Asia Pacific TAVI registry (an APSIC initiative): initial report of early outcomes: Asia Pacific TAVI registry

AIMS

The aim of the study was to report the clinical experience, 30-day mortality and acute outcomes of patients undergoing transcatheter aortic valve implantation (TAVI) in the Asia Pacific region.

METHODS AND RESULTS

The Asia Pacific TAVI registry is an international, multicentre, prospective, observational registry managed under the auspices of the Asian Pacific Society of Interventional Cardiology (APSIC). Patients undergoing TAVI in seven centres from Hong Kong, Japan, Philippines, Singapore and Taiwan, treated with TAVI devices for severe symptomatic aortic stenosis, were assessed. This first review presents the acute results and 30-day mortality. A multivariable analysis was also performed to identify independent predictors of early all-cause mortality. The enrolment was from 2009 to 2017 and a total of 1,125 patients were recruited. The 30-day mortality rate was 2.5%. Baseline logistic EuroSCORE more than 16 was independently associated with a 2.8-times increased risk of 30-day all-cause mortality (p=0.016). Post-procedural stroke (HR 4.9, p=0.008) was also associated with increased mortality.

CONCLUSIONS

This initial report of the Asia Pacific TAVI registry demonstrated good acute success and low 30-day mortality. The preprocedural logistic EuroSCORE and post-procedural stroke incidence were strongly associated with acute mortality. Further attempts to reduce post-procedural stroke should be explored.

Transcatheter aortic valve replacement with Evolut R versus Sapien 3 in Japanese patients with a small aortic annulus: The OCEAN-TAVI registry

OBJECTIVES

To compare safety, efficacy, and hemodynamics of transfemoral transcatheter aortic valve replacement (TAVR) using self-expanding and balloon-expandable transcatheter heart valves (THVs) in patients with a small aortic annulus.

BACKGROUND

Few studies have directly compared TAVR outcomes using third-generation THVs, focusing on patients with small aortic annuli.

METHODS

In a multicenter TAVR registry, we analyzed data from 576 patients with a small annulus and who underwent transfemoral TAVR using third-generation THVs. Propensity score matching was used to adjust baseline clinical characteristics.

RESULTS

The device success rate in the overall cohort was 92.0% (Evolut R: 92.1% vs. Sapien 3:92.0%, p = 0.96). One year after TAVR, patients treated with Evolut R maintained a lower mean pressure gradient (mPG) and a higher indexed effective orifice area (iEOA) in the matched cohort {mPG: 9.0 [interquartile range (IQR): 6.0-11.9] vs. 12.0 [IQR: 9.9-16.3] mmHg, p < .001; iEOA: 1.20 [IQR: 1.01-1.46] vs. 1.08 [IQR: 0.90-1.28] cm² /m² , p < .001}. However, no significant differences were reported in the incidence of severe prosthesis-patient mismatch and aortic regurgitation at 1 year. Furthermore, both groups showed comparable outcomes with no differences in terms of all-cause mortality (log-lank test, p = .81).

CONCLUSIONS

TAVR for patients with a small annulus using third-generation THVs was associated with high device success. Evolut R seems to be superior to Sapien 3 in hemodynamic performance for patients with a small annulus and body surface area up to 1 year after TAVR. Nevertheless, all-cause mortality at 1 year was similar between both groups.

Silent Valsalva thrombus between the native Valsalva and balloon-expandable transcatheter heart valve: multicentre Japanese registry analysis

AIMS

The newly formed geometry between the native Valsalva and implanted transcatheter heart valve (THV) may induce local thrombogenicity. This study aimed to assess the incidence of and the clinical outcomes associated with Valsalva thrombus formation after transcatheter aortic valve implantation (TAVI).

METHODS AND RESULTS

We retrospectively evaluated the multidetector computed tomography (MDCT) data of 338 patients following transcatheter aortic valve implantation (TAVI) using a balloon-expandable THV. The Valsalva and leaflet thrombi were assessed by MDCT at the left coronary cusp (LCC), right coronary cusp (RCC), and non-coronary cusp (NCC). Combined endpoints such as death, stroke, and readmission for heart failure rates in patients with and without Valsalva and/or leaflet thrombus were examined at two years. The overall incidence of Valsalva and leaflet thrombi was 8.9% and 8.3%, respectively. Significant differences in the location of the Valsalva thrombus in the LCC, RCC, and NCC were noted (5.0%, 4.2%, 8.9%, respectively, p<0.001). The independent predictor for increased risk of Valsalva thrombus was high Valsalva area to implanted THV size ratio (odds ratio 11.8, 95% confidence interval [CI]: 1.67-83.0, p=0.013). Combined endpoints were similar in patients with and without Valsalva thrombus, Valsalva/leaflet thrombus, and leaflet thrombus (p>0.05 for all).

CONCLUSIONS

Valsalva thrombus was detected in 8.9% of patients following balloon-expandable THV implantation and was common in the LCC, but it did not increase the risk of adverse events after TAVI.

