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Objective: Elevated red blood cell distribution width (RDW) level has been shown to be associated with poor outcomes in patients with cardiovascular disease. Limited data are available regarding the prognostic value of RDW in transcatheter aortic valve replacement (TAVR) patients. Therefore, we aimed to investigate the impact of RDW variation on outcomes of TAVR patients., Methods: From March 20, 2012, to February 20, 2020, the pre-TAVR RDW levels of 1,163 consecutive TAVR patients were examined. Receiver operating curves were set to define the most accurate cut-point, which was subsequently validated in our validation set. Associations of RDW levels with early and long-term outcomes were investigated., Results: A total of 988 patients were eligible for the analysis. Patients with 30-day, 1-year, and 7-year mortality had significantly higher pre-TAVR RDW levels (15.8% [12.9-19.1] vs 14.7% [11.6-26.3], P = 0.01; 16% [12.3-26.3] vs 14.7% [11.6-24.3], P < 0.001; 15.6% [12.3-26.3] vs 14.6% [11.6-24.3], P < 0.001, respectively). A RDW of 14.5% was found as the most sensitive and specific cut-point for mortality at 1 and 7 years (HR = 2.6, 95% CI: 1.6-4.2, P < 0.001; HR = 1.8, 95% CI: 1.3-2.4, P < 0.001), with mortality of 22% versus 10% at 1 year ( P < 0.001) and 37% versus 27% at 7 years ( P < 0.001) in patients with RDW ≥14.5% versus those with RDW <14.5%., Conclusions: RDW is an important prognostic factor in TAVR patients. A RDW level higher than 14.5% is significantly associated with post-TAVR early and late mortality. RDW levels should be incorporated into current risk assessment models as an additional variable to predict post-TAVR outcomes.

Introduction: Limited data are available about the outcomes of transcatheter mitral valve replacement (TMVR) using transseptal approach in patients with prior mitral valve repair (valve-in-ring) or replacement (valve-in-valve) (TMViVR) and on modes of the prior surgical valve failures. We report our tertiary center TMVR experience in high surgical risk patients with prior mitral valve repair or replacement., Methods: From December 2016 to January 2020, patients with symptomatic severe mitral valve stenosis and/or insufficiency at increased redo surgical risk were included. TMViVR was performed off-label with Sapien S3 valve (Edwards Lifesciences). Patients were followed within 30-days and 1-year from the procedure., Results: Twenty-seven patients underwent transcatheter mitral valve-in-valve (n = 21) or valve-in-ring (n = 6) replacement. Mean ± SD age was 71.8 ± 11 years with Society of Thoracic Surgeons' calculated mortality 7.1 ± 4.6%. The etiology of valve failure was stenosis in 17 (63%) patients, insufficiency in 4 (14.8%) patients, and both in 6 (22.2%) patients. TMViVR technical success was 100% in all patients. Left ventricular outflow track (LVOT) obstruction was observed in only one (3.7%) patient. Zero patients had moderate or severe central mitral valve regurgitation or paravalvular leak. All patients had symptomatic improvement at 30 days. The mean transmitral diastolic pressure gradient decreased from 14.1 ± 4.6 to 6.9 ± 4.6 mm Hg (p < .001) at 30 days. The one patient with LOVT obstruction required readmission at 5-months. One-year survival was 95%. At 1-year mean gradients remained lower than the baseline (7.0 ± 3.0 vs. 12.4 ± 4.0, p = .002)., Conclusions: Transcatheter mitral valve-in-valve and valve-in-ring replacement is feasible and safe. The improvement in mitral valve hemodynamics appears to be durable., (© 2021 Wiley Periodicals LLC.)

Background: Abnormal invasive hemodynamics after transcatheter aortic valve replacement (TAVR) is associated with poor survival; however, the mechanism is unknown., Hypothesis: Diastolic dysfunction will modify the association between invasive hemodynamics postTAVR and mortality., Methods: Patients with echocardiographic assessment of diastolic function and postTAVR invasive hemodynamic assessment were eligible for the present analysis. Diastology was classified as normal or abnormal (Stages 1 to 3). The aorto-ventricular index (AVi) was calculated as the difference between the aortic diastolic and the left ventricular end-diastolic pressure divided by the heart rate. AVi was categorized as abnormal (AVi < 0.5 mmHg/beats per minute) or normal (≥ 0.5 mmHg/beats per minute)., Results: From 1339 TAVR patients, 390 were included in the final analysis. The mean follow-up was 3.3 ± 1.7 years. Diastolic dysfunction was present in 70.9% of the abnormal vs 55.1% of the normal AVi group (P < .001). All-cause mortality was 46% in the abnormal vs 31% in the normal AVi group (P < .001). Adjusted hazard ratio (HR) for AVi < 0.5 mmHg/beats per minute vs AVi ≥0.5 mmHg/beats per minute for intermediate-term mortality was (HR = 1.5, 95% confidence interval [CI] 1.1 to 2.1, P = .017). This association was the same among those with normal diastolic function and those with diastolic dysfunction (P for interaction = .35)., Conclusion: Diastolic dysfunction is prevalent among TAVR patients. Low AVi is an independent predictor for poor intermediate-term survival, irrespective of co-morbid diastolic dysfunction., (© 2020 The Authors. Clinical Cardiology published by Wiley Periodicals LLC.)

Tricuspid valve regurgitation (TR) can be associated with poor prognosis. Transcatheter valve technology was adopted to treat the upstream effects of severe TR by placing a transcatheter valve in the inferior vena cava (IVC). In this study, we report off-label transcatheter valve implantation into the stented IVC in patients with severe TR for compassionate use. From September 2018 to February 2020, 6 inoperable patients with severe TR who failed medical treatment underwent percutaneous caval valve implantation (CAVI). Severity of TR was confirmed by intraoperative transesophageal echocardiography. Z-stents (Cook, Inc., Bloomington, IN, USA) were placed in the proximal IVC, and then a transcatheter valve was deployed in the suprahepatic cava without rapid pacing. Six patients, 2 females and 4 males, with a mean ± SD age of 74.7 ± 8.0 years were included. The procedure was successfully performed in all 6 patients (100%) employing a 29-mm SAPIEN 3 valve (Edwards Lifesciences, Irvine, CA, USA) with supranominal volume. No procedural complication was detected. At 30 days, TR improved from severe to trace in 1 patient, to mild-moderate in 3 patients, and 2 patients remained with severe TR. Among patients with improved TR, left ventricular ejection fraction increased from 47.5% ± 18.5% to 55% ± 20.4% ( P = 0.014). No patient had readmission at 30 days. Four patients needed rehospitalization within 6 months. Percutaneous CAVI is feasible and can be considered as a short-term palliative measure in patients with severe TR. CAVI can improve TR and potentially improve cardiac output in selected patients.

