“缘对缘”联合人工瓣环修复术治疗二尖瓣关闭不全42例分析

【】 目的 探讨“缘对缘”联合人工瓣环修复二尖瓣成形术治疗二尖瓣关闭不全的手术效果。方法 回顾性分析2004年1月至2008年12月对42例非风湿性二尖瓣关闭不全患者行“缘对缘”联合人工瓣环修复二尖瓣成形术的临床资料,男25例,女17例;年龄12～69岁(36.42±14.28岁),其中先天性二尖瓣病变12例,瓣膜退行性病变20例,缺血性二尖瓣关闭不全7例,感染性心内膜炎3例。术前心脏彩超提示：前叶病变27例,前叶 后叶病变17例;二尖瓣重度反流19例,中度至重度14例,中度反流9例;42例患者均在全身麻醉低温体外循环下应用“缘对缘”联合人工瓣环修复术进行二尖瓣成形术。术中应用250mL注射器向左心室注冰盐水观察评价成形后二尖瓣反流情况,脱离体外循环后经食管超声心动图观察成形结果。分别测量术前及术后二尖瓣反流面积、二尖瓣开口面积、左房内径及左室舒张末期内径,左室射血分数,应用t检验,研究手术前后二尖瓣反流、心脏大小变化、心功能改善情况。检验水准α=0.05。结果 全组无死亡病例,出院时心脏功能(NYHA分级)I级32例,Ⅱ级10例。随访39例,随访时间1-60(24.6±18.2)个月。超声心动图提示：术前二尖瓣反流面积为11.0cm₂±3.8cm₂,术后1年无或微量反流13例,轻度反流17例,轻度至中度反流9例,轻度二尖瓣狭窄1例,反流面积为4.1cm₂±1.4cm₂;术前二尖瓣开口面积4.14 cm₂±1.54cm₂,术后一年为3.58 cm₂±1.10cm₂;术前左心房内径为48.6mm±12.4mm,术后1年为36.5 mm±9.4mm;术前左心室舒张末径为64.3 mm±11.4mm,术后1年为50.6 mm±7.6mm;术前左心室射血分数为54.6%±6.2％,术后1年提高为63.4%±4.0％。结论“缘对缘”联合人工瓣环修复二尖瓣成形术治疗二尖瓣关闭不全手术方法安全、有效,可获得良好的治疗效果。     

Predictors for long‐term survival after transcatheter edge‐to‐edge mitral valve repair

Objectives

To determine predictors for long‐term outcome in high‐risk patients undergoing transcatheter edge‐to‐edge mitral valve repair (TMVR) for severe mitral regurgitation (MR).

Background

There is no data on predictors of long‐term outcome in high‐risk real‐world patients.

Methods

From August 2009 to April 2011, 126 high‐risk patients deemed inoperable were treated with TMVR in two high‐volume university centers.

Results

MR could be successfully reduced to grade ≤2 in 92.1% of patients (116/126 patients). Long‐term clinical follow‐up up to 5 years (95.2% follow‐up rate) revealed a mortality rate of 35.7% (45/126 patients). Repeat mitral valve treatment (surgery or intervention) was needed in 19 patients (15.1%). Long‐term clinical improvement was demonstrated with 69% of patients being in NYHA class ≤II. In a multivariable Cox regression analysis, the post‐procedural grade of MR (hazard ratio [HR] 1.55 per grade, P = 0.035), the left ventricular ejection fraction (HR 0.58 for difference between 75th and 25th percentile, P = 0.031) and the glomerular filtration rate (HR 0.33 for 75th vs 25th percentile, P < 0.001) were independent predictors for long‐term mortality. Patients with primary MR and a post‐procedural MR grade ≤1 had the most favorable long‐term outcome.

Conclusions

This study determines predictors of long‐term clinical outcome after TMVR and demonstrates that the grade of residual MR determines long‐term survival. Our data suggest that it might be of benefit reducing residual MR to the lowest possible MR grade using TMVR—especially in selected high‐risk patients with primary MR who are not considered as candidates for surgical MVR.

     

An unusual cause of recurrent mitral regurgitation after percutaneous mitral valve repair

Recurrent flail leaflet represents an infrequent cause of recurrent mitral regurgitation after MitraClip. This report presents a case of recurrent severe MR due to a ruptured chorda tendineae after edge‐to‐edge repair.     

