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Objective: Mitral valve reconstruction (MVR) is one of the cardiosurgical procedures which cannot be substituted by any intervention owing to the quality of the quasi-anatomical, physiological repair. However, technique and strategies have changed over the years. We looked at procedural characteristics and outcome in an all-comer, non-selected cohort of patients., Methods: 738 out of 1.977 patients were retrospectively analyzed receiving MVR with and without concomitant procedures. The cohort was divided into three periods. P1: 2004-2009 (134 pts.); P2: 2010-2014 (294 pts.), and P3: 2015-2019 (310 pts.)., Results: Early mortality increased from P1 to P2 and decreased from P2 to P3 (9% P1, 13% P2, 10% P3). All patients received an annuloplasty-ring. In P1 resection measures dominated. In P3 artificial chordae were dominant. Age, BMI, and risk scores correlated with early mortality. Survival rates were 66% (5-years), 55% (10-years), 44% (15-years) in P1, 63% (5-years), 50% (10-years) in P2, and 80% (5-years) in P3. Odds ratio for reduced long-term survival were concomitant venous only bypass surgery (10-years 2,701, p = 0.026). 10-year survival was positively influenced by isolated MVR (0.246, p = 0.001), concomitant isolated arterial bypass (IMA) (0.153, p = 0.051), posterior leaflet measure (0.178, p<0.001), and use of artificial chordae (5-years 0.235, p<0.001)., Conclusion: Indication for ring implantation remained mandatory while preference changed alongside improved designs. Procedural characteristics changed from mainly resection maneuvers to predominant use of artificial chordae. Long-term results were negatively influenced by co-morbidities and positively influenced by posterior leaflet repair and artificial chordae. MVR underwent a qualitative evolution and remains a valuable cardiosurgical procedure., Competing Interests: The authors have declared that no specific interests exist.

Background and Objectives: Increasing reluctance to perform surgical mitral valve repair or replacement particularly in high-risk patients with poor left-ventricular function is trending. These patients are increasingly treated interventionally, e.g., by MitraClip, but often show only low to moderate improvement. The primary objective of the study was to investigate whether left ventricular ejection fraction (LVEF) influences postoperative mortality. Materials and Methods: The study included 903 patients undergoing mitral valve repair or replacement between 2009 and 2021. Statistical comparison was performed between patients with LVEF ≤ 30% and LVEF > 30%. Finally, statistical analysis was performed according to propensity score matching (1:3 PS matching). Results: No significant difference in in-hospital mortality was found before and after matching regarding LVEF ≤ 30% and LVEF > 30% (Pre: 10.8% vs. 15.1%, p = 0.241, after: 11.6% vs. 18.1%, p = 0.142). After PS matching, the 112 patients with LVEF ≤ 30% compared with 336 patients with LVEF > 30% showed a significantly higher preoperative NT-proBNP (p < 0.001), larger diameters at preoperative left ventricle and atrium (p < 0.001), lower preoperative TAPSE (p = 0.003) and PAP (p = 0.003), and more dilated cardiomyopathy and chronic kidney disease (p < 0.001, p = 0.045). Conclusions: The results of this study demonstrate that poor preoperative LVEF alone does not play a significant role in postoperative outcome and long-term mortality. Prognosis appears to be multifactorial. Poor preoperative LVEF is not a contraindication for surgery and does not justify primary interventional treatment accepting inferior hemodynamic results impeding outcome.

Background and Objectives: Friable or infected tissue remains a challenge in surgical aortic valve replacement. We recently described the "Caput medusae" method, in which circumferential tourniquets temporarily secure the prosthesis and are then gently knotted. Tourniquets have been shown to develop significantly less force than knots. The current study investigates the critical threshold forces for tissue damage to the aortic annulus. Materials and Methods: In 14 fresh porcine hearts, the aortic valve leaflets were removed and several pledgeted sutures were placed along the annulus at defined locations. The hearts were mounted in a self-constructed device. Incremental traction force was applied to every suture and continuously recorded. The movement of each Teflon pledget was filmed with a high-speed camera. Forces at the moment of pledget "cut-in" as well as complete "tear-out" were determined from the recordings. Results: The average threshold force was determined 9.31 ± 6.04 N for cut-in and 20.41 ± 10.02 N for tear-out. Detailed analysis showed that the right coronary region had lower threshold forces than the other regions (4.77 ± 3.28 N (range, 1.67-12.75 N) vs. 10.67 ± 6.04 N (1.62-26.00 N) for cut-in and 10.67 ± 4.04 N (5.40-18.64 N) vs. 23.33 ± 9.42 N (9.22-51.23 N) for tear-out). The findings are discussed in conjunction with the knot and tourniquet forces from our previous study. Conclusions: Even in healthy tissue, moderate forces can reach a critical level at which a Teflon pledget will cut into the annulus, while a complete tear-out is unlikely. The right coronary portion is more susceptible to damage than the remaining regions. When compared to previous data, forces during manual knotting may exceed the critical cut-in level, while rubber tourniquets may provide a higher safety margin against tissue rupture.