Background: In the era of an expanding use of transcatheter aortic valve replacement (TAVR), conduction disturbances and the requirement for permanent pacemaker (PPM) implantation remains a clinical concern., Hypothesis: Using a single-center experience, we sought to identify predictors of ventricular pacing burden after TAVR in patients who required PPM implantation., Methods: We conducted a retrospective study of 359 consecutive patients with symptomatic severe aortic valve stenosis who underwent TAVR at our institution between September 2013 and July 2019. Thirty patients (8.4%) required a PPM within 30 days after TAVR. Pre and post-TAVR electrocardiograms, pre-TAVR echocardiograms and computed tomography (CT), TAVR procedural details and post-TAVR device interrogation records at 1, 3, and 6 months were reviewed., Results: Mean percentage of ventricular pacing (VP%) at 1, 3, and 6 months was 58%, 59%, and 56% respectively. Using univariate logistic regression analysis, patients who had low VP% < 5% at 6 months were more likely to have a prosthesis/echocardiography-derived left ventricular outflow tract (LVOT) diameter ratio < 1.3 (OR 7.00, P-value .048), prosthesis/CT-derived aortic annulus diameter ratio < 1.02 (OR 7.11, P-value .047), post-TAVR new-onset LBBB (OR 16.80, P-value .019), time to PPM implantation greater than 2 days post-TAVR (OR 9.38, P-value .026) and pre-TAVR use of a beta blocker (OR 9.40, P-value .026)., Conclusions: In patients who required a PPM implantation post-TAVR, a lower TAVR prosthesis/LVOT or aortic annulus diameter ratio, post-TAVR new-onset LBBB and later time of PPM implantation showed a trend toward predicting a low VP% at 6 months., (© 2020 The Authors. Clinical Cardiology published by Wiley Periodicals LLC..)

Self-expanding valves have been associated with superior hemodynamics versus balloon-expandable valves. Our aim was to compare invasive gradients between valve types for similarly sized valves. Patients who underwent transcatheter aortic valve replacement (TAVR) at the Malcom Randall Veterans Affairs Medical Center and the Bern University Hospital were considered for this analysis. From 1623 subjects who underwent TAVR, a total of 566 had available invasive hemodynamic data. After applying exclusion criteria, we included 499 for analysis. With immediate invasive hemodynamic assessment, balloon- expandable valves were associated with similar/marginally lower transvalvular gradients versus self-expanding valves. With postoperative echocardiography within 24 hours, self-expanding valves were associated with lower Doppler gradients versus balloon-expandable valves for all size categories.

Objective: Outcomes of the Florida Sleeve (FS) procedure in patients with bicuspid aortic valve (BAV) have not been reported before. We compared outcomes of the FS procedure between patients with BAV and those with tricuspid aortic valve (TAV)., Methods: From May 1, 2002 to January 1, 2016, 177 patients including 18 BAV and 159 TAV underwent the FS procedure. Baseline characteristics, perioperative outcomes, and echocardiographic measurements were compared between the 2 groups. Kaplan-Meier and life-table analyses were used to evaluate survival and freedom from reintervention rates., Results: Mean ± standard deviation age and aortic root diameter were comparable in BAV and TAV groups, 47.83 ± 11.19 versus 49.59 ± 15.79 years ( P = 0.55) and 56.57 ± 6.18 versus 55.17 ± 8.84 mm ( P = 0.46), respectively. The 30-day mortality and stroke rates were zero in the BAV group and 1.88% ( n = 3) in the TAV group ( P = 1.00). One patient (5.55%) in the BAV group and 8 (5.03%) patients in the TAV group needed permanent pacemaker implantation ( P = 0.62). Freedom from reoperation was 93% in the BAV group and 99% in the TAV group at 8 years ( P = 0.041). Patient survival rate was 100% in the BAV group and 91% in the TAV group at 8 years ( P = 0.42). Freedom from aortic insufficiency greater than mild was 93% in the BAV group and 96.5% in the TAV group at 5 years ( P = 0.61)., Conclusions: This is the first study reporting outcomes of the FS procedure in patients with BAV. This technique is feasible, and the results appear to be durable when compared to patients with TAV.

Introduction: Lower transcatheter aortic valve replacement (TAVR) pressure gradients have been reported after implantation of self-expanding valves compared with balloon-expandable valves; however, there is a paucity of data on the relationship between invasively measured transvalvular pressure gradients and Doppler-derived measurements., Methods: From September 2013 to September 2018, patients with native aortic valve stenosis who had both intraoperative invasive and postoperative echocardiography transvalvular pressure gradients were included for analysis. We used parametric and nonparametric statistics to compare aortic gradients within and between groups., Results: Of 171 patients, 152 (88.9%) patients had TAVR with a balloon-expandable valve and 19 (11.1%) with a self-expanding valve. Among all patients, the invasive aortic gradient was 7.8 ± 3.2 mmHg and the Doppler-derived aortic gradient was 11.0 ± 4.5 mmHg (p < 0.001). Among those who received a balloon-expandable valve, the invasive aortic gradient was 7.5 ± 3 mmHg and the Doppler aortic gradient was 11.4 ± 4.5 mmHg (p < 0.001). In contrast, among patients who received a self-expanding valve, the invasive aortic gradient was 10.3 ± 3.4 mmHg and the Doppler aortic gradient was 8.5 ± 4.6 mmHg (p = 0.18)., Conclusions: Balloon-expandable valves were associated with lower invasive measurements versus post-TAVR Doppler gradients, while results were inconclusive regarding self-expanding valves.

Purpose: We investigated the outcomes of patients who underwent Transcatheter Aortic Valve Replacement (TAVR) with and without Balloon Aortic Valvuloplasty (BAV) using the SAPIEN 3 (S3) valve., Methods: All patients who underwent TAVR using S3 valve were included. The primary outcomes were the incidence of stroke and significant paravalvular leak (PVL). Secondary outcomes were the incidence of mortality, balloon post dilation, and need for permanent pacemaker., Results: From July-2014 to April-2018, 34 (9%) patients underwent BAV prior to TAVR and 344 (91%) patients underwent direct TAVR without BAV using the S3 valve. The Society of Thoracic Surgeons (STS) risk score was similar between two groups; 5.8 ± 3.5 in no BAV group and 5.4 ± 3.3 in BAV group, p = 0.53. After TAVR, 6 (1.7%) patients in no BAV group but no patient in BAV group developed stroke (p = 1.0). No patient had severe PVL and only 5 patients (1.3%) had moderate PVL at 30-day; 4 (1.2%) in no BAV group and 1 (2.9%) in BAV group (p = 0.38). Forty-six patients (13.4%) in the no BAV group and 4 (11.8%) patients in the BAV group needed balloon post dilation (p = 1.0). Six (1.6%) patients died during hospitalization, all in the no BAV group (p = 1.0). Forty-five (11.9%) patients needed new pacemaker implantation; 44 (12.8%) patients in no BAV group and 1 (2.9%) patient in BAV group (p = 0.1). Two-year survival rate was 85% in no BAV group and 84% in BAV group (p = 0.46)., Conclusions: TAVR using S3 valves is associated with very low rates of post-TAVR stroke and significant PVL. Outcomes of direct TAVR are similar to the outcomes of TAVR with BAV, without an increased rate of stroke, significant PVL, or balloon post dilation., (Copyright © 2019. Published by Elsevier Inc.)