Prevalence, Clinical Profile, and In-Hospital Outcomes of Sleep-Disordered Breathing in Patients Undergoing Transcatheter Aortic Valve Implantation in Japan

Background: The prevalence, patient profile, and outcomes of sleep-disordered breathing (SDB) in aortic stenosis (AS) remain unknown, especially in East Asia.

Methods and Results: One hundred and eighty-one AS patients undergoing transcatheter aortic valve implantation (TAVI) were enrolled. Sixty-one patients (33.7%) had SDB, and lower stroke volume index was an independent determinant of SDB. Incidence of in-hospital stroke after TAVI was higher in the SDB group.

Conclusions: SDB is associated with left ventricular systolic dysfunction in Japanese AS patients referred for TAVI. SDB was highly associated with the incidence of stroke as a procedural complication.

Update on the clinical impact of mild aortic regurgitation after transcatheter aortic valve implantation: Insights from the Japanese multicenter OCEAN-TAVI registry

OBJECTIVES

This study aimed to compare the clinical impact of mild postprocedural aortic regurgitation (post-AR) to that of none-trivial post-AR after transcatheter aortic valve implantation (TAVI) and to identify the vulnerability factors to mild post-AR.

BACKGROUND

Moderate-severe post-AR, associated with increased mortality, is an important issue. However, the clinical impact of mild post-AR remains controversial.

METHODS AND RESULTS

We analyzed data from 1,572 consecutive patients (1,026 of none-trivial post-AR and 546 of mild post-AR) obtained from the Optimized transCathEter vAlvular Intervention (OCEAN-TAVI) Japanese multicenter registry. We evaluated the 1-year cumulative cardiovascular death and re-hospitalization rates for heart failure (HF) after TAVI according to the degree of post-AR. Kaplan-Meier curves showed no significant difference between "none-trivial post-AR" and "mild post-AR" in terms of cardiovascular death, but a significant difference was noted in the cumulative incidence of re-hospitalization for HF between the two groups (hazard ratio 1.57, 95% confidence interval 1.02-2.41, p = .04). In the stratified analysis, only in patients with not more than 50% of left ventricular ejection fraction (LVEF), concentric left ventricular hypertrophy (LVH), and none-trivial pre-procedural aortic regurgitation (pre-AR), mild post-AR resulted in a higher incidence of re-hospitalization for HF.

CONCLUSIONS

In this study, the clinical impact of mild post-AR compared to none-trivial post-AR tended to be augmented in the presence of reduced LVEF, concentric LVH, and none-trivial pre-AR. Pre-procedure echocardiographic findings including LVEF, left ventricular geometry, and pre-AR may help to judge the necessity of postdilatation in case of mild post-AR just after the bioprosthesis deployment.

Impact of preprocedural echocardiographic parameters on increased stroke volume after transcatheter aortic valve replacement

Aims

Increased stroke volume (SV) is a prognosticator of severe aortic stenosis (AS) after transcatheter aortic valve replacement (TAVR). This study aimed to investigate preprocedural echocardiographic predictors of increased SV after TAVR.

Methods and results

Clinical and echocardiographic data were retrospectively analysed in 129 patients with severe AS who underwent TAVR (2013-2015). We compared the echocardiographic data and cardiac events between the decreased SV group (n=28) and the increased SV group (n=101). Univariate and multivariate analyses were used to assess the predictors of increasing SV. AS severity significantly diminished, left and right ventricular function improved, and SV index (SVi) increased after TAVR: aortic valve area index (0.46±0.13 vs. 1.18±0.33 cm2, p<0.001); aortic regurgitation (AR) grade (1.85±0.55 vs. 1.60±0.54, p<0.001); left ventricular ejection fraction (59.9±12.7 vs. 64.1±12.0%, p<0.001); right ventricular fractional area change (RVFAC) (48.8±11.9 vs. 53.3±14.0%, p<0.001); SV index (SVi) (46.7±11.0 vs. 52.8±12.0 ml/m2, p<0.001). Kaplan-Meier survival estimates suggested that the SVi increase was associated with the decreased cardiovascular events one year after TAVR (hazard ratio 4.08, 95% confidence interval [CI]: 1.32-12.7, p=0.02). On multivariate analysis, preprocedural AR grade (odds ratio [OR] 7.00, 95% CI: 2.76-17.8, p<0.001) and preprocedural RVFAC (OR 1.05, 95% CI: 1.01-1.10, p=0.011) correlated with the SV increase.

Conclusions

Preprocedurally, greater AR and higher RVFAC could predict an increased SVi and thus the occurrence of fewer cardiac events. Preserved preprocedural RV systolic function is crucial for an increased SV after TAVR.

A tale of two sisters with hypertrophic cardiomyopathy and recurrent embolism: When is the optimal timing of the intervention for left atrial appendage?

