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Here we report a recombinant baculoviral vector-based DNA vaccine system against Middle East respiratory syndrome coronavirus (MERS-CoV) and the severe acute respiratory syndrome coronavirus-2 (SARS-CoV2). A non-replicating recombinant baculovirus expressing the human endogenous retrovirus envelope gene (AcHERV) was constructed as a DNA vaccine vector for gene delivery into human cells. For MERS-CoV vaccine construction, DNA encoding MERS-CoV S-full, S1 subunit, or receptor-binding domain (RBD) was inserted into the genome of AcHERV. For COVID19 vaccine construction, DNA encoding SARS-CoV2 S-full or S1 or a MERS-CoV NTD domain-fused SARS-CoV2 RBD was inserted into the genome of AcHERV. AcHERV-DNA vaccines induce high humoral and cell-mediated immunity in animal models. In challenge tests, twice immunized AcHERV-MERS-S1 and AcHERV-COVID19-S showed complete protection against MERS-CoV and SARS-CoV2, respectively. Unlike AcHERV-MERS vaccines, AcHERV-COVID19-S provided the greatest protection against SARS-CoV2 challenge. These results support the feasibility of AcHERV-MERS or AcHERV-COVID19 vaccines in preventing pandemic spreads of viral infections.

Alzheimer's disease (AD) is one of the progressive neurodegenerative diseases characterized by β-amyloid (Aβ) production and Phosphorylated-Tau (p-Tau) protein in the cerebral cortex. The precise mechanisms of the cause, responsible for disease pathology and progression, are not well understood because there are multiple risk factors associated with the disease. Viral infection is one of the risk factors for AD, and we demonstrated that Zika virus (ZIKV) infection in brain organoids could trigger AD pathological features, including Aβ and p-Tau expression. AD-related phenotypes in brain organoids were upregulated via endoplasmic reticulum (ER) stress and unfolded protein response (UPR) after ZIKV infection in brain organoids. Under persistent ER stress, activated-double stranded RNA-dependent protein kinase-like ER-resident (PERK) triggered the phosphorylation of Eukaryotic initiation factor 2 (eIF2α) and then BACE, and GSK3α/β related to AD. Furthermore, we demonstrated that pharmacological inhibitors of PERK attenuated Aβ and p-Tau in brain organoids after ZIKV infection.

Middle East respiratory syndrome coronavirus (MERS-CoV) induces severe respiratory impairment with a reported mortality rate of ~36% in humans. The absence of clinically available MERS-CoV vaccines and treatments to date has resulted in uncontrolled incidence and propagation of the virus. In vaccine design, fusion with the IgG Fc domain is reported to increase the immunogenicity of various vaccine antigens. However, limited reports have documented the potential negative effects of Fc fusion on vaccine antigens. To determine whether Fc fusion affects the immunogenicity of MERS-CoV antigen, we constructed a Fcassociated MERS-CoV spike protein (eS770-Fc, 110 kDa), whereby human IgG4 Fc domain was fused to MERS-CoV spike protein (eS770) via a Gly/Pro linker using baculovirus as the expression system. For comparative analyses, two eS770 proteins lacking the IgG4 Fc domain were generated using the IdeS protease (eS770-ΔFc) or His tag attachment (eS770-His) and the immunogenicity of the above constructs were examined following intramuscular immunization in mice. Contrary to expectations, non-Fc spike proteins (eS770-ΔFc, eS770-His; 90 kDa) showed higher immunogenicity than the Fc fusion protein (eS770-Fc). Moreover, unlike non- Fc spike proteins, eS770-Fc immunization did not elicit neutralizing antibodies against MERSCoV. The lower immunogenicity of Fc-fused eS770 was related to alterations in the structural conformation of the spike protein. Taken together, our results indicate that IgG Fc fusion reduces the immunogenicity of eS770 by interfering with the proper folding structure.