Introduction: Inappropriate sinus tachycardia (IST) is characterized by increased heart rate out of proportion to normal physiologic demand. IST ablation is challenging for the electrophysiology community due to the epicardial location of the sinus node and the risk of phrenic nerve (PN) injury during catheter ablation. In this study, we investigated the safety and efficacy of a minimally invasive thoracoscopic surgery for elimination of IST., Methods: Patients with IST who failed medical therapy or endocardial ablation underwent minimally invasive thoracoscopic epicardial ablation. Epicardial activation mapping was performed to identify the earliest activation site and any possible migration of earliest activation along the lateral right atrium. The PN in each patient was protected by a pericardial retraction suture., Results: From 1 January 2000 to 15 June 2018, 10 patients (eight females and two males) underwent minimally invasive thoracoscopic IST ablation. Mean age of the patients was 36.7 ± 12.5 years. Mean baseline sinus rate was 113.8 ± 21.8 beats per minute. After surgery, the mean heart rate significantly decreased to 79.8 ± 8.2 at postoperative day 1 and to 75.8 ± 8.1 at day 30 (both P < .001). No in-hospital death, stroke, or PN injury occurred. One patient required reintubation, one patient developed postoperative pericarditis, and another patient had a pulmonary embolus. Median follow-up was 6 months (range, 1-50). Freedom from reintervention was 88% at 6 months., Conclusion: Minimally invasive thoracoscopic ablation for IST is a safe and effective approach that preserves the phrenic nerve. Due to the possibility of IST activation site migration, continued follow-up after surgery is required., (© 2019 Wiley Periodicals, Inc.)

Aortic stenosis (AS) is the most common valvular disease that can lead to increased afterload, left ventricular (LV) remodeling, and myocardial fibrosis. We reviewed the literature addressing the impact of transcatheter aortic valve replacement (TAVR) on LV remodeling and patients' outcomes by elimination of AS-related high afterload. TAVR reduces afterload and improves LV remodeling recovery. However, myocardial fibrosis may not completely reverse after the TAVR. The LV diastolic dysfunction (LVDD) induced by AS is an independent predictor of post-TAVR mortality, and mortality increases with severity of LVDD. The impact of diastolic dysfunction on patient outcomes emerges at 30 days but continues to persist during mid-term follow-up. Based on severity of the baseline LVDD, some patients may tolerate post-TAVR aortic regurgitation (AR), but even minimal post-TAVR AR in patients with severe baseline LVDD can have an additive negative impact on survival. It is crucial to consider TAVR prior to development of advanced LVDD. Appropriate device selection and deployment technique are important in improvement of TAVR outcomes via elimination of AR.

Objective: Limited data is available about the effect of implanted valve size on prosthesis-patient mismatch (PPM) incidence and aortic gradient (AG) after transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR). We compared PPM incidence and postprocedural AG between TAVR and SAVR patients considering the impact of implanted valve size., Methods: From March 20, 2012, to September 30, 2015, 563 consecutive patients underwent TAVR ( n = 419) or isolated SAVR ( n = 144). Postprocedural transthoracic echocardiography was obtained within 30 days; AG, effective orifice area (EOA), and EOA index were calculated., Results: A total of 381 patients in TAVR group and 82 patients in SAVR group were included. Mean preoperative AG and mean aortic valve area were not significantly different between the 2 groups. Postprocedural AG was significantly lower in TAVR than SAVR group, 7.74 ± 5.39 versus 14.27 ± 8.16 ( P < 0.001). Between patients who had TAVR and SAVR with a valve size ≤23 mm, SAVR patients were 3 times more likely to have greater than mild AG after the procedure, OR: 3.1 (95% CI, 1.1 to 8.9) ( P < 0.001). PPM incidence was significantly higher in SAVR group than TAVR group, 44 (53.7%) versus 112 (29.4%), OR = 2.8 (95% CI, 1.7 to 4.5) ( P < 0.001). The PPM incidence was also higher in SAVR group than TAVR group among those who had the procedures with a valve size ≤23 mm, 35 (64.8%) versus 56 (47.9%), OR = 2 (95% CI, 1.1 to 3.9) ( P = 0.048). Postprocedural outcomes were comparable between the 2 groups., Conclusions: In comparison to SAVR, TAVR is associated with less PPM and lower AG, especially in patients receiving a valve size ≤23 mm.

Background: We compared outcomes of single-stage hybrid aortic arch replacement (frozen elephant trunk) versus 2-stage hybrid repairs with primary open arch procedures followed by thoracic endovascular stenting., Methods: This study reports a single-center retrospective review (2003 to 2016) of 118 patients undergoing hybrid repair of the aortic arch including 48 single-stage repairs versus 70 two-stage repairs., Results: Single-stage repair was performed in 48 patients, including 31 (64.6%) men and 17 (35.4%) women with a mean age of 64 ± 11 years and a 2-stage procedure was performed in 70 patients, including 42 (60%) men and 28 (40%) women with a mean age of 65.67 ± 13.3 years (p = 0.46). More emergent single-stage procedures were performed in 23 of 48 (47.9%) patients versus 2-stage procedures in 8 of 70 (11.43%) patients (p < 0.001). Between the single- and 2-stage groups, there was no difference in stroke (6.25% [3 of 48] versus 14.28% [10 of 70]; p = 0.23), spinal cord ischemia (4.16% [2 of 48] versus 5.7% [4 of 70]; p = 1.0), or 30-day mortality rate: 8 of 48 (16.7%) patients versus a combined 30-day mortality rate of the 2-stage procedure of 14.8% (4 of 70 [5.7%] at the first stage and 5 of 55 [9.1%] at the second stage; p = 0.56), respectively. After exclusion of the 30-day mortality, midterm survival was 86% at 1 to 2 years for single-stage patients versus 80% at 1 year and 46% at 2 years for the 2-stage patients (p = 0.0019)., Conclusions: Both single-stage and 2-stage hybrid arch replacements are effective approaches for treating complex aortic arch diseases. Early deaths and neurological outcomes in the single-stage group are comparable to those in the combined 2-stage group. Furthermore, in this series, patients who had a single-stage hybrid procedure had a higher survival rate at 2 years., (Copyright © 2019 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background:  The Florida (FL) Sleeve procedure was introduced as a simplified approach for valve-sparing correction of functional Type I aortic insufficiency (AI) associated with aortic root aneurysms. In this study, short- and long-term outcomes after the FL Sleeve procedure were investigated., Methods:  From May 2002 to January 2016, 177 patients underwent the FL Sleeve procedure. Left ventricular end-diastolic diameter (LVEDD), left ventricular end-systolic diameter, left ventricular ejection fraction, and degree of AI (none = 0, minimal = 1, mild = 2, moderate = 3, severe = 4) were evaluated by echocardiography., Results:  Mean ± standard deviation of age was 49.41 ± 15.37 years. Survival rate was 98% at 1 year, 97% at 5 years, and 93% at 8 years. Freedom from reoperation was 99% at 1 year and 98% at 2 to 8 years. Three patients (1.69%) died during hospitalization. Three patients (1.69%) developed periprocedural stroke. Postoperative follow-up echocardiography was available in 140 patients at 30 days, and 31 patients at 5 years. AI grade significantly improved from baseline at 30 days (2.18 ± 1.26 vs. 1.1 ± 0.93, p  < 0.001) and at 5 years (2.0 ± 1.23 vs. 1.45 ± 0.88, p  = 0.04). Preoperative mean LVEDD significantly decreased from 52.20 ± 6.73 to 46.87 ± 8.40 ( p  < 0.001) at 30 days, and from 53.22 ± 7.07 to 46.61 ± 10.51 ( p  = 0.01) at 5 years., Conclusions:  The FL Sleeve procedure is a safe, effective, and durable treatment of aortic root aneurysm and Type I AI. Long-term survival and freedom from reoperation rates are encouraging., Competing Interests: The authors declare no conflict of interest related to this article., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Introduction: When transcatheter aortic valve replacement (TAVR) was introduced, pre-implantation balloon aortic valvuloplasty (BAV) was a routine part of the procedure. Smaller device profiles have resulted in selective use of BAV; however, there is a paucity of data about the trend in use of direct TAVR and the safety of this strategy., Methods: All patients who underwent TAVR at a Veterans Affairs Medical Center from September 2013 to November 2016 were included in this retrospective analysis. We reviewed angiography films and verified with procedure reports to assess if direct TAVR was performed. Troponin T was assessed within 72 h after the TAVR. Multivariate analysis examined the association between direct TAVR and periprocedural myocardial infarction (MI) or 1-year mortality., Results: Overall, 207 patients were available for analysis. The mean follow-up was 13.3 months. A balloon-expandable valve was used 93.2% of the time, and 35.3% of patients were treated with conscious sedation. Periprocedural MI or 1-year mortality occurred in 12.5% of the direct TAVR group versus 18.3% of the pre-implantation BAV group (p = 0.30). After controlling for potential confounding variables, direct TAVR was not associated with periprocedural MI or 1-year mortality., Conclusions: Direct TAVR appears to be safe and is not associated with periprocedural MI or 1-year mortality. With current generation devices, this strategy can be considered for most patients undergoing TAVR.