Hypertrophic cardiomyopathy (HCM) is an extremely heterogeneous genetic disease that affects the left ventricle (LV) and has a varied clinical course and phenotypic expression. Here, we report a case of two sisters with HCM who developed a massive refractory left atrial appendage (LAA) thrombus and recurrent embolism. The older sister, who was at a high surgical risk due to progressive LV systolic dysfunction with an ejection fraction of 19%, underwent LAA plication in combination with implantation of an LV assist device after progression to treatment-refractory heart failure at the age of 49. The younger sister underwent surgical thrombectomy, LAA plication, and Maze surgery before deterioration of heart failure at the age of 47. She was free from embolism and atrial fibrillation for 2years after surgery. Individualized therapeutic approaches targeting the LAA at a relatively early stage are required in the subgroups of HCM patients with left atrial dysfunction.

Frequency and Consequences of Cognitive Impairmentin Patients Underwent Transcatheter Aortic Valve Implantation

Cognitive impairment is common in patients underwent transcatheter aortic valve implantation (TAVI) and might affect procedure outcomes. This study evaluated the incidence of preprocedural cognitive impairment and its impact on clinical outcomes after TAVI. We analyzed the data of 1,111 patients (age ≥70 years) obtained from the Optimized CathEter vAlvular iNtervention (OCEAN-TAVI) registry. The cognitive performance of all patients was assessed using the Mini-Mental State Examination (MMSE) at baseline. We evaluated the 1-year cumulative mortality after TAVI according to the MMSE performance. Cognitive impairment was present in 420 (38%) of 1,111 patients. Compared with patients with normal cognition, those with cognitive impairment showed higher cumulative all-cause and noncardiovascular mortality rates at 1 year (14% vs. 8%, p = 0.001; 11% vs. 5%, p <0.001, respectively). Moreover, cognitive impairment increased the risk of mortality from sepsis (2% vs. 0.4%; hazard ratio, 4.2; 95% confidence interval, 1.3 to 13.5; p = 0.02). In adjusted models, cognitive impairment was an independent risk factor for 1-year all-cause mortality (adjusted hazard ratio, 2.1; 95% confidence interval, 1.1 to 4.0; p = 0.02). Although patients with cognitive impairment had more in-hospital adverse outcomes, including prolonged hospital stays, major bleeding and vascular complications, and acute kidney injury, than did those with normal cognition, the 30-day mortality was similar between the groups (1% in the two groups; p >0.99). In conclusion, cognitive impairment based on the MMSE score was an independent predictor of mortality at 1 year after TAVI.

Hospital readmission following transcatheter aortic valve implantation in the real world

BACKGROUND

There is limited data on hospital readmissions following transcatheter aortic valve implantation (TAVI). The aim of this study was to investigate hospital readmissions post-TAVI.

METHODS

Data from the Optimized transCathEter vAlvular iNtervention (OCEAN-TAVI) multicenter registry (registration no. UMIN000020423) were collected from 1215 patients who underwent TAVI. Incidence, timing, causes, and predictors of readmission in addition to the impact on patient outcomes were analyzed.

RESULTS

Of 1215 patients, 223 (18.4%) were readmitted within 1 year post-TAVI. Early readmission (≤30 days) occurred in 42 patients, while late readmission (>30 days) occurred in 181 patients. Readmissions were due to cardiac disorders, such as heart failure and arrhythmia, in 77 patients and non-cardiac disorders, such as respiratory disorders, infections, and cerebrovascular events, in 146 patients. Kaplan-Meier analysis revealed that early readmission was associated with a lower 1-year survival compared to non-early readmission (72.4% vs. 89.0%, p < 0.05). Multivariate Cox regression analysis showed that acute kidney injury (hazard ratio [HR], 2.27; p = 0.03) was an independent predictor of early readmission, while anemia (HR, 2.21; p < 0.01), hypoalbuminemia (HR, 1.37; p = 0.04), atrial fibrillation (HR, 1.70; p < 0.01), and more than mild postprocedural aortic regurgitation (HR, 1.62; p < 0.01) were independent predictors of late readmission.

CONCLUSION

Readmission occurred in approximately one-fifth of patients post-TAVI and was associated with poor patient outcomes. Early readmission was mainly due to procedural complications, while late readmission was mainly determined by baseline comorbidities including a frailty criterion. Measures should be taken to reduce hospital readmissions and improve patient outcomes post-TAVI.

Subclinical leaflet thickening and stent frame geometry in self-expanding transcatheter heart valves

AIMS

This study aimed to assess the potential relationship between subclinical leaflet thickening and stent frame geometry in patients who underwent aortic valve replacement with a self-expanding transcatheter heart valve (THV).

METHODS AND RESULTS

Seventy-five patients with a self-expanding THV were studied with 4D-computed tomography and analysed for leaflet thickening. There was no difference in THV size, overall THV expansion, eccentricity or implantation depth between patients with and those without leaflet thickening. Moderate-to-severe regional THV underexpansion (≤90°) more frequently occurred at the non-coronary and right coronary cusps with a significantly higher incidence of leaflet thickening than in cases of full regional THV expansion (24% vs. 3%, p<0.01). Regional THV underexpansion at the inflow level more often translated into the same issue at the valvular level in THV with intra-annular as compared to supra-annular valve position (54% vs. 17%; p=0.04). In case of post-dilatation, regional THV underexpansion occurred less frequently as compared to THV that were not post-dilated (18% vs. 43%, p=0.028). A similar but non-significant trend was found for leaflet thickening.