Objectives: Liver cirrhosis increases the risk of death in patients having cardiac surgery, and the risk is markedly dependent on the actual stage. The EuroSCORE II, however, does not specifically address the risk of death of patients with liver cirrhosis. We investigated the predictive power of EuroSCORE II in patients with liver cirrhosis., Methods: Between 2000 and 2020, a total of 218 patients with liver cirrhosis underwent cardiac surgery. To improve the predictive value of the EuroSCORE II, we calculated additional β-coefficients to include liver cirrhosis in the EuroSCORE IIb. The control group included 5,764 patients without liver cirrhosis from the same period., Results: Of the 5,764 patients without cirrhosis, 8.9% died early. Of those with cirrhosis, 8.9% of 146 patients with Child A stage, 52.9% of 51 patients with Child B stage and 100% of 21 patients with Child C stage died. Moreover, the EuroSCORE II showed a poor predictive value for patients in Child B and C stages. The resulting values of calculated β using the area under the curve of the receiver operating characteristic and bootstrapping for Child stages as predictors of mortality were as follows: βA = 0.1640205, βB= 2.9911625 and βC= 6.2501248. By calculating the updated EuroSCORE IIb and regenerating the receiver operating characteristic curves, we were able to demonstrate an improvement in area under the curve values. Postoperative complications, need for extracorporeal membrane oxygenation or intra-aortic balloon pump implants, intensive care unit stays and hospital stays were significantly higher in cirrhotic patients with cirrhosis compared with patients without cirrhosis. The most common cause of liver cirrhosis was alcohol abuse (55.5%)., Conclusions: Although patients with liver cirrhosis represent only a small proportion of cardiac surgical cases, the poor outcomes are particularly relevant in patients with advanced stages of the disease. Our study results show that Child class A patients show outcomes similar to those of patients without liver disease whereas Child class C patients appear to be nearly inoperable, i.e. can only be operated on with exceptional risks. Including these patients in the EuroSCORE II calculation would thus represent an improvement in preoperative mortality risk assessment., (© The Author(s) 2022. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: Patients undergoing pancreatic surgery are predominately very ill and therefore have a high potential for postoperative complications, which often has a life-limiting effect. As leakage of aggressive pancreatic secretions into the abdomen is one of the main reasons for an adverse outcome, measures to reduce it can be beneficial. Platelet-Rich Fibrin (PRF) is often used to seal areas that are already leaking or are susceptible to leakage at the end of the procedure. We sought to determine whether this positive intraoperative effect is associated with a positive postoperative outcome with regard to a reduction of complications., Methods: We investigated 85 patients who underwent pancreatic surgery in our surgical department. All patients were treated intraoperatively with PRF in the surgical field. The occurrence of fistulas (biochemical leakage, post-operatic pancreatic fistula (POPF) grade B and POPF grade C). We compared our clinical data with patient data from the literature., Results: The production of PRF from the patient's own blood is simple, safe, and not stressful for the patient. Complications related to production or use were not observed. Our patient group showed a lower fistula rate compared to those patient groups in the literature (POPF grade B and C: <13% vs. 16-72%)., Conclusion: The results showed that use of PRF had a beneficial effect in patients undergoing pancreatic surgery, as reflected by a reduction in postsurgical fistula formation and better outcomes.

Objective: Disturbed wound healing is a significant problem in patients after cardiac surgery. Problems with deep sternal wound healing are rare, but can be quite difficult to treat. Furthermore, the therapy is highly expensive and consumes many of the patient's personal resources. Another major obstacle in this patient group is reinfection after secondary wound closure. We examined how to prevent early reinfection through the use of growth factors in combination with local antibiotics., Methods: Our study included 232 patients with a deep sternal wound healing problem. After initial vacuum therapy, we planned secondary wound closure. During wound closure, we used only platelet-rich fibrin in a PRF group (109 patients). In another group (123 patients), we covered the wounds intraoperatively with a combination of PRF and local antibiotics (PRF CoDelivery). All patients were observed for 30 days for signs of early surgical site infection., Results: After 30 days, 22 patients (20.2%) in the PRF group showed a persistent problem with wound healing with or without reinfection. In contrast, only 12 patients (9.8%) in the PRF CoDelivery group had this problem (p=0.023 PRF vs. PRF CoDelivery)., Conclusion: The combination of growth factors and antibiotics was associated with a significantly reduced incidence of early reinfection and thus can be expected to have a positive impact on wound healing in complicated scenarios. Furthermore, the combination of PRF and local antibiotics was easy to use. Further studies are needed to verify these initial findings.

Extracorporeal circulation (ECC) is an integral part of cardiac surgery. Yet, the contact with artificial surfaces, mechanical stress, shear, and suction forces within the ECC pose a pronounced risk for damaging the corpuscular components of the blood. These suction forces may be reduced by a repositioning of the roller pumps employed below the reservoir. Furthermore, the repeated compression of the involved silicone tubing is likely to cause degradation. We present our observations regarding changes in the ECC performance following this degradation process. In vitro experiments were performed in a standard as well as a simplified ECC setup and included measurements of pressure, effective flow, and tubing restoring force over a time frame of 12 hours with two different pump positions utilizing transit time flow measurement. Suction forces within the tubing could be significantly reduced by shifting the pump position below the reservoir. Regardless of the setup, the tubing showed significant loss of restoring force as well as effective flow over time. A shift of the pump position within the ECC setup can be recommended to prevent blood damaging negative pressures. Further research is necessary to evaluate the exact cause of the reduction of restoring force overtime as well as its risks for the patients. Finally, our results underline the importance of transit time flow measurements to collect reliable flow data., (© 2020 The Authors. Artificial Organs published by International Center for Artificial Organ and Transplantation (ICAOT) and Wiley Periodicals LLC.)