Background: Bicuspid aortic valve (BAV) stenosis has been considered a relative contraindication to transcatheter aortic valve replacement (TAVR). We compared the outcomes of TAVR in patients with BAV stenosis versus patients with trileaflet aortic valve stenosis., Methods: From March 2012 to September 2017, 727 patients underwent TAVR. Thirty-two patients with BAV were included in this study and compared to 96 patients with comparable risk factors (1:3) with a trileaflet aortic valve (TAV). Transesophageal echocardiography was used to estimate post-TAVR degree of paravalvular leak (PVL)., Results: Mean ± standard deviation Society of Thoracic Surgeons risk was 6.01 ± 3.42 in the BAV group and 6.08 ± 3.76 in the TAV group (P = 0.92). Thirty-day mortality was 4.2% (N = 4) in the TAV group and 6.25% (N = 2) in the BAV group (P = 0.63). Three (3.1%) patients in the TAV group and two (6.25%) patients in the BAV group developed a post operative stroke (P = 0.59). Following TAVR, mean aortic valve gradient significantly decreased in both TAV (42.56 ± 14.93 vs 9.27 ± 5.57, P < 0.001) and BAV (44.12 ± 11.82 vs 9.03 ± 7.29, P < 0.001) groups. No patient had a severe PVL after TAVR, and only two (2.08%) patients in the TAV group and one (3.12%) patient in the BAV group had moderate PVL (P = 1.0). Patient survival rate at 1 and 2 years was 86% in the BAV group and 90% at 1 and 2 years in the TAV group (P = 0.74)., Conclusions: TAVR in BAV disease is feasible with favorable valve performance. Immediate and mid-term outcomes of TAVR in patients with BAV are comparable to those with TAV., (© 2018 Wiley Periodicals, Inc.)

Objective: Transcatheter aortic valve replacement is now commercially available for intermediate-risk, high-risk, or inoperable patients with severe aortic stenosis. In this study, we investigated change in the safety and efficiency of the transcatheter aortic valve replacement procedure at our institution and patient outcomes comparing our first 100, second 100, and last 100 patients., Methods: From March 2012 to June 2016, 544 patients underwent transcatheter aortic valve replacement at our center. Three hundred patients were selected for this study and were categorized in the following three groups: group A, first to 100th patient; group B, 101st to 200th patient; and group C, 444th to 544th patient. Preoperative, intraoperative, and postoperative data were collected., Results: Three hundred patients, 162 male (54%) male and 138 female (46%) with a mean ± SD age of 79.10 ± 8.93 years and mean ± SD society of thoracic surgeons' risk score of 7.47 ± 0.76 were included. Fluoroscopy time, operation time, and incision time significantly decreased form group A to group C (all P < 0.05). Mean of contrast volume was also the highest in group A and the lowest in group C (P < 0.001). Acute kidney injury rate was 26% (n = 26) in group A versus 23% (n = 23) in group B (P = 0.743), and only one patient in group C (group C vs. group B, P < 0.001). Strokes declined over time: five (5%) stroke in group A; two (2%) stroke in group B, and no patient in group C (group C vs. group B, P = 0.1, and group C vs. group A, P = 0.059). In-hospital mortality was 5% (n = 5) in group A, 4% (n = 4) in group B, and 1% in group C (P = 0.21)., Conclusions: Progressive experience and technology advances with transcatheter aortic valve replacement procedures improved operators' expertise, making the transcatheter aortic valve replacement more efficient and safer over time.

Introduction: Hemodynamic measurements can assess for paravalvular aortic regurgitation after transcatheter aortic valve replacement (TAVR). This study compared the utility of different invasive hemodynamic measures in providing prognostic information., Methods: This retrospective observational study of TAVR patients at a Veterans Hospital assessed aortic regurgitation index, diastolic delta, pulse pressure, and heart rate adjusted diastolic delta obtained at valve implantation. The primary outcome was total mortality., Results: Overall, 151 patients underwent TAVR. Immediately after implantation, mean aortic regurgitation index was 31 ± 8.6, mean diastolic delta was 38 ± 9.8 mmHg, mean pulse pressure was 67 ± 18 mmHg, and mean heart rate adjusted diastolic delta was 47 ± 14.3 mmHg/beats per minute. Two percent of patients had ≥ moderate paravalvular aortic regurgitation by postoperative transthoracic echocardiography. Total mortality was 15.2% at a mean follow-up of 12.7 ± 9.2 months. Aortic regurgitation index <25 vs. ≥25, diastolic delta <19 vs. ≥19 mmHg, and pulse pressure >60 vs. ≤60 mmHg were not associated with total mortality. However, total mortality was 50% for heart rate adjusted diastolic delta <25 mmHg/beats per minute vs. 12.6% for heart rate adjusted diastolic delta ≥25 mmHg/beats per minute (p = 0.017). In a multivariate Cox regression analysis, heart rate adjusted diastolic delta <25 mmHg/beats per minute vs. heart rate adjusted diastolic delta ≥25 mmHg/beats per minute was associated with total mortality (hazard ratio 9.4, 95% confidence interval 2.0-44, p = 0.004)., Conclusions: Among a cohort of TAVR patients, the only invasive hemodynamic test independently associated with total mortality was heart rate adjusted diastolic delta.

