenital factors which predisposed to the development of coronary artery disease. The aim of this work was to determine the variations in the origin, length and divisions of the left coronary artery trunk in the eastern region population of India. MATERIALS AND METHODS: The present study was carried out on 100 heart samples which were collected from a mixed race population group from West Bengal, India, after preserving them in 10% formalin solution. While carefully maintaining all standard precautions, scientifically well-planned cadaveric dissections were done and variations were noted. RESULTS: It was found that in all specimens, left coronary artery arose from single ostia at the left posterior aortic sinus. In about 65% cases, ostia was below or at the sinotubular junction (STJ) and in a significant number (35%) of cases, it is above the level of STJ. The mean length of the left coronary artery trunk was found to be 11.42 ± 4.98 mm. LMCA were bifurcated in 56% cases, they were trifurcated in 40% cases and they were tetrafurcated in 2% cases. The results were compared with those of other studies, which showed considerable variations. CONCLUSION: Thus, this morphometric study done on left coronary artery trunk in the eastern Indian population will be helpful for interventional cardiologists and radiologists for avoiding inadvertent vascular trauma during diagnostic and therapeutic procedures.

Aortic root geometry in patients with aortic stenosis assessed by real-time three-dimensional transesophageal echocardiography.

BACKGROUND: The authors hypothesized that aortic root geometry is different between bicuspid and tricuspid aortic stenosis (AS) that can be assessed using real-time three-dimensional (3D) transesophageal echocardiography. The aims of this study were (1) to validate the accuracy of 3D transesophageal echocardiographic measurements of the aortic root against multidetector computed tomography as a reference, (2) to determine the difference of aortic root geometry between patients with tricuspid and bicuspid AS, and (3) to assess its impact on pressure recovery. METHODS: In protocol 1, 3D transesophageal echocardiography and contrast-enhanced multidetector computed tomography were performed in 40 patients. Multiplanar reconstruction was used to measure the aortic annulus, the sinus of Valsalva, and the sinotubular junction area, as well as the distance and volume from the aortic annulus to the sinotubular junction. In protocol 2, the same 3D transesophageal echocardiographic measurements were performed in patients with tricuspid AS (n = 57) and bicuspid AS (n = 26) and in patients without AS (n = 32). The energy loss coefficient was also measured in patients with AS. RESULTS: In protocol 1, excellent correlations of aortic root geometric parameters were noted between the two modalities. In protocol 2, compared with patients without AS, those with tricuspid AS had smaller both sinotubular junction areas and longitudinal distances, resulting in a 23% reduction of aortic root volume. In contrast, patients with bicuspid AS had larger transverse areas and longitudinal distances, resulting in a 30% increase in aortic root volume. The energy loss coefficient revealed more frequent reclassification from severe AS to moderate AS in patients with tricuspid AS (17%) compared with those with bicuspid AS (10%). CONCLUSIONS: Three-dimensional transesophageal echocardiography successfully revealed different aortic root morphologies between tricuspid and bicuspid AS, which have different impacts on pressure recovery.

Pattern of aortic dilatation in different bicuspid aortic valve phenotypes and its association with aortic valvular dysfunction and elasticity.

OBJECTIVES: We aim to study the pattern of aortic dilatation in different BAV phenotypes and to find any correlations between aortic dilatation, aortic elasticity and AS and/or AR in our local population. METHODS: All BAV patients and controls were retrospectively studied. Aortic distensibility and stiffness index of the ascending aorta were calculated. RESULTS: A total of 191 patients with BAV and 180 controls were enrolled. Aortic dilatation involving a single site was more common with dilatation involving only the ascending aorta (R-N phenotype) and aortic root (N-L phenotype). AR was most common in patients with N-L and R-L phenotypes and AS in R-N phenotype. Aortic elasticity had no correlation with the different BAV phenotypes. CONCLUSIONS: There are different patterns of aortic dilatation in different BAV phenotypes, which may further contribute to the development of aortic stenosis or regurgitation. Aortic elasticity is independent of the BAV phenotypes and is impaired in BAV patients regardless of AS or AR severity.

Pattern of ascending aortic dimensions predicts the growth rate of the aorta in patients with bicuspid aortic valve.

OBJECTIVES: This study sought to identify risk factors for rapid growth of the ascending aorta in patients with bicuspid aortic valve (BAV) disease, taking into account its phenotypic variability. BACKGROUND: Phenotypic heterogeneity of BAV-related aortopathy has recently been widely recognized. However, few studies have addressed the determinants of aortic growth so far, not distinguishing among morphological phenotypes. METHODS: Serial retrospective data on 133 adult outpatients with BAV undergoing echocardiographic follow-up were analyzed to search for factors associated with aortic diameter growth over time and with rapid aortic growth (fifth quintile of growth rate distribution), focusing on the impact of different valve morphotypes (i.e., cusp fusion pattern: right-left coronary [RL] and right-noncoronary [RN]) and previously defined aortic phenotypes (nondilated aorta, ascending dilation, root dilation). RESULTS: The RL pattern was present in 69% of patients with BAV and RN in 31%. At baseline, an ascending dilation phenotype was observed in 57% of patients and a root phenotype in 13.5%. No patient with RN-BAV had a root dilation phenotype at either baseline or last examination. Follow-up time averaged 4.0 ± 2.7 years (535 patient-years). The mean growth rate was 0.3 mm/year at the sinuses and 0.6 mm/year at the ascending level. Aortic regurgitation predicted an increase in ascending diameter over time (odds ratio [OR]: 2.3; p = 0.03). Root phenotype at presentation, not absolute baseline diameter, was an independent predictor of fast progression (>0.9 mm/year) for the ascending tract (OR: 14; p = 0.001). Fast growth was rarely seen in patients with the RL morphotype and ascending phenotype (6% at the root and 10% at the ascending level). CONCLUSIONS: In patients with BAV, the root phenotype (aortic dilation predominantly at the sinuses, with normal or less dilated ascending tract) may be a marker of more severe aortopathy, warranting closer surveillance and earlier treatment. The more common ascending phenotype proved to be a more stable disease entity, generally with slower progression.