Objectives: Although indications for the MitraClip are becoming increasingly liberal, the number of patients requiring valve surgery after an insufficient outcome of the procedure is growing. Referral to surgery is, however, frequently delayed. During this time, the patients often deteriorate. We retrospectively analysed patients before MitraClip implantation and after mitral valve surgery., Methods: A total of 49 patients who received a mitral valve replacement (average 8 ± 12 months after MitraClip implantation) were assessed. Of these, 53% had 2-4 clips inserted. The mean age was 73 years, and the mean log EuroSCORE was 20.79 ± 14.42%. Echocardiographic data obtained prior to MitraClip implantation and preoperatively, 10 days and 6 and 12 months after cardiac surgery were reviewed. Survival analysis, risk profile and postoperative complications were analysed., Results: The 30-day and 1-year mortality was 26.5% and 59.2%, respectively. Prior to MitraClip implantation, 42.8% of patients had mild tricuspid insufficiency and 6.1% had moderate tricuspid insufficiency. Prior to surgery, 26.5% showed mild, 32.7% moderate and 38.8% severe tricuspid insufficiency (P < 0.001). Furthermore, right heart function assessed by tricuspid annular plane systolic excursion deteriorated significantly after Implantation of the MitraClip (P < 0.001). In patients with a MitraClip, the pulmonary artery pressure was significantly higher at the time of mitral replacement than it was before the MitraClip was implanted (P < 0.001)., Conclusions: A subgroup of patients does not benefit from a MitraClip and shows progressive deterioration in cardiac function, making valve replacement under difficult circumstances inevitable. The earlier these patients are operated on, the better it is. It can be assumed that some patients would be better off with primary surgery, especially if mitral reconstruction is then still feasible. Therefore, the indications for MitraClip implantation should be carefully considered and caution should be exercised during monitoring., (© The Author(s) 2020. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Purpose: Currently, there is a paucity of studies on the prevalence of Elimination Disorders among Iranian children and adolescents. Due to the ongoing need to monitor the health status of these children and adolescents, the present study aims to investigate the prevalence of Elimination Disorders and comorbid disorders in Iranian children and adolescents., Methods: In this cross-sectional study, 29,781 children and adolescents age 6 to 18 years old were selected and studied from all the provinces in Iran. The sampling was carried out by employing a multistage cluster sampling method, and several clinical psychologists using semi-structured interviews collected the data. Furthermore, clinical psychologists collected demographic information (including information about gender, age, place of residence, education level, and parental education level). The collected data were analyzed using SPSS version 20., Results: Generally, the prevalence of Elimination Disorders was found to be 5.4% covering both enuresis (p= 5.4, 95% CI = 5.1-5.7) and encopresis (p= 0.13, 95% CI = 0.09-0.2). The total prevalence of comorbid disorders was 38%, and among the comorbid disorders, Attention Deficit Hyperactivity Disorder (ADHD) (p= 11, 95% CI = 9.5-12.7) and Separation Anxiety (p= 10.6, 95% CI = 9.1-12.2) were the most prevalent., Conclusion: The prevalence of Elimination Disorders in Iranian children and adolescents is moderate compared to similar studies elsewhere. As for comorbid disorders, ADHD and Separation Anxiety were found to be the most prevalent disorders. Since Elimination Disorders coexist with psychiatric disorders in children, further studies of these comorbidities may give better insight into the treatment and prognosis of Elimination Disorders.

Background: Polymeric heart valves are constructed from flexible synthetic materials, therefore aiming to combine the advantageous hemodynamic of biological and the longevity of mechanical valve prostheses. One such valve prototype in development is the PIZZA valve constructed of flexible triangular silicone leaflets on a foldable metal base for perspective transcatheter implantation. Here we present further improvements in its performance through structural modifications., Methods: Structurally modified prototypes were constructed from silicone sheets and stainless-steel wires. Their performance was then tested in a hemodynamic testing device of the type HKP 2.0., Results: Shift from a planar to a cone shape as well as overlapping of the leaflets significantly improved the valves performance, reducing regurgitation as well as systolic pressure gradients., Conclusions: The results of the modified prototypes expressed superior performance and represented a step forward on the road to an easily producible, polymeric transcatheter valvular prosthesis., Competing Interests: J. M. Albes is the inventor of the valve. All commercial rights have been transferred to NVT AG Luzernerstrasse 91, 5630 Muri, Switzerland., (Thieme. All rights reserved.)

Background: Conventional stented valves (CV) remain gold standard for aortic valve disease. Bovine prostheses have been improved and rapid deployment valves (RDV) have arrived in the recent decade. We compare clinical and hemodynamic short-term outcome of six bovine valves., Methods: We retrospectively evaluated 829 consecutive patients (all-comers) receiving bovine aortic valve replacement (AVR). Four CV from different manufacturers (Mitroflow, Crown, Perimount, Trifecta) and two RDV (Perceval, Intuity) were compared in terms of pre-, intra-, and postprocedural data. A risk model for mortality was created., Results: All valves reduced gradients. From 23 mm, all CV showed acceptable gradients. Twenty-one millimeter Mitroflow/Perceval and 19 mm Crown showed above-average gradients. As baseline data differed, we performed propensity matching between aggregated isolated CV and RDV groups. Cardiopulmonary bypass (CPB), clamp, and surgery times were shorter with RDV (87.4 ± 34.0 min vs 111.0 ± 34.2, 54.3 ± 21.1 vs 74.9 ± 20.4, 155.2 ± 42.9 vs 178.0 ± 46.8, p  < 0.001). New pacemaker rate (10.1 vs 1.3%, p  = 0.016) and the tendency toward neurologic events (8.9 vs 2.5%, p  = 0.086) were higher using RDV, induced mainly by the Perceval. Early mortality was equal (2.5 vs 1.3%, p  = 0.560). Revision for bleeding, dialysis, blood products, length-of-stay, gradients, and regurgitation was also equal. Risk analysis showed that low valve size, low ejection fraction, endocarditis, administration of red cells, and prolonged CPB time were predictors of elevated mortality., Conclusion: Isolated bovine AVR has low mortality. Valves ≥ 23 mm show comparable gradients while the valve model matters < 23 mm. RDV should be used with care. Procedure-related times are shorter than those of CV but pacemaker implantation and neurologic events are more frequent (Perceval). Early mortality is low and valve performance comparable to CV., Competing Interests: None., (Thieme. All rights reserved.)