Background: The Florida sleeve (FS) procedure was developed as a simplified approach for repair of functional type I aortic insufficiency secondary to aortic root aneurysm. We evaluated postoperative aortic valve function, long-term survival, and freedom from reoperation in Marfan syndrome patients who underwent the FS procedure at our center., Methods: All Marfan syndrome patients undergoing FS procedure from May 2002 to December 2014 were included. Echocardiography assessment included left ventricular end-diastolic diameter (LVEDD), left ventricular end-systolic diameter (LVESD), ejection fraction, and degree of aortic insufficiency (none = 0, minimal = 1, mild = 2, moderate = 3, severe = 4). Social Security Death Index and primary care physicians' report were used for long-term follow-up., Results: Thirty-seven Marfan syndrome patients, 21 (56.8%) men and 16 (43%) women with mean age of 35.08 ± 13.45 years underwent FL repair at our center. There was no in-hospital or 30-day death or stroke. Two patients required reoperation due to bleeding. Patients' survival rate was 94% at 1 to 8 years. Freedom from reoperation was 100% at 8 years. Twenty-five patients had postoperative follow-up echocardiography at 1 week. Aortic insufficiency grade significantly decreased after the procedure (preoperative mean ± SD: 1.76 ± 1.2 versus 1-week postoperative mean ± SD: 0.48 ± 0.71, p < 0.001), and mean LVEDD decreased from 52.23 ± 5.29 mm to 47.53 ± 8.89 mm (p = 0.086). Changes in LVESD (35.33 ± 9.97 mm to 36.58 ± 9.82 mm, p = 0.58) and ejection fraction (57.65% ± 6.22% to 55% ± 10.83%, p = 0.31) were not significant., Conclusions: The FS procedure can be performed safely in Marfan syndrome patients with immediate improvement in aortic valve function. Long-term survival and freedom from reoperation rates are encouraging., (Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: We compared stroke occurrence and outcomes between Transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR), both periprocedural and at follow-up., Methods: From March 2012 to December 2014, 391 consecutive patients underwent TAVR (N.=290) or isolated SAVR (N.=101), concomitantly. Patients' data were prospectively collected., Results: TAVR patients had more comorbidities. One (0.34%) TIA and 9 (3.11%) strokes occurred in-hospital following TAVR, but no cerebrovascular event occurred after SAVR (P=0.11). One stroke (0.99%) and one TIA (0.99%) were detected in SAVR group within 30 days. Among TAVR patients, one (0.75%) stroke at 6 months, 2 (1.9%) strokes and 2 (1.9%) TIAs at 12 months were diagnosed. Kaplan-Meier analysis revealed that 96% and 99% 12-month CVA free survival following TAVR and SAVR, respectively (P=0.67). Preoperative mean trans-aortic valve systolic pressure gradient higher than 40 mmHg remained as risk factor for stroke in TAVR patients only, OR: 4.48 (CI: 1.2-16.54, P=0.02). One intraoperative death, and 5 (4 with CVA) in-hospital deaths occurred after TAVR; whereas only one patient died in SAVR group (P=0.49). Thirty-day mortality was 3.8% (11/290) for TAVR and 0.99% (1/101) for SAVR patients. SAVR patients' survival was 99% at 6 months, 97.9% at 12, and 96.4% at 24 months, whereas survival in TAVR was 97.5% at 6, 92% at 12, and 73.6% at 24 months (HR: 8.43 (CI: 2.47-28.73), P<0.001)., Conclusions: Even with significant differences in patients' baseline characteristics; in-hospital and mid-term stroke rates are not significantly higher following TAVR than SAVR. Although periprocedural stroke is not uncommon in TAVR, mid-term stroke rate is low.

Background: Complex aortic arch disease can be a formidable challenge and is often treated with a two-stage elephant trunk technique. We examined our experience with hybrid arch repair with combined zone 0 stent graft deployment., Methods: A retrospective review was conducted of all patients who underwent type 2 hybrid arch replacement and zone 0 antegrade endovascular stent graft deployments at a single university center from June 2010 to August 2015., Results: The review included 48 patients, 25 (52%) elective and 23 (48%) nonelective, with a mean ± SD age of 64 ± 11 years. Overall in-hospital mortality was 17% (8 of 48). Age exceeding 65 years (odds ratio, 9.5; 95% confidence interval, 1.2 to 36), preoperative international normalized ratio exceeding 1.3 (odds ratio, 14.2; 95% confidence interval, 2.1 to 95.87), and postoperative acute kidney injury (odds ratio, 5.6; 95% confidence interval, 1.1 to 29) were associated with in-hospital death. Postoperative stroke occurred in 3 patients (6%) and permanent paraplegia in 1 patient (2%). One (2%) patient underwent reoperation due to bleeding, and 6 patients (13%) experienced respiratory failure/reintubation. Acute kidney injury developed in 12 patients (25%), according to Acute Kidney Injury Network criteria, with 7 (14.6%) at stage 1 and 5 (10.4%) at stage 3. At the 1-year follow-up, type II endoleak developed in 2 of the 40 patients (5%), and 2 others required reoperation due to progression of chronic aortic dissection. Median follow-up time was 17 months (range, 1 to 63 months). The overall survival rate was 92% ± 0.04% at 6 months and 89% ± 0.05% at 1 and at 3 years., Conclusions: Hybrid repair of complex aortic arch pathology with antegrade stent graft deployment can be performed safely with high technical success while obviating the need for a second operation. Reasonable midterm survival can be anticipated; however, older age, preoperative coagulopathy, and postoperative acute kidney injury are factors associated with poor outcome., (Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background and Aim: Septic emboli (SE) associated with infectious endocarditis (IE) can result in splenic abscesses and infectious intracranial aneurysms (IIA). We investigated the impact of SE on patient outcomes following surgery for IE., Method: From January-2000 to October-2015, all patients with surgical IE (n = 437) were evaluated for incidence and management of SE., Results: Overall SE was found in 46/437 (10.52%) patients (n = 17 spleen, 13 brain, and 16 both). No mortality was seen in the brain emboli groups, but in the splenic abscess group the in-hospital mortality was 8.69% (n = 4); and was associated with Age >35 (OR = 2.63, 1.65-4.20) and congestive heart failure (OR = 14.40, 1.23-168.50). Patients with splenic emboli had excellent mid-term outcome following discharge (100% survival at 4-years). Splenic emboli requiring splenectomy was predicted by a >20 mm valve vegetation (OR = 1.37, 1.056-1.77) and WBC >12000 cells/mm (OR = 5.58, 1.2-26.3). No patient with streptococcus-viridians infection had a nonviable spleen (OR = 0.67, 0.53-0.85). Postoperative acute-kidney-injury was higher in the splenectomy group (45.45% vs 9%) (p = 0.027). There were 6 patients with symptomatic IIAs that required coiling/clipping which was associated with age <30 years, (OR = 6.09, 1.10-33.55). Survival in patients with cerebral emboli decreased to 78% at 3-4 years. Patients with both splenic and brain emboli had a 92% survival rate at 1-year and 77% at 2-4 years., Conclusion: Septic emboli is common in endocarditis patients. Patients with high preoperative WBC level and large valve vegetations require CT imaging of the spleen. Both spleen and brain interventions in the setting of IE can be performed safely with excellent early and mid-term outcomes., (© 2017 Wiley Periodicals, Inc.)