CONCLUSIONS

Regional THV stent frame underexpansion is associated with an increased risk of leaflet thickening. Post-dilatation of self-expanding THV as well as a supra-annular valve position seem to reduce the occurrence of this phenomenon.

Electron photoejection from dianion of an expanded phthalocyanine

Photoelectron ejection from the dianion of pentabenzotriazasmaragdyrin (PBTAS) which is an expanded phthalocyanine, is observed using femtosecond transient absorption spectroscopy. The PBTAS dianion was produced by chemical reduction using excess cobaltocene as a reductant, which was confirmed by their steady-state absorption spectrum as compared to the absorption spectrum obtained by electrochemical reduction, and characterized by magnetic circular dichroism (MCD). Upon photoexcitation of the PBTASdianion, the generation of a radical anion was confirmed by the characteristic absorption peaks that are observed at 950 and 1000 nm. The radical anion was relaxed to form a dianion with a time constant of 0.7 ps.

Transcatheter aortic valve implantation in patients with an extremely small native aortic annulus: The OCEAN-TAVI registry

BACKGROUND

Transcatheter aortic valve implantation (TAVI) has been reported to be advantageous over surgical aortic valve replacement owing to the low incidence of prosthesis-patient mismatch (PPM) and large effective orifice area (EOA). However, data on TAVI for extremely small annuli are limited. The present study aimed to compare post-procedural hemodynamics and morphology between 20-mm and 23-mm Sapien XT (SXT) transcatheter heart valves (THVs) with extremely small annuli (<314mm²).

METHODS

All patients with severe aortic stenosis treated with TAVI at eight Japanese centers between October 2013 and January 2016 were prospectively included in the Optimized CathEter vAlvular iNtervention (OCEAN-TAVI) registry. In the overall cohort of 20-mm (19 patients) and 23-mm SXTs (492 patients) with extremely small annuli, the patient groups were matched one-to-one using propensity scores, and post-procedural echocardiography and multidetector computed tomography data were compared for 18 matched patients from each group (matched cohort).

RESULTS

In the matched cohort, the mean gradient was higher (15.4±4.1 vs. 12.2±4.8mmHg, p=0.04), EOA was lower (1.22±0.25 vs. 1.44±0.37cm², p=0.02) and THV area was lower (245.6±19.1 vs. 298.5±33.3mm², p<0.01) in the 20-mm group than in the 23-mm group. However, all patients in both groups were asymptomatic. Although moderate PPM was more prevalent in the 20-mm group than in the 23-mm group (31.6% vs. 7.9%, p<0.01), the incidence of severe PPM was low and similar between the groups (0% vs. 0.4%, p=1.00) in the overall cohort.

CONCLUSION

A 20-mm SXT in patients who require a small bioprosthesis leads to favorable short-term outcomes.

Aluminium nanopillars reduce thermal conductivity of silicon nanobeams

In search of efficient thermoelectric nanostructures, many theoretical works predicted that nanopillars, placed on the surface of silicon membranes, nanobeams, or nanowires, can reduce the thermal conductivity of these nanostructures. To verify these predictions, we experimentally investigate heat conduction in suspended silicon nanobeams with periodic arrays of aluminium nanopillars. Our room temperature time-domain thermoreflectance experiments show that the nanobeams with nanopillars have 20% lower thermal conductivity as compared to pristine nanobeams. We discuss possible explanations of these data, including coherent effects, and conclude that the thermal conductivity is reduced mainly by phonon scattering at the pillar/beam interface due to the intermixing of aluminium and silicon atoms, as supported by the transmission electron microscopy. As this intermixing does not only reduce thermal conductivity but may also increase electrical conductivity, these nanostructures are exceptionally promising for thermoelectric applications.

Impact of the Clinical Frailty Scale on Outcomes After Transcatheter Aortic Valve Replacement

Background:

The semiquantitative Clinical Frailty Scale (CFS) is a simple tool to assess patients’ frailty and has been shown to correlate with mortality in elderly patients even when evaluated by nongeriatricians. The aim of the current study was to determine the prognostic value of CFS in patients who underwent transcatheter aortic valve replacement.

Methods:

We utilized the OCEAN (Optimized Catheter Valvular Intervention) Japanese multicenter registry to review data of 1215 patients who underwent transcatheter aortic valve replacement. Patients were categorized into 5 groups based on the CFS stages: CFS 1-3, CFS 4, CFS 5, CFS 6, and CFS ≥7. We subsequently evaluated the relationship between CFS grading and other indicators of frailty, including body mass index, serum albumin, gait speed, and mean hand grip. We also assessed differences in baseline characteristics, procedural outcomes, and early and midterm mortality among the 5 groups.