The aim was to evaluate the lifetime prevalence of conduct disorder according to sociodemographic characteristics, determine the sociodemographic predictors of conduct disorder, and estimate the rates of comorbidities of psychiatric disorders in children and adolescents with conduct disorder by age and gender. The National Epidemiology of Iranian Children and Adolescents Psychiatric Disorders was a cross-sectional, general population-based study on 30,532 children and adolescents aged 6-18 years from all provinces of Iran, which was done using multistage cluster sampling. Iranian citizens aged 6-18 years who resided at least 1 year in each province were included, and children and adolescents with severe physical illnesses that prevented them to participate in the study were excluded. The sample weighting adjustment was used, since we had randomly selected the equal number of 1000 participants of each province from the urban and rural areas. Trained psychologists conducted diagnostic interviews with the adolescents and the children's parents using the Persian version of the Kiddie Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version (K-SADS-PL). In this study, 54 children aged 6-9 years (0.58%, CI 0.47-0.77), 64 adolescents aged 10-14 years (0.57%, CI 0.47-0.77), and 117 adolescents aged 15-18 years (1.22%, CI 0.96-1.44) met the criteria of the lifetime conduct disorder. Conduct disorder was significantly more common in boys than in girls, and was significantly less prevalent among those participants whose fathers had no history of psychiatric hospitalization. Of the participants with conduct disorder, 83.4% met the criteria for at least one other psychiatric disorder. Conduct disorder had a high rate of comorbidity with oppositional defiant disorder (54.89%, CI 48.50-61.12), attention-deficit/hyperactivity disorder (32.34%, CI 26.68-38.56), tobacco use (20.43%, CI 15.77-26.04), and depressive disorders (18.30%, CI 13.88-23.74). Because of using the diagnostic instrument, we found a low total rate of prevalence for conduct disorder; however, higher rates of it were observed among boys and adolescents. Further studies are needed to explore the nature of comorbidities of conduct disorder and to consider them in a large clinical population.

Childhood anxiety may lead to serious health consequences in later life. The present study provides the prevalence, comorbidity, and predictors of anxiety disorders among children and adolescents. This was a cross-sectional national project that was implemented on 28,698 children and adolescents in Iran. Participants entered the study by multistage cluster sampling with an equal number of each gender and three age groups (6-9, 10-14, and 15-18 years) within each cluster. The tools used in this research were the demographic questionnaire and K-SADS-PL. To analyze the data logistic regression and chi-square tests were used in SPSS (ver. 16). The prevalence of anxiety disorder in children and adolescents was 13.2 in boys and 15.1 in girls. Furthermore, gender, age, place of residence and history of psychiatric hospitalization of parents could predict anxiety disorders. Anxiety disorders had comorbidity with behavioral disorders, neurodevelopmental disorders, mood disorders, psychotic disorders, substance abuse disorders, and elimination disorders. According to our findings in this study, anxiety disorders affect the performance, health and life of children and adolescents, identifying the childhood anxiety, as well as finding diseases that are associated with anxiety disorders, can help in the prevention of the disorder., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Background: Prosthetic replacement of aneurysms of the ascending aorta is the gold standard in terms of long-term stability. Wrapping seems to be a less invasive procedure. It has not yet been shown if it is as safe in terms of long-term outcome., Methods: We present a single-center analysis of our experience over 13 years. We retrospectively analyzed data from patients who received either aortic prosthetic wrapping (AW) or aortic prosthetic replacement (AR) with or without aortic valve replacement and assessed them through phone calls. We used propensity score matching to adjust the baseline of the groups., Results: Before propensity matching, 144 patients received AW and 91 patients underwent AR. Mean age was 64 ± 11.8 years. After propensity score matching and adjusting for significant differences in age, gender, body mass index, logistic EuroSCORE I, and left ventricular function, 69 patients in each group remained for further analysis. Rate of early reoperation due to tamponade, inhospital mortality, and survival rates did not differ. In both groups, the surgically treated aortic segment did not show enlargement, whereas the nontreated aortic arch showed comparable aneurysmatical progression., Conclusions: AW is safe and feasible and can be used in elderly or frail patients in order to avoid an AR. Progression of the remaining native aortic segments occurs, thus requiring strict life-long follow-up to ensure an elective and thus safe approach for appropriate consecutive surgical measures, if required., Competing Interests: None., (Georg Thieme Verlag KG Stuttgart · New York.)