Altered microRNA expression is implicated in cardiovascular diseases. Our objective was to determine microRNA signatures in thoracic aortic aneurysms (TAAs) and abdominal aortic aneurysms (AAAs) compared with control non-aneurysmal aortic specimens. We evaluated the expression of fifteen selected microRNA in human TAA and AAA operative specimens compared to controls. We observed significant upregulation of miR-221 and downregulation of miR-1 and -133 in TAA specimens. In contrast, upregulation of miR-146a and downregulation of miR-145 and -331-3p were found only for AAA specimens. Upregulation of miR-126 and -486-5p and downregulation of miR-30c-2*, -155, and -204 were observed in specimens of TAAs and AAAs. The data reveal microRNA expression signatures unique to aneurysm location and common to both thoracic and abdominal pathologies. Thus, changes in miR-1, -29a, -133a, and -221 are involved in TAAs and miR-145, -146, and -331-3p impact AAAs. This work validates prior studies on microRNA expression in aneurysmal diseases.

Background: Acute kidney injury (AKI) during transcatheter aortic valve replacement (TAVR) increases morbidity and mortality. In this study, we investigated the incidence and risk factors for AKI in patients undergoing TAVR., Methods: Two hundred ninety consecutive patients underwent TAVR. Valve Academic Research Consortium (VARC)-I criteria for AKI diagnosis at 72 hours, and VARC-II criteria at seven days were employed., Results: Overall AKI incidence was 24.62% (65/264): 50 patients at 72 hours and 15 patients at seven days. Multivariate logistic regression determined transapical (TA) approach (OR: 4.46 [1.37-7.63]), preprocedural glomerular filtration rate less than 45 mL/min (OR: 3.47 [1.35-14.70]), and blood transfusion (OR: 3.34 [1.58-11.09]) as independent predictors for AKI at 72 hours; and prior coronary artery bypass grafting (OR: 3.02 [1.007-9.09]) and peripheral artery disease (PAD) (OR: 3.53 [1.06-11.62]) for AKI at seven days. In-hospital and 30-day mortality was higher in AKI patients. Non-AKI patients' survival was 93% at six months, 89% at 12 months, and 86% at 24 months, whereas survival in AKI at 72 hours was 66% at 6, 12, and 24 months (HR AKI vs. non-AKI: 3.9 [CI: 2.0-7.6]), and survival in AKI at seven days was 64% at 6, 12, and 24 months, HR: 3.13 (CI: 1.42-6.92). For the 12 dialysis patients survival was 82% at 6, 12, and 24 months., Conclusions: AKI after TAVR is associated with worse outcomes. Blood transfusion should be administered restrictively in TAVR. Patients with CKD, PAD, prior CABG, and TA approach require close surveillance as they are at risk for AKI through seven days after TAVR. doi: 10.1111/jocs.12768 (J Card Surg 2016;31:416-422)., (© 2016 Wiley Periodicals, Inc.)

Objective: Atrial fibrillation (AF) has a demonstrable effect on quality of life (QOL). Recurrent stroke occurs in 10% of patients with AF. The objective of this study was to demonstrate proof of concept that thoracoscopic pulmonary vein isolation and atrial appendage ligation (TPVIAL) could prevent recurrent stroke and could potentially improve QOL in patients with AF with a previous stroke., Methods: The study was a National Institutes of Health-funded single-center proof-of-concept design that randomized 23 patients with AF-related stroke to TPVIAL (n = 12) or to medical management (n = 11). Quality of life was the primary outcome variable; secondary end points included restoration of rhythm, recurrent stroke, and surgical morbidity., Results: Quality-of-life subscores at 3 and 6 months revealed improvements in energy and decreases in fatigue in the TPVIAL arm [baseline, 33 (19.8); 3 months, 49.5 (20.6), P = 0.01; 6 months, 55.5 (14.4), P = 0.03]. At 12-month follow-up, there were no recurrent strokes in the TPVIAL group. In the medically treated arm, two patients at 6 months (P = 0.22) and three total patients at 12 months (P = 0.09) had recurrent ischemic stroke. There was one death in the medical management arm. In the TPVIAL arm, no AF recurrence occurred in patients with paroxysmal AF, and one patient had recurrence of persistent and long-standing AF. Seven patients in the TPVIAL arm discontinued warfarin therapy for secondary stroke prevention., Conclusions: This small proof-of-concept study showed that TPVIAL improved QOL on two subscores and restored normal sinus rhythm in all but one patient, and it showed the potential to prevent secondary stroke. A larger study will be needed.

Human aging is a complex process with pivotal changes in gene expression of biological pathways. Immune system dysfunction has been recognized as one of the most important abnormalities induced by senescent names immunosenescence. Emerging evidences suggest miR role in immunosenescence. We aimed to systemically review all relevant reports to clearly state miR effects on immunosenescence process. Sensitive electronic searches carried out. Quality assessment has been performed. Since majority of the included studies were laboratory works, and therefore heterogen, we discussed miR effects on immunological aging process nonstatically. Forty-six articles were found in the initial search. After exclusion of 34 articles, 12 studies enrolled to the final stage. We found that miRs have crucial roles in exact function of immune system. MiRs are involved in the regulation of the aging process in the immune system components and target certain genes, promoting or inhibiting immune system reaction to invasion. Also, miRs control life span of the immune system members by regulation of the genes involved in the apoptosis. Interestingly, we found that immunosenescence is controllable by proper manipulation of the various miRs expression. DNA methylation and histone acetylation have been discovered as novel strategies, altering NF-κB binding ability to the miR promoter sites. Effect of miRs on impairment of immune system function due to the aging is emerging. Although it has been accepted that miRs have determinant roles in the regulation of the immunosenescence; however, most of the reports are concluded from animal/laboratory works, suggesting the necessity of more investigations in human.