Background The renal benefits of sodium-glucose cotransporter-2 inhibitors (SGLT2) are now well established, and these agents are recommended by the American Diabetes Association and Kidney Disease: Improving Global Outcomes guidelines for patients with type 2 diabetes and chronic kidney disease. However, the safety profile of SGLT2 inhibitors in chronic kidney disease is not as clear. We describe the adverse event rates of SGLT2 inhibitors, primarily empagliflozin, in Kaiser Permanente Southern California members with diabetic kidney disease. Methods This study was a multicenter retrospective descriptive analysis evaluating Kaiser Permanente Southern California members with type 2 diabetes and chronic kidney disease 1, 2, or 3 who first filled an SGLT2 inhibitor prescription in 2018, with follow-up through 2019. Primary outcomes were event rates of diabetic ketoacidosis, bone fracture, amputation, urinary tract infection, genital mycotic infection, hyperkalemia, and acute kidney injury. Secondary outcomes were mean changes in estimated glomerular filtration rates, serum creatine levels, urine albumin-to-creatinine ratios, and hemoglobin A1c percentages during the follow-up period. Results Of 213 patients, 39 experienced at least 1 adverse event, for a total of 50 adverse events. Urinary tract infection had the highest incidence (62.1 events/1000 person-years), followed by genital mycotic infection (58.0 events/1000 person-years). Favorable changes were observed during the follow-up period for urine albumin-to-creatinine ratios and hemoglobin A1c percentages, with mean decreases of 81.8 mg/g and 0.7%, respectively. SGLT2 inhibitors were discontinued in 47.4% of patients, with the top reasons including increase in serum creatinine (8%) and urinary or genital side effects (5.6%). Conclusion Although most patients did not experience adverse events, urinary tract infections and genital mycotic infections were more common. Our detection of rates and types of adverse effects replicated most results reported in clinical trials. Discontinuations were largely attributed to reasons other than adverse events.

Baculovirus expression systems have been widely used to produce recombinant mammalian proteins owing to the lack of viral replication in vertebrates. Although several lines of evidence have demonstrated impacts of baculovirus infection in mammalian hosts, genome-wide effects have not been fully elucidated. Here, we provide comparative transcriptome profiles of baculovirus and host-immune response genes in recombinant baculovirus-infected mammalian and insect cells. Specifically, to decipher the impacts of baculovirus infection in mammalian cells, we conducted total RNA-seq on human 293TT cells and insect Sf9 cells infected with recombinant baculovirus. We found that baculovirus genes were rarely expressed under the control of baculoviral promoters in 293TT cells. Although some baculovirus early genes, such as PE38 and IE-01, showed limited expression in 293TT cells, baculoviral late genes were mostly silent. We also found modest induction of a small number of mammalian immune response genes associated with Toll-like receptors, cytokine signaling, and complement in baculovirus-infected 293TT cells. These comprehensive transcriptome data will contribute to improving recombinant baculovirus as tools for gene delivery, gene therapy, and vaccine development.

Zika virus (ZIKV) is a mosquito-borne flavivirus and the infection of pregnant women can cause a wide range of congenital abnormalities, including microcephaly in the infant. However, there is no vaccine available yet. In this study, we intended to use PrM/E, which is the main target gene of neutralizing antibodies, for the development of a DNA vaccine for ZIKV. To enhance the gene delivery, a recombinant baculovirus whose surface was modified to express human endogenous retrovirus (HERV) envelope was constructed. Baculovirus with HERV envelope (AcHERV) showed distinguished higher gene delivery than wild type. Using the AcHERV as a delivery vector, we constructed major antigen (prM-E)-encoding DNA under the CMV promoter, AcHERV–ZIKA. Transducing of prM/E gene in a mammalian cell was confirmed by Western blot. Immunization in mice with 10e7 of AcHERV–ZIKA elicited high IgG and neutralizing antibodies. In the challenge test, AcHERV–ZIKA immunized A129 mice showed perfect protection. These results suggest that AcHERV–ZIKA could be a potential vaccine candidate for human application.

PERV is a major virus concerning xenotransplantation study. However, the interesting part is that PERV is present in all kinds of pigs without pathogenicity and immune response. Furthermore, since pig cells have receptors for PERV, the gene delivery system using PERV envelope is highly likely to develop into an excellent viral vector in pigs. We developed a recombinant baculovirus with a modified surface for expressing the porcine endogenous retrovirus (PERV) envelope. Porcine reproductive and respiratory syndrome virus (PRRSV) infection is a severe concern in the porcine industry due to reproduction failure and respiratory symptoms. GP5 and M proteins are major immunogenic proteins of PRRSV. Using PERV-modified baculovirus (Ac mPERV) as a delivery vector, we constructed a dual antigen (GP5 and M)-encoding DNA vaccine system, Ac mPERV-C5/C6. Intramuscular immunization in mice and pigs, Ac mPERV-C5/C6 induced comparative high humoral and cellular immune responses. Our results support further development of Ac mPERV-C5/C6 as a potential PRRSV vaccine in the porcine industry. In addition, the Ac mPERV system may be applied to the generation of other effective DNA vaccines against porcine viral diseases.