Results:

Patient distribution into the 5 CFS groups was as follows: 38.0% (CFS 1-3), 32.9% (CFS4), 15.1% (CFS 5), 10.0% (CFS 6), and 4.0% (CFS ≥7). The CFS grade showed significant correlation with body mass index (Spearman’s ρ=−0.077, P =0.007), albumin (ρ=−0.22, P <0.001), gait speed (ρ=−0.28, P <0.001), and grip strength (ρ=−0.26, P <0.001). Cumulative 1-year mortality increased with increasing CFS stage (7.2%, 8.6%. 15.7%, 16.9%, 44.1%, P <0.001). In a Cox regression multivariate analysis, the CFS (per 1 category increase) was an independent predictive factor of increased late cumulative mortality risk (hazard ratio, 1.28; 95% confidence interval, 1.10–1.49; P <0.001).

Conclusions:

In addition to reflecting the degree of frailty, the CFS was a useful marker for predicting late mortality in an elderly transcatheter aortic valve replacement cohort.

Spontaneous Regression of Possible Transcatheter Aortic Valve Thrombosis Without Additional Anticoagulant: Two-Year Follow-Up

An 84-year-old man with symptomatic severe aortic stenosis received transcatheter aortic valve implantation (TAVI). Dual-antiplatelet therapy was continued for 6 months post TAVI, and aspirin alone was used thereafter. Four-dimensional multidetector computed tomography revealed a new hypoattenuated leaflet thickening (HALT) with reduced leaflet motion at 1 year, considered to indicate leaflet thrombosis. At the 2-year follow-up, leaflet mobility had improved, with spontaneous regression of HALT. This is the first report of confirmed spontaneous regression of possible transcatheter heart valve thrombosis and recovery of leaflet mobility without the need for additional anticoagulant.

Impact of Subclinical Vascular Complications Detected by Systematic Postprocedural Multidetector Computed Tomography After Transcatheter Aortic Valve Implantation Using Balloon-Expandable Edwards SAPIEN XT Heart Valve

Complications after transcatheter aortic valve implantation (TAVI) remain an important issue. This study aimed to evaluate the impact of systematic postprocedural multidetector computed tomography (MDCT) to detect subclinical complications after TAVI. From October 2013 to August 2015, a total of 135 patients who underwent transfemoral TAVI (n = 116) or transapical TAVI (n = 19) with Sapien XT and MDCT preprocedure and postprocedure were enrolled. Postprocedural MDCT findings were compared with the preprocedural MDCT findings. Cardiovascular complications were observed in 25.9% of patients, including 6 cases (4.5%) with major complications. Of those, clinically apparent major complications were reported in 2 cases including rupture of the sinus of Valsalva and iliac rupture. The complications in the remaining 4 cases (3.0%) included aortic dissection, aortic intramural hematoma, and left ventricular apical pseudoaneurysm, which were totally asymptomatic and only detected by MDCT. The apical pseudoaneurysm required surgical repair. Minor complications were observed in 21.5% of patients, 50% of which were subclinical. Only 1 case with femoral pseudoaneurysm required an additional procedure. Noncardiovascular findings were detected in 27.4% of patients; the most frequent were pleural effusions and atelectasis, which were predominantly observed in those treated through a transapical approach. Contrast-induced acute kidney injury after postprocedural MDCT was reported in 1 patient whose clinical course was complicated by sepsis. In conclusion, postprocedural MDCT was useful in detecting important subclinical complications that may affect the clinical course without deterioration of renal function.

Incidence, Predictors, and Mid-Term Outcomes of Possible Leaflet Thrombosis After TAVR

OBJECTIVES

This study sought to clarify the incidence and predictors of hypoattenuated leaflet thickening (HALT) and mid-term outcomes after transcatheter aortic valve replacement.

BACKGROUND

HALT detected on multidetector computed tomography (MDCT) scanning raised concerns about possible subclinical leaflet thrombosis.

METHODS

We studied 70 of 100 consecutive patients from a single-center registry who underwent implantation with the Edwards SAPIEN-XT device. MDCT results, echocardiographic data, and laboratory findings obtained at the 6-month and 1-year follow-ups were analyzed.

RESULTS

Of 70 patients, MDCT scans revealed HALT in 1 patient (1.4%) at discharge, 7 (10.0%) at 6 months, and 10 (14.3%) at 1 year post-transcatheter aortic valve replacement cumulatively. The degree of leaflet immobility correlated with the HALT area on 4-dimensional MDCT (r = 0.68) on the basis of data from 10 patients. HALT was associated with male sex (70% vs. 25%; p = 0.008) and larger sinus of Valsalva (31.0 ± 2.0 mm vs. 28.6 ± 2.6 mm; p = 0.005). HALT was found in 3 of 49 patients with a 23-mm bioprosthesis and in 7 of 21 patients with a 26-mm bioprosthesis (6.1% vs. 33.3%; p = 0.006). D-dimer levels were significantly increased in the HALT group at the 6-month (2.3 μg/ml [interquartile range (IQR): 2.1 to 6.1 μg/ml] vs. 1.1 μg/ml [IQR: 0.8 to 2.2 μg/ml]; p = 0.002) and 1-year (2.7 μg/ml [IQR: 1.7 to 4.8 μg/ml] vs. 1.2 μg/ml [IQR: 0.9 to 2.1 μg/ml]; p = 0.006) follow-ups, despite no differences at discharge. The pressure gradient was decreased in the HALT group at the 1-year follow-up (8.3 ± 0.8 mm Hg vs. 11.1 ± 4.9 mm Hg; p = 0.005). After detecting HALT, additional anticoagulation therapy was not administered. Clinical outcomes, including all-cause mortality (0% vs. 1.7%; p = 1.00) and stroke (0% vs. 0%; p = 1.00), were similar between the groups.