Background: Obesity is associated with chronic disorders like coronary artery diseases, metabolic syndrome, cancers, and psychiatric disorders. Stress may contribute to weight gain by disrupting weight concern, and lead to uncontrolled eating behavior. This study aimed to investigate the effects of stress on weight concern and control behaviors in normal weight and obese adults., Methods: A total of 9544 subjects were selected by multi-stage random sampling from three provinces in central Iran. Information related to weight concern and control behavior was registered in normal weight and obese participants. Psychological distress was measured by a 12-item General Health Questionnaire (GHQ-12) and subjects were divided into high and low stress groups. Logistic regression was used for analysis., Results: The mean age of participants was 38.7 ± 15.5 years and 50% (4772) of them were males. The adjusted odds ratio (OR) for age, sex and education of high stress to low stress level for weight concern, weight control behavior and acceptable physical activity behavior was more than 1; but the OR was less than 1 for waist circumference, obesity and healthy diet behavior. Among obese participants, higher levels of stress were associated with lower weight concern with OR, 95%CI: 0.821, (0.682 - 0.988), lower acceptable physical activity with OR = 0.833, 95%CI: (0.624 - 0.912), but higher rates of healthy diet behavior with OR = 1.360, 95% CI: (1.040 - 1.780)., Conclusion: Individuals with high stress level have lower weight concern and lower physical activity; therefore, they are prone to weight gain and obesity. It could be concluded that stress management should be considered as a crucial component of obesity prevention and control programs.

Background: Recent genome wide association studies (GWAS) have shown important roles of single nucleotide polymorphisms (SNP) near region of interleukin B 28 (IL28B) gene in spontaneous and drug-induced clearance of hepatitis C virus (HCV) in genotype 1 HCV infection., Objectives: This meta-analysis was designed to determine the world-wide distribution patterns of IL28B genotypes and alleles, and to find possible linkages between IL28B and HCV genotypes., Patients and Methods: Manual and electronic databases were searched. Critical appraisal was performed. According to the results of heterogeneity tests, we used fix/random model for the analysis. The data concerning patients' ethnicity and HCV genotypes were analyzed by using statistical analysis software., Results: A total of 255 articles were found. After article review and quality assessment, 50 studies, including 18662 patients and 1313 healthy subjects, were analyzed. Presence of HCV genotype 3 versus genotype 1 was significantly associated with a higher frequency of CC genotype and C allele, with an odds ratio (OR) of 1.68 (95% CI: 1.44-1.99) and 1.49 (95% CI: 1.33-1.67), respectively. Prevalence of the rs12979860 CC genotype among genotype 1 HCV infected patients of Asian ethnicity was 69.48% (95% CI: 65.20-73.77), which was significantly higher than its prevalence [33.27% (95% CI: 28.88-37.67)] in the Caucasian genotype 1 HCV infected patients. Prevalence of rs12979860 TT genotype in the African-American genotype 1 HCV infected patients was the highest [36.20% (95% CI: 32.91-39.49)], and significantly different compared to all other ethnicities., Conclusions: There were significant linkages between HCV genotypes and IL28B genotypes/alleles. Patients with a favorable IL28B and genotypes 1 and 4 HCV infection stand a better chance to clear HCV in the acute phase.

The roles of miRNAs in human diseases are emerging. Manipulation of miRNA expression seems to be an effective approach to control disease severity. It has recently been found that Toll-like receptors and miRNAs work by exerting reciprocal effects. Toll-like receptor stimulation can lead to up-/down-regulation of various miRNA expressions. Lipopolysaccharide induction may result in interactions between different miRNAs. Several miRNAs are involved in cancers, indicating the importance of identifying strategies to properly manipulate their expression level. The control of various miRNA expression levels, taking into consideration the plethora of their target genes and the possibility that this may lead to contracting function, which is an important issue in treatment of any miRNA-based (phenotype) disease.

Toll like receptors (TLRs) are one of the major families of pattern recognition receptors (PRRs). MicroRNAs (MiRs) are small noncoding RNAs with regulatory effects on biological process, and it has been recently shown that they can control inflammatory process and the response to an infection by modulating the function of TLRs. In this study, we designed a systematic review to clarify the reciprocal interaction between TLRs and MiRs, in order to identify possible future therapeutic targets and strategies. On the one hand, TLRs stimulation can change expression level of miRs in various ways, which can lead to modulating their effects. On the other hand, MiRs also influence the expression of TLRs and the intensity of the inflammatory reaction. We therefore conclude that the interaction between MiRs and TLRs is a key regulator of innate immune system. Investigations discovering therapeutic approaches by manipulation of miRs expression level may open a new approach for the treatment of inflammatory diseases., (Copyright © 2013 The British Infection Association. Published by Elsevier Ltd. All rights reserved.)

Background: Hepatitis D Virus (HDV) causes the most threatening form of chronic viral hepatitis. To date, there is no overall estimation of HDV prevalence in the Eastern Mediterranean Region Office of WHO (EMRO) countries., Objectives: To provide a clear estimation of HDV prevalence in the aforementioned region., Patients and Methods: In the current systematic review, databases such as PubMed, Embase, Web of sciences and Google scholar were searched Until December 2010. The summary estimate of HDV prevalence in the EMRO region was calculated as an average of the pooled infection prevalence of each country weighted by the ratio of the country's HBV population to the study's sample size in the survey data analysis., Results: We included 62 eligible studies. The weighted mean of HDV prevalence in the EMRO region was 14.74% (95% CI: 14.73 - 14.77), 27.8% (95% CI: 27.78 - 27.82), 36.57% (95% CI: 36.55 - 36.59) and 16.44%. (95% CI: 16.42 - 16.46) in asymptomatic HBsAg positive carriers, chronic hepatitis patients, cirrhosis/ hepatocellular carcinoma, and high risk group, respectively. Among the asymptomatic HBsAg positive group, HDV prevalence was increased by years in older patients in Saudi Arabia but its prevalence was decreased in Iran. No specific pattern was seen according to chronological analysis during years among the EMRO countries., Conclusions: HDV infection is endemic in the EMRO countries and it is more common among patients with severe forms of hepatitis. Due to the high HDV infection rates in the EMRO countries, we recommend blood screening for HDV infection in this region.