Objective: This study investigated the prevalence of feeding and eating disorders, and identified their correlates and comorbidities among children and adolescents., Method: We used the nationally representative sample of the Iranian Children and Adolescents' Psychiatric disorders (IRCAP) survey, with 30,532 participants randomly selected by a multistage cluster sampling method. We employed the kiddie schedule for affective disorders and schizophrenia-present and lifetime version (K-SADS-PL) semi-structured face-to-face interview to screen for any psychiatric disorders, including feeding and eating disorders, and associated factors. We used multivariate binary logistic regression to analyze the data., Results: Valid data from 27,111 participants were analyzed. The total prevalence of feeding and eating disorders among children and adolescents was 0.89 (0.81-1.10). In all types of feeding and eating disorders, the adjusted odds ratio was higher among girls (except binge-eating disorder) and older adolescents but was lower among rural residents. The most common psychiatric comorbidities observed in children and adolescents with feeding and eating disorders were obsessive-compulsive disorder (20.2%), agoraphobia (20.2%), depressive disorder (16.4%), social phobia (10.1%), oppositional defiant disorder (10.1%), generalized anxiety disorder (9.4%), attention deficit hyperactivity disorder (7.5%), and conduct disorder (5.7%), which were significantly more common compared to their peers without feeding and eating disorders., Discussion: Older age, female gender and living in an urban area are predisposing factors in feeding and eating disorders (in binge-eating disorder, the male gender is a positive correlate). We suggest that future works pay attention to the role of gender, comorbidities and predisposing factors., (© 2019 Wiley Periodicals, Inc.)

Background:  Endocarditis remains one of the most threatening diagnoses in cardiac surgery and is still increasing. Particularly, device-related as well as prosthetic endocarditis appears to be on the rise. Early mortality and periprocedural complications are high jeopardizing the success of surgical efforts. We looked at the development of the numbers and the distribution of endocarditis in an all-comer analysis., Methods:  From 2003 to 2017, 752 patients with endocarditis were transferred to our cardiosurgical institution (mean age 65 ± 13 years; mean logistic EuroSCORE 28.01%; males 74.33%). A total of 89.49% of them were surgically treated; 30.01% redo cases thereof; and 9.17% had been operated previously for acute endocarditis., Results:  While the total number of cardiosurgical procedures remained relatively stable throughout the years, 20 patients were admitted in 2003 and 79 in 2017 yielding more than fourfold increase ( p  < 0.001). Early mortality of all patients was 25.1%. Septic emboli occurred in 23.7% and 43.8% cerebral emboli thereof. A significant increase of aortic, mitral, and tricuspid valves involvement was observed ( p  < 0.001). An increase of device-related endocarditis was also noted ( p  < 0.001)., Conclusion:  Endocarditis remains a serious problem with high early mortality and morbidity. The vast increase of electrophysiological device implantations has resulted in an increase of tricuspid valve involvement. Liberalization of endocarditis prophylaxis, that is, more restrictive use of antibiotics in 2007 may have at least partially contributed to an increase of the individual risk to suffer from acute endocarditis. A renaissance of a stricter endocarditis-prophylaxis may thus be considered., Competing Interests: None declared., (Georg Thieme Verlag KG Stuttgart · New York.)

Background:  Transcatheter heart valve (THV) as valve-in-ring is increasingly used in the mitral position. Semi-rigid rings may serve as a more appropriate scaffold for proper anchoring of a THV as they may change from their oval to a round shape thereby fitting to the implanted THV., Methods:  One rigid and five semi-rigid rings of four manufacturers, Edwards Physio I and II, Sorin 3D Memo, Medtronic Simulus, and St. Jude Medical (SJM) Saddle and SJM Sequin, with sizes 28 to 36 mm and Edwards Sapien III THV 23, 26, and 29 mm were used. Preevaluation comprised insertion/inflation of the THV into the ring and visual inspection for the paravalvular gap ≥ 4 mm 2 . Only valves not showing paravalvular gap were then submitted to hemodynamic evaluation with a pulse duplicator. Cusp movement was assessed with a high-speed-camera. Mean transvalvular gradients (TVGs) were measured., Results:  SJM Saddle ring of all sizes and SJM Sequin ring 34 showed marked gaps combined with all THV sizes, thus not undergoing hemodynamic testing. It was further shown that ring sizes ≥ 36 mm did not allow for a proper fit of even the largest THV into the ring of all the manufacturers and were consequently not hemodynamically evaluated. The 23 mm THV was too small for any ring size. The lowest gradients were achieved with the 26 mm THV in 30 and 32 mm and the 29 mm THV in 32 and 34 mm rings., Conclusion:  Not all currently available annuloplasty rings are ideal scaffolds for THV placement. It appears that a more proper fit can be achieved with semi-rigid rings than with rigid ones. Note that 23 mm THV appeared to be too small for an adequate anchoring in even the smallest available ring. Thus, 26 mm as well as 29 mm THV fit properly in ring sizes between 28 and 34 mm. Surgeons may consider to choose from those ring brands and sizes which allow for good placement of a THV in view of possible valve degeneration in the later course., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (Georg Thieme Verlag KG Stuttgart · New York.)