Zika virus (ZIKV), a mosquito-borne flavivirus that has recently emerged globally, poses a major threat to public health. To control this emerging disease, accurate diagnostics are required for monitoring current ZIKV outbreaks. Owing to the high nucleotide sequence similarity and cross-reactivity of ZIKV with other members of the Flaviviridae family, discrimination from other flavivirus infections is often difficult in endemic areas. ZIKV NS1 induces major virus-specific antibodies and is therefore utilized as a serological marker for ZIKV diagnosis. To identify ZIKV specific epitopes for clinical application, 33 NS1 peptides that are 15-30 amino acid in length covering whole NS1 were synthesized and analyzed linear B-cell epitopes with 38 human serum samples (20 ZIKV-positive and 18 ZIKV-negative). As a result of screening, eight epitope regions were identified. In particular, the Z8 and Z14 peptides located in the β-ladder surface region showed higher levels of binding activity in ZIKV-positive sera without cross-reactivity to other flaviviruses. These identified sensitive and specific epitopes provide a tool for design of diagnostics and structure-based vaccine antigens for ZIKV infection.

The emergence of oseltamivir-resistant variants of influenza virus has highlighted the necessity for the development of more effective novel antiviral drugs. To date, numerous researchers have focused on developing antiviral drugs using natural resources, such as traditional herbal medicines. Poncirus trifoliata is widely used in oriental medicine as a remedy for gastritis, dysentery, inflammation and digestive ulcers. In this study, we investigated the potential antiviral effect of the Poncirus trifoliata orange seed extract against influenza virus. An ethanol extract of Poncirus trifoliata seeds (PTex) inhibited the activity of influenza viruses, in particular, oseltamivir- resistant strains, in Madin-Darby canine kidney cells. In contrast to oseltamivir, PTex exerted a significant inhibitory effect on the cellular penetration pathway of the virus rather than HA receptor binding. The potent antiviral effect and novel working mechanism of PTex support its further development as an effective natural antiviral drug with a wide spectrum of activity against influenza and oseltamivir-resistant viruses.

Zika virus (ZIKV) is a mosquito-borne flavivirus, that could cause congenital Zika syndrome (CZS), characterized by microcephaly, neurological complications and fetal deaths. No specific treatments for ZIKV are currently available, highlighting the urgent global need to identify and develop therapeutic agents. Drug repositioning of approved natural compounds can provide effective alternative solutions for novel antiviral development. The current study focused on curcumin, a component of turmeric known to exert diverse antiviral effects. We integrated in silico information from publicly available databases to predict interactions between curcumin and potential targets of ZIKV. In our network analysis, we identified four targets, TP53, AKT1, PTEN, and TNF, which were identified as potential targets associated with ZIKV. Based on retrieved targets, we performed molecular docking study and identified curcumin-TNF showed the strongest binding among four targets. The anti-Zika effects of curcumin were validated in vitro with the aid of antiviral and plaque reduction assay. Curcumin at concentrations ranging from 12.5 to 50 μM displayed significant antiviral activity in a dose-dependent manner (p 0.05). In view of its natural abundance and prevalence in the human diet, curcumin holds significant promise for treatment of ZIKV infections.

PurposeThis study investigated the effect of gabapentin on lower urinary tract dysfunction focusing on urethral activities and cystitis-induced hyperalgesia in a mouse model of painful bladder syndrome/interstitial cystitis (PBS/IC). The electromyography(EMG) of external urethral sphincter(EUS) was difficult to obtain, but contained useful information to examine the drug effect in mice.MethodsFemale C57BL/6J mice were intraperitoneally (ip) administration with either saline or 200mg/kg of cyclophosphamide (CYP) 48h before experimental evaluation. Cystitis mice were treated with administration of gabapentin (25 or 50mg/kg, ip). Cystometry and EUS EMG were obtained and analyzed during continuous bladder infusion. The visceral pain-related visceromotor reflex (VMR) was recorded in response to isotonic bladder distension.ResultsCystitis mice showed shorter inter-contraction intervals and increased occurrence of non-voiding contractions during bladder infusion, with increased VMR during isotonic bladder distension, indicating cystitis-induced bladder hyperalgesia. Gabapentin (50mg/kg) suppressed effects of CYP on cystometry, but not on EUS EMG activity, during bladder infusion. The effect on urodynamic recordings lasted 4h. VMR was significantly reduced by gabapentin.ConclusionsThe present study showed that CYP-induced cystitis in mice is a model of visceral hyperalgesia affecting detrusor contractions, not urethral activations. The technique of using EUSEMG to evaluate the drug effects on urethral activities is novel and useful for future investigations. Gabapentin can be as a potential treatment for detrusor overactivity and PBS/IC.