Introduction: Association of increased levels of CD4(+)CD25(+) regulatory T cells (Tregs) with impaired immune response and hepatitis B infection progression has been proposed. For determination of Tregs various effects among hepatitis B infected patients we performed a meta-analysis of the available literature., Methods: Current content, abstract books of congresses, and electronic databases were searched. Critical appraisal has been done. According to the result of heterogeneity tests (Q, I-squared, and Tau-squared), we used fix/random model for analysis., Result: Twelve studies that fulfilled inclusion criteria entered to analysis. Pooled estimation of reported results showed that CD4(+)CD25(+) Tregs have higher expression of forkhead box P3 (FoxP3) versus CD4(+)CD25(-) Tregs, odd ratio (OR) was 31.49 (95% Confidence Intervals (CI): 5.09-194.94). Tregs level among chronic hepatitis B (CHB) patients was 77% (OR=1.77 95% CI: 1.43-2.19) higher than healthy controls. Patients with more than 10,000,000 HBV copies/ml have higher level of Tregs (OR: 1.24 95% CI: 1.08-1.41) comparing subjects with less than that. CHB patients have increased level of Tregs versus acute hepatitis B patients (OR=1.33 95% CI: 1.16-1.52). CD8 cells activity increased significantly after depletion of circulating Tregs (OR=1.93 CI: 1.37-2.73). Also, Tregs reduce response to treatment and non-responders to INF-α had higher level of Tregs (OR=1.60 95% CI: 1.09-2.36). In addition, Tregs increase risk of hepatocellular carcinoma (HCC) (OR=1.36 95%CI: 1.10-1.69)., Conclusion: Tregs influence HBV infected patients in various states. Tregs determine the disease prognosis by leading to infection progression and impairing immune response. So, Tregs are therapeutic target for immunotherapy of HBV infection., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Background: Hepatitis C is a major reason of morbidity and mortality among hemophilia patients. Although combination therapy with peginterferon (peg-INF) and ribavirin is considered as standard treatment for chronic hepatitis C (CHC), but more evidence of the efficacy and safety is needed., Objectives: In this study, efficacy and tolerability of combination therapy with peginterferon α-2a-ribavirin was investigated among hemophilia HCV infected patients., Patients and Materials: In a quasi-experimental, 45 naive hemophilia patients with chronic HCV received 180 mg of pegylated interferon (Pegasys) by subcutaneous injection weekly plus an oral dose of 800-1200 µg ribavirin daily according to body weight. The treatment continued 48 weeks in patients with genotype one and 24 weeks in those with genotype 3. Sustained virological response (SVR) was considered as efficacy of treatment., Result: Forty three patients (95.6%) reached to end of treatment response (ETR); only two (4.4%) patients did not respond and were discontinued from treatment. None of 43 patients relapsed. SVR obtained in 43 of 45 patients (95.6%), in multivariate logistic regression model, third month's treatment WBC (WBC > 2000) remained the only significant predictor of SVR. Regimen dose reduced in three patients; two of those because of ALT increasing and other one for his retinal bleeding. In repeated measurement analysis, alanine aminotransferase (ALT) and hemoglobin (Hb) decreased significantly during treatment, but reduction of platelet (PLT) was not significant., Conclusions: Results show high efficacy and safety of combination therapy of Peg-IFN-α 2a plus ribavirin among hemophiliacs with chronic hepatitis C.

Context: Hepatitis C virus (HCV) infection is a public health problem. HCV alone is responsible for 90% cases of acute hepatitis among multiply transfused patients who are at risk of cirrhosis and hepatocellular carcinoma (HCC)., Objectives: To provide a clear picture of available data, we performed a systematic review of the epidemiological characteristics of HCV infection among patients with inherited coagulation disorders in the countries under the Eastern Mediterranean Region Office (EMRO)., Evidence Acquisition: Meta-analysis was carried out on the basis of results of electronic and manual search. This analysis included studies in English, French, and Persian that met with the following criteria: (1) appropriate study design: cross-sectional, case-control, and cohort; (2) studies reporting HCV prevalence according to enzyme immune assay; (3) studies in which the sample population was enrolled from EMRO countries. According to the results of the heterogeneity tests, we used fixed-effect/random-effect model for our meta-analysis, with the "Metan" command., Results: We included 30 studies, most of which were from Iran. The mean age of the subjects ranged from 13 to 27.1 years. The majority of the patients were male (range, 81% to 100%). The pooled estimate of HCV infection among patients with inherited coagulation disorders was 48.07% (95% confidence interval [CI], range: 27.39-55.68) in Iran, 36.03% (95% CI, range: 4.466-67.598) in Pakistan, and 48.27% (95% CI, range: 36.12-60.43) in all the EMRO countries taken together., Conclusions: In Iran and other EMRO countries, the HCV infection rate among patients with inherited coagulation disorders is high. Our study shows that there is a lack of knowledge about infections in such patients in most of the EMRO countries. It is the responsibility of health-policy makers to address this knowledge gap and provide safe and adequate treatment for patients in high-risk groups.

Context: Hepatitis delta virus (HDV) leads to the most severe form of chronic viral hepatitis., Objectives: To determine the prevalence of HDV and create pooled estimations of possible risk factors, a systematic review was conducted to collect all epidemiological studies on HDV among chronic hepatitis B patients in Iran., Data Sources: In this systematic review, databases such as PubMed, Embase, ISI, Google scholar, and Iranian databases (MagIran, Iranmedex, and SID) were searched., Study Selection: Studies that clearly stated information about the number of HBsAg positive patients infected with HDV were selected., Data Extraction: The name of the city, the author's name, year of study, HDV detection method, sample size, HBsAg positive frequency, mean age, total prevalence of HDV, and risk factors were extracted., Results: The pooled HDV prevalence was 7.8% (95% CI: 5.89 - 9.71). In the survey-data analysis, HDV prevalence was 6.61%. HDV prevalence was 30.47% (95% CI: 9.76 to 51.19), 14.4% (95% CI: 7.72 to 21.07), and 4.94% (95% CI: 3.73 to 6.15) in cirrhotic, chronic-hepatitis, and inactive-carrier patients, respectively. Pooled ORs were calculated for several factors common to Iranian HBsAg-positive patients, including history of blood transfusion [OR: 1.1 (95% CI: 0.40 to 2.98)], intravenous drug abuse [OR: 1.6 (95% CI: 0.78 to 3.21)], previous hemodialysis [OR: 1.72 (95% CI: 0.79 to 3.76)], and HBeAg-positive status [OR: 1.26 (95% CI: 0.66 to 2.4)]., Conclusions: The prevalence of HDV is less common in Iran than in endemic regions such as Italy and Turkey; however, it is a severe form of hepatitis in HBsAg-positive patients. The most probable route of HDV transmission is hematologic, which suggests the importance of blood screening for HDV, especially in groups with numerous blood transfusions.

Introduction: Hepatitis B is a major health problem with serious consequences. In hepatitis B treatment host cellular immune responses have a determinant role and T helper cells are the main active members of immune system against virological infection. The aims of this study are to investigate response rate of patients to INF-α therapy and evaluation of sCD26 and sCD30 roles as presenters of T cells activities in predicting the outcome of therapy in chronic hepatitis B patients., Methods and Materials: Fifty three chronic hepatitis B patients received IFN-α 9 MU S.C three times weekly for 24 weeks, and were followed up for 24 weeks. Serum levels of sCD26 and sCD30, before, 1 and 3 months after treatment commencement were evaluated in 53 chronic hepatitis B patients and 30 healthy individuals as control group., Results: Normal level of ALT was seen in 64.1% (34/53) of patients and undetectable DNA was observed in 39.6% (21 out of 53) of them. Finally, 33.9% (18/53) of patients obtained sustain virological response. CD26 levels changes was correlated with response to treatment and significantly (p<0.001) increased during first 3 months of treatment among patients with successful response to therapy., Conclusion: Interferon is an effective and safe treatment for chronic hepatitis B patients and sCD26 serum level changes might be useful in predicting the outcome of therapy in naïve chronic hepatitis B patients undergoing treatment with IFN-α, as it can help clinicians for withdrawing non-responder patients for prevention of adverse events and economical burden., (Copyright © 2011 Elsevier Ltd. All rights reserved.)