Objectives: The invention of new surgical procedures requires testing at different stages including animal models. To facilitate this process, we have developed a computer-controlled extracorporeal circulation system for testing of an explanted porcine heart simulating a variety of physiological parameters. Mitral valve function can be assessed before and after induced valve insufficiency and after valve repair. Accordingly, techniques and instruments can be modified at early stages of prototype development., Methods: In the diastole, the left atrium is passively filled through the reservoir. The loading pressure of the atrium and flow rates can be widely adjusted. To simulate the systole, a linear motor-driven piston pump promotes volume into the left ventricle and the aorta. An additional circulatory pump compensates for undesired total emptying of the heart chambers. The processor control of the linear pump allows for various settings of flow rate, velocity and even irregular rhythm. Twenty-one isolated porcine hearts were used. The leaflet movement was filmed using a universal serial bus (USB)-probe camera., Results: With 80 mm stroke and 1 m/s speed, a volume of 150 ml can be pumped at a heart rate of up to 73 bpm. Cardiac outputs of up to 10.9 l/min can be achieved. Constant visualization and continuous measurements of the pressure gradients before and after the induction of mitral insufficiency and after repair allowed quantitative verification of repair quality under beating-heart conditions., Conclusions: This model allows a controllable pulsation, loading and unloading of a porcine heart in a wide range. Thus, the function of the leaflets and repair results can be qualitatively and quantitatively evaluated under quasiphysiological conditions., (© The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: Examining the conditions for hospital admission and its appropriateness, and continuous investigation of hospital services are important issues that can improve resource productivity, service quality, and hospital efficacy. So, the present study was conducted to determine the appropriateness of the services provided in Yasuj educational hospitals., Methods: This descriptive-analytical study was carried out on 204 hospitalized patients who were selected through multistage quota sampling in 2016. The appropriateness evaluation protocol (AEP) was used to collect the data. Analytical tests such as paired t-test, chi-square test, and Fisher's exact test were used to determine the relationship between appropriate and inappropriate admission and hospitalization and demographic characteristics. The data were analyzed using the SPSS18 statistical software., Results: A total of 980 days of stay were evaluated, and according to the AEP, 35 days of hospitalization were considered inappropriate (3.57%). The mean hospitalization duration was 6/16 ± 5/53 days. The results showed that inappropriate admission and hospitalization rates were respectively 0.6% and 13.8%., Conclusion: Unnecessary admissions and hospitalizations can be considered as one of the challenges of the health system. Reducing unnecessary hospitalization will increase hospital productivity, reduce the waiting list and hospitalization costs, and also reduce the risk of exposure to hospital infections. In order to prevent inappropriate admissions and unnecessary hospitalizations, special measures can be taken, including the use of clinical guidelines, modification of the discharge process, and modification of the lower levels of the service providing system., (© 2019 John Wiley & Sons, Ltd.)

Purpose: Today, cancers have become a major cause of mortality in developed and developing countries. Among various cancers, gastric cancer imposes a huge economic burden on patients, their families, and on the health-care system. This study aimed to determine the economic burden of gastric cancer in Kohgiluyeh and Boyer Ahmad province of Iran in 2016., Methods: This was a cross-sectional cost of illness study conducted in Kohgiluyeh and Boyer Ahmad province of Iran in 2016, using a prevalence-based approach. All patients were studied using the census method (N = 110). The required data on direct medical, direct nonmedical, and indirect costs were collected using a data collection form from the patients' medical records, tariffs of diagnostic, and therapeutic services approved by the Ministry of Health and Medical Education in 2016., Results: The total cost and burden of gastric cancer in Kohgiluyeh and Boyer Ahmad province of Iran in 2016 were $US436 237, among which the majority were direct medical costs (59%). The highest costs among direct medical costs, direct nonmedical costs, and indirect costs were, respectively, related to the costs of medications used by the patients (35%), transportation (31%), and absence of patients' families from work and daily activities caused by patient care (56%)., Conclusion: Our study has revealed for the first time high costs of gastric cancer in Iran. To decrease the total costs and burden, the following suggestions can be made: increasing insurance coverage and government subsidies for purchasing necessary medications, providing the required specialized care and services related to cancer diseases such as gastric cancer in other provincial cities rather than just in capital cities, and so on.

Objective: Considering the impact of rapid sociocultural, political, and economical changes on societies and families, population-based surveys of mental disorders in different communities are needed to describe the magnitude of mental health problems and their disabling effects at the individual, familial, and societal levels. Method : A population-based cross sectional survey (IRCAP project) of 30 532 children and adolescents between 6 and 18 years was conducted in all provinces of Iran using a multistage cluster sampling method. Data were collected by 250 clinical psychologists trained to use the validated Persian version of the semi-structured diagnostic interview Kiddie-Schedule for Affective Disorders and Schizophrenia-PL (K-SADS-PL). Results: In this national epidemiological survey, 6209 out of 30 532 (22.31%) were diagnosed with at least one psychiatric disorder. The anxiety disorders (14.13%) and behavioral disorders (8.3%) had the highest prevalence, while eating disorders (0.13%) and psychotic symptoms (0.26%) had the lowest. The prevalence of psychiatric disorders was significantly lower in girls (OR = 0.85; 95% CI: 0.80-0.90), in those living in the rural area (OR = 0.80; 95% CI: 0.73-0.87), in those aged 15-18 years (OR = 0.92; 95% CI: 0.86-0.99), as well as that was significantly higher in those who had a parent suffering from mental disorders (OR = 1.96; 95% CI: 1.63-2.36 for mother and OR = 1.33; 95% CI: 1.07-1.66 for father) or physical illness (OR = 1.26; 95% CI: 1.17-1.35 for mother and OR = 1.19; 95% CI: 1.10-1.28 for father). Conclusion: About one fifth of Iranian children and adolescents suffer from at least one psychiatric disorder. Therefore, we should give a greater priority to promoting mental health and public health, provide more accessible services and trainings, and reduce barriers to accessing existing services.