CONCLUSIONS

HALT with reduced leaflet motion was not rare but usually subclinical. Valve hemodynamics and mid-term outcomes were uneventful even without additional anticoagulant therapy in our limited number of cases. Male sex, larger sinus and bioprosthesis size, and elevated D-dimer levels during follow-up were associated with this phenomenon.

Pulmonary Exposure to Diesel Exhaust Particle Components Enhances Circulatory Chemokines during Lung Inflammation

This study examines the effects of DEP components on circulatory CC and CXC chemokines, potent activators and chemoattractants for macrophage and leukocyte subpopulations, in a murine model of lung inflammation. 1CR mice were divided into six experimental groups which received intratracheal inoculation of vehicle, LPS alone (2.5 mg/kg), organic chemicals in DEP (DEP-OC: 4 mg/kg) extracted with dichloromethane, residual carbonaceous nuclei after the extraction (washed DEP: 4 mg/kg), DEP-OC + LPS, or washed DEP + LPS. Intratracheal instillation of each DEP component alone did not significantly change the circulatory level of macrophage inflammatory protein (MIP)-1α, MIP-2, and macrophage chemoattractant protein-1 (MCP-1) 24 h after the exposure as compared with vehicle instilled alone. In the LPS group, MCP-1, but not MIP-1α or MIP-2, was significantly greater than in the vehicle group. The combined administration of LPS and washed DEP caused a further three to five-fold increase in MIP-1α, MIP-2, and MCP-1 proteins in the serum as compared with LPS administered alone. No significant difference between the LPS + DEP-OC group and the LPS group was observed. These results indicate that pulmonary exposure to washed DEP enhances circulatory level of chemokines during lung inflammation. The enhancement may be important in the aggravations of systemic inflammatory responses and ischemic cardiovascular conditions associated with air pollution.

Candida Soluble Cell Wall β-D-Glucan Induces Lung Inflammation in Mice

Bioactivity of cell wall component(s) of fungi has not been fully elucidated, especially in vivo. We isolated Candida soluble beta-D-glucan (CSBG) from Candida albicans (C. albicans). We investigated the effects of airway exposure to CSBG on the immune systems in the airways in mice. CSBG exposure induced neutrophilic and eosinophilic inflammation in the lung, which was concomitant with the increased local expression of proinflammatory cytokines including tumor necrosis factor - α, interleukin (IL)-1 β, IL-6, macrophage inflammatory protein -1 α, macrophage chemoattractant protein -1, RANTES (regulated on activation and normal T cells expressed and secreted), and eotaxin. The lung inflammation with enhanced expression of proinflammatory proteins caused by CSBG was directly related to its structure, since structurally degraded products of CSBG by formic acid induced negligible responses in the lung. CSBG enhanced nuclear localization of phosphorylated signal transducer and activator of transcription (STAT)-6 in the lung. These results suggest that airway exposure to CSBG induces lung inflammation, at least partly, via the enhanced expression of proinflammatory cytokines and the activation of STAT-6 pathway, and can be a proper murine model for fungal lung inflammation.

Factors related to allergic transfusion reactions and febrile non-haemolytic transfusion reactions in children

BACKGROUND AND OBJECTIVES

Allergic transfusion reactions (ATRs) and febrile non-haemolytic transfusion reactions (FNHTRs) are the two major types of transfusion-related adverse reactions (TRARs). Although prestorage leucocyte reduction and diversion of the first aliquot of blood (LR/D) could reduce FNHTRs and bacterial contamination in adult transfusion, ATRs are still problematic. In addition, there is little information about TRARs in paediatric population.

MATERIALS AND METHODS

We conducted a single-centre retrospective analysis of all transfusions, except washing products, and TRARs for 153 months to evaluate related factors such as delivery of treatment and the characteristics of recipients.

RESULTS

Most TRARs were FNHTRs and/or ATRs in children. In delivering blood products with LR/D, the frequencies of not only FNHTRs but also ATRs were significantly reduced with both platelet concentrates (PCs) and red cell concentrates (RCCs). TRARs of fresh-frozen plasma were infrequent in children. In addition, even after the introduction of LR/D, ATRs were significantly more frequent in patients with primary haematological and malignant diseases who received PCs and RCCs, older patients who received PCs and patients who received frequent RCCs.

CONCLUSION

These results suggest that leucocytes or mediators from leucocytes are underlying cause of ATRs in addition to FNHTRs in children. Furthermore, particular characteristics of patients would be other risk factors for ATRs.