Objectives This study sought to evaluate the determinants and prognostic implications of periprocedural myocardial injury (PMI) in successful percutaneous coronary intervention (PCI) of chronic total occlusions (CTOs). Background There are limited studies addressing the risk factors and clinical implication of PMI in patients undergoing CTO-PCI. Methods We examined 1,058 consecutive CTO patients who underwent successful drug-eluting stent implantation and serial measurements of creatine kinase-myocardial band (CK-MB) values between March 2003 and August 2014. PMI was defined as elevations of CK-MB >3 times the upper reference limit (URL). Results PMI occurred in 121 patients (11.4%). Multivariable analysis revealed that the presence of renal failure (odds ratio [OR]: 4.25; 95% confidence interval [CI]: 1.59 to 11.35; p = 0.004), attempted retrograde approach (OR: 2.27; 95% CI: 1.34 to 3.84; p = 0.002), concomitant non–target lesion intervention (OR: 1.74; 95% CI: 1.17 to 2.59; p = 0.006), and stent number (OR: 1.38; 95% CI: 1.08 to 1.77; p = 0.011) were predictors associated with PMI. During a median follow-up of 4.4 years, PMI was associated with an increased risk of mortality (adjusted hazard ratio: 1.86; 95% CI: 1.09 to 3.17; p = 0.02). These findings were also consistent when higher CK-MB cutoff was used to define PMI. Although there was a trend toward higher all-cause mortality with increasing peak CK-MB levels, in multivariable analyses, this association was statistically significant only for peak CK-MB levels of >10 times the URL. Conclusions PMI was associated with an increased risk of long-term mortality after successful CTO-PCI. Patients with renal insufficiency, those who require more stents, multiple lesion treatment, and retrograde approach have a higher likelihood of having PMI.

Sodium nickel chloride (Na-NiCl2) battery is one of the most promising candidates as a large scale electrochemical energy storage device since it offers high safety, long lifetime, and high energy density. The battery comprises molten metallic Na and NiCl2 as negative and positive electrodes, respectively, separating them by a β”-Al2O3–family solid electrolyte (BASE). In order to facilitate fast sodium-ion transport in the cathode compartment, the battery typically operates at 300oC accompanying with molten NaAlCl4 (catholyte), which is infiltrated into the cathode materials powder. A drawback of the efficient battery hampering broader market penetration is high manufacturing cost as it adopts expensive heterogeneous sealing technologies, such as thermal compression bonding, glass sealing, and laser beam welding, which are inevitable to withstand its high operating temperature. However, when lowering the operating temperature down to below 200oC, inexpensive polymer can be introduced replacing all the expensive sealing technologies, through which cell manufacturing process can be substantially simplified at the same time. In developing the lower temperature operating planar Na-NiCl2 battery, one of the major cell failure modes is mechanical failure in solid electrolytes either by thermal stress accumulation upon freeze-thaw cycles or by stresses developed by pressure difference between cathode and anode compartments during charge-discharge cycles. The presentation will start with defining failure modes of this new class of Na beta-alumina battery with special emphasis on electrolyte failure. In order to understand the stress accumulation in the vicinity of the solid electrolyte, a set of finite element analyses (FEA) has been conducted for various simulated conditions. It turns out that (1) sealing temperature, and (2) inner volumes of cathode and anode compartments need to be carefully designed to avoid the mechanical failure. The results of the calculation and cell design strategy for this novel battery will be discussed. Figure 1

A 52-year-old male with Brugada syndrome presented with repeated and appropriate shock from an implantable cardioverter defibrillator (ICD). Catheter ablation for substrate elimination targeting low-voltage, complex, and fractionated electrocardiograms and late potentials in the epicardial right ventricular outflow tract was successfully performed. Brugada phenotype in the right precordial leads from the third intercostal space disappeared in the early stage after catheter ablation and that from the standard fourth intercostal space disappeared later. He remained free from ventricular fibrillation over the next fourteen months. We suggest that this novel ablation strategy is effective in Brugada syndrome patients with ICD, and early response after catheter ablation can be predicted by high precordial leads.