Background: MitraClip (Abbott Inc.) is propagated as a palliative option for high-risk patients with mitral insufficiency considered not qualifying for surgical repair. A proportion of patients requires consecutive surgery because of technical failure or inappropriate clinical improvement. Furthermore, surgical reconstruction is impossible in almost all patients after MitraClip implantation. Consequently, these patients receive replacement although primary repair may have been possible. The outcome of those patients compared with patients receiving primary mitral valve replacement (MVR) or mitral valve repair (MVP) was analyzed., Methods: A total of 23 patients were retrospectively analyzed after MVR following MitraClip. Overall, 46 patients with corresponding demographic data and risk profile receiving primary MVR (23 patients) or MVP (23 patients) were retrieved for matched pair analysis., Results: Mean age was 70 years in all groups, log European system for cardiac operative risk evaluation (EuroSCORE) was 22.47% ± 16.30 in MVR after MitraClip (MC), 22.34% ± 16.23 in MVP, and 22.33% ± 16.14 in MVR group. Preoperative left ventricular ejection fraction (LVEF) was 44%, and postoperative LVEF was 48% in all groups. The 30-day mortality was 21.7% in the MitraClip group whereas it was 4.3% in the MVR and 13.0% in the MVP group. The 1-year survival was 56.5% in the MitraClip group while it was 95.6% in the MVR group and 82.6% in the MVP group (Wilcoxon test: p  = 0.007; chi - square test: p  = 0.001 MitraClip vs. MVR; p  = 0.054 MitraClip vs. MVP)., Conclusions: Patients requiring surgical MVR after the previous MitraClip fared worse than matched cohorts receiving primary MVR or MVP. Indication for MitraClip should, therefore, be made very cautiously given the excellent results gained with primary surgery., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (Georg Thieme Verlag KG Stuttgart · New York.)

Background: Chronic and abnormal increase of different types of dyslipidemia leads to some important diseases, such as constriction and abstraction of vessels in various parts of the body, especially in the heart. High lipid profile, such as increased total cholesterol and LDL as well as decreased HDL are recognized as cardiovascular disease risk factors. The present study aimed to estimate the prevalence of different types of dyslipidemia in Iran by a meta-analysis method., Methods: A literature search for studies published during 1998-2015 was carried out using both Persian and English databases (SID, Magiran, IranMedex, MedLib, PubMed, and Scopus). Keywords such as lipid, dyslipidemia, CVD, cardiovascular risk factors, hypercholesterolemia, high LDL-C, low HDL-C, and prevalence were used in the search. Random-effects model was used for the analysis using STATA (version 11.2)., Results: In total, 163 articles were identified of which 49 articles fulfilled the inclusion criteria. The estimated prevalence (95% confidence interval) of eligible articles for high cholesterol ≥200 mg/dl and ≥240 mg/dl was 42% (95% CI: 38-45) and 17% (95% CI: 14-20), respectively. Moreover, the prevalence (95% confidence interval) for high LDL-C ≥130 mg/dl and ≥160 mg/dl was 40% (95% CI: 32-48) and 19% (95% CI: 16-23), respectively. The pooled prevalence estimate for low HDL-C (<40 among males, <50 among females) was 43% (95% CI: 33-53) in both sexes of the Iranian people. All types of lipid component abnormalities (hypercholesterolemia, high LDL-C, and low HDL-C) were more prevalent in women., Conclusion: The results indicate that the prevalence of different types of dyslipidemia in Iran is substantial. Given the risk of complications (e.g. cardiovascular disease and control of different types of dyslipidemia) in Iranian people, it is important to reduce the burden of cardiovascular diseases., Competing Interests: Conflict of Interest: None declared.

Background: Metabolic syndrome) MetS( is a complex risk factor which increases the risk of cardiovascular diseases and type 2 diabetes. There are many studies with various populations and results about the prevalence of MetS in Iran; in order to authenticate these studies and have an overall estimation of its prevalence in Iran, performing a meta-analysis seems to be necessary., Objective: This study aimed to investigate the prevalence of MetS and its components in Iran via meta-analysis method., Methods: All associated published papers in national and international journals of PubMed, Scopus, Web of Science, Magiran, Iranmedex, Science Direct, Medlib, and SID databases were searched from January, 2000 to October, 2016. All types of studies, including local and national surveys that reported the prevalence of MetS among healthy populations in Iran were reviewed. The effects of age, sample size and publication date as possible sources of heterogeneity among the study findings was examined by meta-regression. P-values less than 0.05 were considered as significant in heterogeneity tests. All analysis was done by R Ver. 3.2.1 and STATA (version 10)., Results: Seventy eligible studies were selected for meta-analysis. The overall estimation of MetS prevalence was 25% (95% CI: 22-29%) based on the Adult Treatment Panel III (ATP III) criteria, 30% (95% CI: 25-36%) according to the International Diabetes Federation (IDF), and 39% (95% CI: 26-52%) based on the Joint Interim Societies (JIS) criteria. The prevalence of MetS was lower in men than in women (26.9% versus 35.7%). The prevalence of various MetS components including High TG (triglyceride), Low HDL-C, High BP and High FBS (fasting blood sugar) was 43%, 54%, 38% and 22% among the adult population., Conclusion: Findings from the present meta-analyses study displayed a high prevalence of metabolic syndrome in Iran, especially in women, which increases with age in both sexes. It alerts health care providers and policy makers to find solutions in order to take action to reduce MetS risk in society., Competing Interests: Conflict of Interest: There is no conflict of interest to be declared.

The functions of dance and music in human evolution are a mystery. Current research on the evolution of music has mainly focused on its melodic attribute which would have evolved alongside (proto-)language. Instead, we propose an alternative conceptual framework which focuses on the co-evolution of rhythm and dance (R&D) as intertwined aspects of a multimodal phenomenon characterized by the unity of action and perception. Reviewing the current literature from this viewpoint we propose the hypothesis that R&D have co-evolved long before other musical attributes and (proto-)language. Our view is supported by increasing experimental evidence particularly in infants and children: beat is perceived and anticipated already by newborns and rhythm perception depends on body movement. Infants and toddlers spontaneously move to a rhythm irrespective of their cultural background. The impulse to dance may have been prepared by the susceptibility of infants to be soothed by rocking. Conceivable evolutionary functions of R&D include sexual attraction and transmission of mating signals. Social functions include bonding, synchronization of many individuals, appeasement of hostile individuals, and pre- and extra-verbal communication enabling embodied individual and collective memorizing. In many cultures R&D are used for entering trance, a base for shamanism and early religions. Individual benefits of R&D include improvement of body coordination, as well as painkilling, anti-depressive, and anti-boredom effects. Rhythm most likely paved the way for human speech as supported by studies confirming the overlaps between cognitive and neural resources recruited for language and rhythm. In addition, dance encompasses visual and gestural communication. In future studies attention should be paid to which attribute of music is focused on and that the close mutual relation between R&D is taken into account. The possible evolutionary functions of dance deserve more attention.