Soft X-ray absorption spectroscopy and resonant inelastic X-ray scattering spectroscopy below 100 eV: probing first-row transition-metal M-edges in chemical complexes.

X-ray absorption and scattering spectroscopies involving the 3d transition-metal K- and L-edges have a long history in studying inorganic and bioinorganic molecules. However, there have been very few studies using the M-edges, which are below 100 eV. Synchrotron-based X-ray sources can have higher energy resolution at M-edges. M-edge X-ray absorption spectroscopy (XAS) and resonant inelastic X-ray scattering (RIXS) could therefore provide complementary information to K- and L-edge spectroscopies. In this study, M2,3-edge XAS on several Co, Ni and Cu complexes are measured and their spectral information, such as chemical shifts and covalency effects, are analyzed and discussed. In addition, M2,3-edge RIXS on NiO, NiF2 and two other covalent complexes have been performed and different d-d transition patterns have been observed. Although still preliminary, this work on 3d metal complexes demonstrates the potential to use M-edge XAS and RIXS on more complicated 3d metal complexes in the future. The potential for using high-sensitivity and high-resolution superconducting tunnel junction X-ray detectors below 100 eV is also illustrated and discussed.

Histopathology of the great vessels in patients with pulmonary arterial hypertension in association with congenital heart disease: large pulmonary arteries matter too.

BACKGROUND: Pulmonary arterial hypertension (PAH) is considered primarily a disease of the distal pulmonary arteries whereas little is known on the effect of long-standing pulmonary hypertension on the larger proximal pulmonary arteries. This study aims to investigate the structural changes in the great arteries of adults who developed PAH in association with congenital heart disease (CHD), with severe cases termed Eisenmenger syndrome. METHODS: We performed macroscopic and light microscopy analyses on the great arteries of 10 formalin-fixed human hearts from patients with PAH/CHD and compared them to age-matched healthy controls. A detailed histology grading score was used to assess the severity of medial wall abnormalities. RESULTS: Severe atherosclerotic lesions were found macroscopically in the elastic pulmonary arteries of 4 PAH/CHD specimens and organised thrombi in 3; none were present in the controls. Significant medial wall abnormalities were present in the pulmonary trunk (PT), including fibrosis (80%), and atypical elastic pattern (80%). Cyst-like formations were present in less than one third of patients and were severe in a single case leading to wall rupture. The cumulative PT histology grading score was significantly higher in PAH/CHD cases compared to controls (p<0.0001) and correlated positively with larger PT diameters (ρ=0.812, p<0.0001) and the degree of medial wall hypertrophy (ρ=0.749, p<0.0001). CONCLUSIONS: Chronic PAH in association with CHD results in marked macroscopic and histological abnormalities in the large pulmonary arteries. These abnormalities are likely to affect haemodynamics and contribute to morbidity and mortality in this cohort.

Numerical model of the aortic root and valve: optimization of graft size and sinotubular junction to annulus ratio.

OBJECTIVE: The aim of this study was to determine the influence of aortic annulus (AA) diameter and the ratio of the sinotubular junction (STJ) diameter to the AA diameter on aortic valve hemodynamics and tissue mechanics and to suggest optimal values. METHODS: Sixteen cases of aortic roots with AA diameters between 22 and 28 mm and an STJ/AA diameter ratio between 0.8 and 1.4 were numerically modeled. Average coaptation height and mechanical stresses were calculated from 3-dimensional finite element analysis of the aortic valve and root. Five additional fluid structure interaction (FSI) models with an AA diameter of 24 mm and an STJ/AA ratio between 0.6 and 1.4 were also constructed. The material properties of the tissues were from porcine valves and boundary conditions were physiologic and normal blood pressures. RESULTS: In most cases, average coaptation height decreased with an increase in the STJ/AA ratio. Those cases with AA diameters between 24 and 26 mm and an STJ/AA ratio between 0.8 and 1.0 had a relatively large average coaptation height (>3 mm) and similar stress distribution during diastole. The flow shear stress values on the cusps at peak systole increased at the same time as the STJ/AA ratio decreased, similar to the opening area. CONCLUSIONS: Relatively large coaptation, low stress in the tissues during diastole, and low flow shear stress during systole is the best combination for cases of AA diameter between 24 and 26 mm with identical STJ diameter. Valve-sparing procedures that prevent AA expansion are preferable.