Tooth shape reconstruction from dental CT images with the region-growing method

OBJECTIVES

The three-dimensional shape information of teeth provides useful information. However, obtaining accurate three-dimensional shapes of teeth is difficult without extracting them physically. In this study, we aimed to develop a method for automatically extracting accurate three-dimensional shapes of teeth from dental CT images.

METHODS

The proposed method includes pre-processing and region extraction. Pre-processing is a combination of image-processing techniques that enhances tooth regions. In the region-extraction process, the region-growing method is introduced for extracting a region of each tooth. Constraint conditions determined by considering the characteristics of the structure of teeth are introduced for accurate extraction. Finally, morphological image processing is applied for eliminating discontinuous points.

RESULTS

We carried out an experiment in which the three-dimensional shapes of teeth were reconstructed from dental CT images. Quantitative evaluation was performed by measuring the three-dimensional spatial accordance rates between the region obtained by the proposed method and the manually extracted region. The proposed method was significantly more accurate than an existing method at the 5% level.

CONCLUSIONS

The experimental results showed that the proposed method reconstructs the shapes of teeth with high precision. However, an unextracted region remained at the surface of the enamel. Solving this problem and improving the extraction accuracy are important topics for future work.

Insulin resistance and bariatric surgery

The objective of this article is to systematically review the changes in insulin resistance after various types of bariatric surgical procedures. A Pubmed and EMBASE search for studies measuring insulin resistance before and after bariatric surgery was done and all original research articles from 1980 to present (2011) were included. Only the currently widely performed bariatric procedures were included. A meta-analysis of change in HOMA-IR was conducted, grouping studies with similar duration of follow-up. The percentage decrease in HOMA-IR at <=2 weeks, 1 month, 3 months, 6 months, 12 months and >16-18 months was found to be (mean ± standard error) -33.48 ± 5.78, -46.43 ± 6.99, -38.79 ± 9.64, -58.62 ± 7.38, -44.91 ± 7.98 and -67.04 ± 10.78%, respectively. RYGB (gastric bypass) and BPD (biliopancreatic diversion) produced a significant decrease in insulin resistance at 2 weeks after surgery, while LSG (sleeve gastrectomy) was strongly trending. LSG produced an earlier decrease in insulin resistance when compared to LAGB (gastric banding). RYGB, BPD and LSG produce an early decrease in insulin resistance through yet unknown mechanisms.

Dietary Supplementation with Fructooligosaccharides Attenuates Airway Inflammation Related to House Dust Mite Allergen in Mice

Fructooligosaccharides (FOS) are prebiotic supplements that can enhance immunological responses in the host to activate mucosal immunity, probably through regulation of gastrointestinal microflora. An area that has not been investigated, however, is the therapeutic potential of prebiotics on allergic airway diseases. The purpose of this study is to evaluate the effects of dietary supplementation with FOS on a murine model of airway inflammation induced by the house dust mite allergen Dermatophagoides farinae (Der f). Male C3H/HeN mice were intratracheally administered with Der f and were fed a diet containing 0% or 2.5% FOS ad libitum. Supplementation with FOS alleviated mite allergen-related airway inflammation characterized by eosinophilic inflammation and goblet cell hyperplasia, which was evidenced by cytological and histological examinations. In addition, the FOS-supplemented diet reduced the serum allergen-specific IgG1 level as compared with a control diet in the presence of the mite allergen. Moreover, FOS tended to suppress the expression of IL-5 and eotaxin in the lungs, which is enhanced by mite allergen. These results suggest that dietary supplementation with FOS can prevent/improve airway inflammation induced by the mite allergen. This effect can be at least partially associated with the inhibition of allergen-specific Ig production and probably with that of IL-5 and eotaxin expression.

Size Effects of Polystyrene Nanoparticles on Atopic Dermatitis-like Skin Lesions in NC/NGA Mice

Nano-sized particles are diffusing in the environment with the development of nanotechnology. Polystyrene (PS) nanoparticles are modified industrial products and pharmaceutical agents, however, adverse effects of PS nanoparticles remain to be elucidated. In the present study, we investigated the effects of PS nanoparticles with different sizes on the atopic dermatitis (AD)-like skin lesions in NC/Nga mice assumed to show the skin barrier defect/dysfunction in the presence or absence of mite allergen. Male NC/Nga mice were injected intradermally with three different-sized PS nanoparticles (25, 50, or 100 nm) and/or mite allergen into their right ears. We evaluated clinical scores, ear thickening, histological findings and the local protein expression of inflammatory molecules in the ear and Ig production in serum. PS nanoparticles aggravated AD-like skin lesions related to mite allergen, which was paralleled by the local protein levels of interleukin-4, CCL2/monocyte chemotactic protein-1, CCL3/macrophage inflammatory protein-1 alpha, and CCL4/macrophage inflammatory protein-1 beta. In contrast, PS nanoparticles decreased interferon-γ expression. Furthermore, exposure to PS nanoparticles induced ear swelling and CC-chemokine expression in the absence of allergen. These effects were greater with the smaller PS nanoparticles than with the larger ones regarding overall trend. These results suggest that exposure to PS nanoparticles under skin barrier defect/dysfunction can exacerbate AD-like skin lesions related to mite allergen in a size-dependent manner. The enhancing effects may be accounted for by T helper 2-biased immune responses. Furthermore, PS nanoparticles can evoke skin inflammation via the overexpression of CC-chemokines even in the absence of allergen in atopic subjects.