Algorithm effects on computerized vessel analysis from digitized cine film and a new method of generating the centerline of a vessel

This study concerns methods of accurately measuring vessel diameters using coronary cineangiograms. Various edge detection filters are compared and a new method for determining the centerline of a vessel is developed. Vessel phantoms of different sizes are used to evaluate the precision and accuracy of an entropy filter, a combined first and second derivative filter, a Laplace-Gaussian filter, a first derivative filter and a second derivative filter. The entropy filter is found to yield the most reliable, precise and accurate data. For use in a clinical case with an irregular arterial wall, a new method of determining the centerline is delineated in which the centerline of a vessel (which we define as a set of points having equal distance to each of any two opposite edge lines) is calculated with images called distance maps. We find that this method of detecting the centerline provides an acceptable assessment of the centerline on visual evaluation.     

Influence of experience on procedure steps,safety, and functional results in edge to edge mitral valve repair—a single center study

Objectives: We sought to determine the effects of experience on the Mitraclip^® procedure steps as well as procedure safety and functional results. Background: MR has proven deleterious in heart failure. Mitraclip^® therapy evolved an important option in patients with severely reduced left ventricular function (LVEF). Methods: Between 2011 and 2016, 126 consecutive patients were grouped in three groups and investigated in a prospective observational study. We evaluated the duration of procedural steps, safety endpoints, and functional results. Results: The median logistic EuroScore was 32% (7–40%). Ninety‐five percent of patients were in NYHA‐stage ≥III and 51% had a LVEF <30%. Groups were homogeneous as to their baseline NYHA status and right heart catheterization data. Echocardiography data are comparable, albeit with a decreasing effective regurgitant orifice area (0.44 ± 0.21 group I vs. 0.34 ± 0.22 group III, P = 0.02). Frailty was less frequent and baseline 6 min walking test results improved from group I to group III. Duration of a first clip placement decreased from 106 ± 50 to 50 ± 21 min (P < 0.001). Total procedure time decreased from 221 ± 70 to 144 ± 68 (P < 0.001). The number of clips implanted increased from 66 to 79 (P = 0.02). MitraClip^® implantation was effective in either group but the combined safety endpoint was reached less frequent in group III (P = 0.01). There was no difference in MACCE rate, 30 day‐ or intrahospital‐mortality between groups. Conclusion: Safety and duration of procedure steps improved substantially with experience. MR reduction was sustained from the beginning without further improvement. Patient selection is a key factor for success. © 2016 Wiley Periodicals, Inc.     

Echocardiographic evaluation of mitral valve repair by modified "edge to edge" technique

The "edge to edge" or "double-orifice" technique is an alternative surgical option of mitral valve repair to treat mitral regurgitation. Echocardiography is very useful to evaluate the postoperative valve function, but since this technique is not frequently used, there is little experience about its echocardiographic features, which are different from those of the classic mitral valve repair. In this report, we present a patient who underwent this repair with a modified approach called "triple-orifice technique" and was evaluated by transthoracic and transesophageal echocardiography.     

Topological quantum phase transitions driven by external electric fields in Sb₂Te₃ thin films

Using first-principles calculations, we show that topological quantum phase transitions are driven by external electric fields in thin films of Sb(2)Te(3). The film, as the applied electric field normal to its surface increases, is transformed from a normal insulator to a topological insulator or vice versa depending on the film thickness. We identify the band topology by directly calculating the Z(2) invariant from electronic wave functions. The dispersion of edge states is also found to be consistent with the bulk band topology in view of the bulk-boundary correspondence. We present possible applications of the topological phase transition as an on/off switch of the topologically protected edge states in nano-scale devices.     

Manual or semi-automated edge detection of the maximal far wall common carotid intima-media thickness: a direct comparison