Background: MRI is a new and expensive diagnostic technology, which has been used increasingly all over the world. Low back pain is a worldwide prevalent disorder and MRI technique is one of the several ways to diagnose it. This paper aims to identify the appropriateness of lumbar spine MRI prescriptions in Shiraz teaching hospitals using standardized RAND Appropriateness Method (RAM) criteria in 2012., Methods: This study consisted of two phases. The first phase involved a qualitative enquiry and the second phase had a quantitative cross-sectional nature. In the first phase RAM was used for developing lumbar spine MRI indications and scenarios. In the second phase, the finalized scenarios were compared with the history and physical examination of 300 patients with low back pain. The rate of appropriateness of lumbar spine MRI prescription was then calculated., Results: Of 300 cases of lumbar spine MRI prescriptions, approximately 167 (56%) were considered inappropriate, 72 (24%) were uncertain, and 61 (20%) were deemed to be appropriate. The economic burden of inappropriate prescriptions was calculated at 88,009,000 Rials. In addition, the types of expertise and physical examination were considered as related factors to appropriateness of prescriptions., Conclusion: In conclusion, a large proportion of lumbar spine MRI prescriptions, which result in financial burden on the insurance companies and the patients alike is unnecessary. This study suggests that policy makers consider this evidence while decision-making. Our findings highlight the imperative role of Health Technology Assessment (HTA) and Clinical Practice Guidelines (CPGs). As a result, developing local clinical guidelines may create the commitment needed in physicians in prescribing appropriate prescriptions within the health sector. The study further recommends that appropriate scenarios should be considered as a criterion for payment and reimbursement.

Background: Studies show that a large proportion of healthcare offered may be inappropriate or unnecessary. Magnetic resonance imaging (MRI) is a new and expensive diagnostic technology which has been increasingly used all over the world. Moreover, this trend has been more rapidly increasing in Iran. Low back pain is a common disorder all over the world and MRI technique is one of the several ways to assess its cause., Objectives: The present study aims to develop scenarios for lumbar spine MRI., Materials and Methods: In the present study, the RAND Appropriateness Method (RAM) was used in order to reach consensus regarding developing scenarios for lumbar spine MRI. We generated scenarios from valid clinical guidelines as well as the experts' opinion. The panel members included nine specialists from various medical specialties that had scored scenarios in two rounds, the first of which was without interaction, while the second one was with interaction., Results: We extracted 97 scenarios for the lumbar spine MRI in the scenario extracting phase of the study and the panel members added 18 scenarios. After implementation of two rounds, the scenarios were categorized into three ranges. Sixty seven (58%) of the scenarios were considered as appropriate, 45 (39%) as uncertain, and three (2.6%) as inappropriate., Conclusions: RAM is useful for identifying stakeholder views in settings with limited resources. Since RAM has precise instructions for consensus developing, a large number of scenarios were considered as uncertain. Therefore, more research has to be conducted on the issue.

Background: The aim of this study was to identify the appropriateness of cesarean sections, performed in Tehran hospitals using standardized Rand Appropriateness Method (RAM) criteria., Methods: In this study we used the RAM criteria. In order to prepare the list of cesarean scenarios, clinical guidelines were selected, and the Appraisal of Guidelines for Research and Evaluation was used to choose the most appropriate. Two panels were held with the participation of related specialists. The scenarios derived through this method were compared with data existing in the medical records of 250 women who underwent cesarean sections in selected hospitals affiliated with Tehran University of Medical Sciences. The appropriateness rate of the cesarean sections was calculated., Results: Out of 250 cases of cesarean sections performed, 91 (36.4%) were inappropriate, 41 (16.4%) were equivocal and 118 (47.2%) were considered to be appropriate. Appropriateness differed between public and private hospitals, which were statistically significant., Conclusion: This study shows that as with many other health services, cesarean section has many scenarios that there are different opinions about them and no decision about presenting these scenarios as yet. Moreover the result of study showed the rate of inappropriate cesarean sections in this study is one of the highest reported rates from different communities.

Background: Cesarean section rates are increasing worldwide, and a rapid increase has been observed in Iran. Disagreement exists between clinicians about when to use cesarean section. We aimed to identify the appropriateness criteria for the use of cesarean section in Iran., Method: A consensus development study using a modified version of the RAND Appropriateness Method (RAM). We generated scenarios from valid clinical guidelines and expert opinions. A panel of experts participated in consensus development: first round via mail (12 members), second round face-to-face (9 members). We followed the RAM recommendations for the development of the scenario lists, rating scales, and statistical analyses., Results: 294 scenarios relevant to cesarean section were identified. 191 scenarios were considered appropriate, of which 125 scenarios were agreed upon. The panel found cesarean inappropriate for 21% of scenarios, and 'equivocal' for 14% of scenarios., Conclusion: RAM is useful for identifying stakeholder views in settings with limited resources. The participants' views on appropriateness of certain indications differed with available evidence. A large number of scenarios without agreement may partly explain why it has been difficult to curb the growth in cesarean section rate.