Pulmonary exposure to soluble cell wall beta-(1, 3)-glucan of aspergillus induces proinflammatory response in mice

Compared to the significant immunomodulation of cell wall component(s) of bacterium such as lipopolysaccharide (E. Coli), that of pathogenic fungi has not been well elucidated, especially in vivo. Furthermore, although it has been implied that beta-(1, 3)-glucan of fungi possesses various biological activities, the impacts of the component have not been properly clarified, possibly due to its insolubility in water and alkali solutions. Previously, we isolated a soluble type of beta-(1, 3) -glucan from Aspergillus (referred to as ASBG). The present study investigated the effects of a single pulmonary exposure to ASBG on the immune (proinflammatory) responses in naïve mice. ASBG (12.5-100micorg/animal) exposure Induced neutrophilic lung inflammation with an enhanced local expression of proinflammatory cytokines such as interleukin (IL)-1beta and chemokines such as macrophage inflammatory protein -1a, and keratinocyte-derived chemoattractant in a dose-dependent fashion with overall trends. On the other hand, ASBG at relatively lower doses significantly amplified the lung expression of IL-2, IL-6, and IL-12 as compared with vehicle. ASBG significantly induced pulmonary edema. Furthermore, ASBG augmented the nuclear translocation of nuclear factor (NF)-kB and its binding capacity to the promoter site of DNA in the lung homogenate. These results suggest that pulmonary exposure to ASBG confers lung inflammation, at least partly, via the enhanced local expression of proinflammatory cytokines, likely through NF-kB-dependent pathway.

The effects of microbial materials adhered to Asian sand dust on allergic lung inflammation

Asian sand dust (ASD) containing microbiological materials, sulfate (SO(4)(2)), and nitrate (NO(3)(-) ) derived from air pollutants in East China, reportedly cause adverse respiratory health effects. ASD aggravates ovalbumin (OVA)-associated experimental lung eosinophilia. In this study, the toxic materials adsorbed onto ASD were excluded by heat treatment at 360 degrees C for 30 min. The effects of nonheated ASD or heated ASD (H-ASD) toward the allergic lung inflammation were compared in murine lungs. ICR mice were administered intratracheally with normal saline (control), H-ASD, ASD, OVA, OVA + H-ASD, and OVA + ASD, four times at 2-week intervals. ASD only increased neutrophils in bronchoalveolar lavage fluids (BALFs) along with pro-inflammatory mediators, such as keratinocyte chemoattractant (KC). H-ASD and ASD enhanced eosinophil recruitment induced by OVA in the alveoli and in the submucosa of the airway, which has a goblet cell proliferation in the bronchial epithelium. The two ASDs synergistically increased interleukin-5 (IL-5), monocyte chemotactic protein-3 (MCP-3), and eotaxin, which were associated with OVA, in BALF. The enhancing effects were much greater in ASD than in H-ASD. The two ASDs induced the adjuvant effects to specific IgE and IgG1 production by OVA. In the in vitro study using RAW264.7 cells, ASD increased the expression of Toll-like receptor 2 (TLR 2) mRNA but not TLR4 mRNA. H-ASD caused no expression of either TLR mRNA. These results suggest that the aggravated lung eosinophilia by ASD may be due to activation of Th2-associated immune response via the activation of TLR2 by microbial components adhered to ASD.

Antioxidative Role of Interleukin-6 in Septic Lung Injury in Mice

We have previously demonstrated the protective role of interleukin (IL)-6 against septic lung injury induced by lipopolysaccharide (LPS) using IL-6 knock-out (−/−) mice. This protection is mediated, at least partly, through the inhibition of the enhanced local expression of proinflammatory cytokines. In the present study, we addressed whether IL-6 regulates oxidative stress in the lung generated by LPS exposure using IL-6 (−/−) and corresponding wild type (WT) mice. Intraperitoneal LPS (1 mg/kg) challenge induced transcriptional expressions of inducible nitric oxide synthase and heme oxygenase −1 in the lung of mice with both genotypes. In the presence of LPS, these expressions were significantly greater in IL-6 (−/−) than in WT mice. Immunohistochemistry also showed that LPS induced a significant increase in 8-hydroxy-2′-deoxyguanosine formation in the lung as compared to vehicle. Furthermore, the formation was more intense in IL-6 (−/−) than in WT mice in the presence of LPS challenge. In the presence of LPS, lipid peroxidation in the lung was significantly greater in IL-6 (−/−) than in WT mice. These data suggest that the possible mechanisms in which endogenous IL-6 protects against septic lung injury induced by LPS involve, at least in part, its antioxidative properties.