Abstract. Peters SAE, den Ruijter HM, Palmer MK, Grobbee DE, Crouse JR, O’Leary DH, Evans GW, Raichlen JS, Lind L, Bots ML, on behalf of the METEOR Study Group (University Medical Center Utrecht, Utrecht, The Netherlands; Keele University, Keele, UK; Wake Forest University School of Medicine, Winston‐Salem, NC, USA; Caritas Carney Hospital, Boston, MA, USA; Wake Forest University School of Medicine, Winston‐Salem, NC, USA; AstraZeneca, Wilmington, DE, USA; and Uppsala University Hospital, Uppsala, Sweden). Manual or semi‐automated edge detection of the maximal far wall common carotid intima–media thickness: a direct comparison. J Intern Med 2012; 271 : 247–256. Background. Automated edge detection is thought to be superior to manual edge detection in quantification of the far wall common carotid intima–media thickness (CIMT), yet published evidence making a direct comparison is not available. Methods. Data were used from the METEOR study, a randomized placebo‐controlled trial among 984 individuals showing that rosuvastatin attenuated the rate of change of 2 year change in CIMT among low‐risk individuals with subclinical atherosclerosis. For this post hoc analysis, CIMT images of the far wall of the common carotid artery were evaluated using manual and semi‐automated edge detection and reproducibility, relation to cardiovascular risk factors, rates of change over time and effects of lipid‐lowering therapy were assessed. Results. Reproducibility was high for both reading methods. Direction, magnitude and statistical significance of risk factor relations were similar across methods. Rate of change in CIMT in participants assigned to placebo was 0.0066 mm per year (SE: 0.0027) for manually and 0.0072 mm per year (SE: 0.0029) for semi‐automatically read images. The effect of lipid‐lowering therapy on CIMT changes was ?0.0103 mm per year (SE: 0.0032) for manual reading and ?0.0111 mm per year (SE: 0.0034) for semi‐automated reading. Conclusion. Manual and semi‐automated readings of the maximal far wall of the common CIMT images both result in high reproducibility, show similar risk factor relations, rates of change and treatment effects. Hence, choices between semi‐automated and manual reading software for CIMT studies likely should be based on logistical and cost considerations rather than differences in expected data quality when the choice is made to use far wall common CIMT measurements.     

Repeated MitraClip procedure in patients with recurrent MR after a successful first procedure: Limitations and outcome

Objectives

The present study aimed to evaluate the outcome and potential limitations of a repeated MitraClip procedure (ReClip).

Background

The MitraClip procedure has emerged as a treatment option in high surgical risk patients suffering from severe mitral regurgitation (MR). However, despite successful initial repair a significant number of patients develops severe recurrent MR.

Methods

Patients undergoing a ReClip procedure in our institution were retrospectively identified. Baseline data and the procedural outcome were assessed to identify potential limitations of such procedures.

Results

Fifteen out of 234 patients undergoing a mitral‐valve repair with the MitraClip device (Abbott Vascular) underwent a ReClip due to recurrent MR. In 11 patients, a MR reduction of at least one degree without causing mitral valve stenosis (trans‐mitral mean gradient ≥5 mmHg) was achieved by performing a ReClip. After 1 year, two patients developed severe recurrent MR again. Pulmonary artery pressures significantly decreased after the procedure in individuals with successful repair (MR reduction of at least one degree and mitral valve mean gradient <5 mmHg).

Conclusion

A ReClip procedure may be feasible in patients with recurrent MR but the risk benefit ratio should be carefully balanced against other treatment options.     

经皮冠状动脉介入治疗后支架边缘夹层的光学相干断层成像评价

目的 应用高分辨率的光学相干断层成像（OCT）对支架术后支架边缘夹层的发生率及其预后进行评价.方法 选取2009年11月至2012年11月行经皮冠状动脉介入（PCI）治疗后接受OCT检查的患者,利用OCT对支架边缘的图像进行分析与测量,计算OCT观察到的支架边缘夹层的发生率,记录支架边缘夹层的撕裂深度、开口宽度、撕裂片最大长度等数据并进行分析,观察斑块的性质并随访12个月观察预后.结果 入选92例患者,扫描106枚支架,纳入分析的支架边缘区域184个,最终发现18例患者的20个支架部位和24个支架边缘出现夹层,应用OCT观察PCI术后夹层发生率为19.6％,明显高于造影发现.这些患者的特征是年龄更大（P＜0.001）、高血压（P=0.007）及吸烟（P=0.049）的更多,多发生于钙化斑块（P=0.002）、纤维斑块较少见（P=0.008）.随访12个月,仅被OCT发现的夹层患者与无夹层患者相比,主要不良心血管事件差异无统计学意义.结论 应用OCT观察发现PCI术后夹层的发生率明显高于造影,其中仅被OCT发现的夹层预后良好.     

The role of filament-packing dynamics in powering amoeboid cell motility

Although several models have been proposed to account for how cytoskeleton polymerization drives protrusion in cell motility, the precise mechanism remains controversial. Here, we show that, in addition to force exerted directly against the membrane by growing filaments, the way elongating filaments pack also contributes to protrusion by generating an expansion of the cytoskeleton gel. Tomography shows that filament packing in the major sperm protein (MSP) -based nematode sperm-motility machinery resembles that observed with rigid rods. Maximum rod-packing density decreases dramatically as the rods lengthen. Therefore, as filaments elongate, the cytoskeleton gel expands to accommodate their packing less densely. This volume expansion combines with polymerization to drive protrusion. Consistent with this hypothesis, an engineered MSP mutant that generates shorter filaments shows higher filament-packing density and slower movement.