Introduction and objectivesEndoscopic injection of urethral bulking agents is an office procedure that is used to treat stress urinary incontinence secondary to internal sphincteric deficiency. Validation studies important part of simulator evaluation and is considered important step to establish the effectiveness of simulation-based training. The endoscopic needle injection (ENI) simulator has not been formally validated, although it has been used widely at University of California, Irvine. We aimed to assess the face, content, and construct validity of the UC, Irvine ENI simulator.MethodsDissected female porcine bladders were mounted in a modified Hysteroscopy Diagnostic Trainer. Using routine endoscopic equipment for this procedure with video monitoring, 6 urologists (experts group) and 6 urology trainee (novice group) completed urethral bulking agents injections on a total of 12 bladders using ENI simulator. Face and content validities were assessed by using structured quantitative survey which rating the realism. Construct validity was assessed by comparing the performance, time of the procedure, and the occlusive (anatomical and functional) evaluations between the experts and novices. Trainees also completed a postprocedure feedback survey. Effective injections were evaluated by measuring the retrograde urethral opening pressure, visual cystoscopic coaptation, and postprocedure gross anatomic examination.ResultsAll 12 participants felt the simulator was a good training tool and should be used as essential part of urology training (face validity). ENI simulator showed good face and content validity with average score varies between the experts and the novices was 3.9/5 and 3.8/5, respectively. Content validity evaluation showed that most aspects of the simulator were adequately realistic (mean Likert scores 3.9-3.8/5). However, the bladder does not bleed, and sometimes thin. Experts significantly outperformed novices (p < 001) across all measure of performance therefore establishing construct validity.ConclusionThe ENI simulator shows face, content and construct validities, although few aspects of simulator were not very realistic (e.g., bleeding).This study provides a base for the future formal validation for this simulator and for continuing use of this simulator in endourology training.

Pigs are used as potential donor animals for xenotransplantation. However, porcine endogenous retrovirus (PERV), shown to infect both human and non-human primate (NHP) cells in vitro, presents a risk of transmission to humans in xenotransplantation. In this study, we analyzed PERV transmission in various organs after pig-to-NHP xenotransplantation. We utilized pig-to-NHP xenotransplant tissue samples obtained using two types of transgenic pigs from the National Institute of Animal Science (NIAS, Republic of Korea), and examined them for the existence of PERV genes in different organs via PCR and RT-PCR with specific primers. To determine PERV insertion into chromosomes, inverse PCR using PERV long terminal repeat (LTR) region-specific primers was conducted. The PERV gene was not detected in NHP organs in cardiac xenotransplantation but detected in NHP bladders in renal xenotransplantation. The insertion experiment confirmed that PERVs originate from porcine donor cells rather than integrated provirus in the NHP chromosome. We also demonstrate the presence of pig cells in the NHP bladder after renal xenotransplantation using specific-porcine mitochondrial DNA gene PCR. The PERV sequence was detected in the bladder of NHPs after renal xenotransplantation by porcine cell-microchimerism but did not integrate into the NHP chromosome.

Purpose Correlations between NT-proBNP with diastolic echocardiographic parameters were not analyzed precisely. We sought to evaluate the clinical implication of NT-proBNP on the LV diastolic function in large scale databases. Methods NT-proBNP(n=23,029) and echocardiography databases(n=48,750) were collected. Cases measured within 24 hours were enrolled and increased serum creatinine level(>2.0 pg/ml) or acute coronary syndrome were excluded. Finally, echocardiographic parameters were compared with serum NT-proBNP levels in 1,852 patients. Results Among patients (54% female, mean age 63.0±0.3), 460 patients (24.8%) showed preserved LV systolic functions (LVEF ≥40%, 53.5±0.4%). NT-proBNP levels were significantly correlated with LVEF(r=-0.52, p=0.01), LA volume index(r=0.50, p=0.01), E/E’(r=0.44, p=0.01), RV systolic pressure (r=0.43, p=0.01) and LV mass index(r=0.40, p=0.01). NT-proBNP showed low sensitivities to determine E/E’ ratio above 15 and LAVI above 27 on cut-off values of the ROC curve with specificity of 80% (51.7% at 686.6 ng/L, 58.7% at 643.1 ng/L). Interestingly, in patients with preserved systolic function (55.9% male, mean age 61.2±0.7), NT-proBNP showed slightly high sensitivity than in total study group (53.5% at 717.0 ng/L, 60.9% at 443.3 ng/L). Conclusion Although NT-proBNP was proved as a useful parameter for assessing LV diastolic function as well as systolic function, it showed relatively low sensitivity to determining LV diastolic function. Therefore, NT-proBNP may imply LV diastolic function but should be interpreted with combining clinical informations.

Statin and angiotensin II type 1 receptor blocker therapy improves endothelial dysfunction using distinct mechanisms. We evaluated simultaneous vascular and metabolic responses to pravastatin and valsartan therapy, alone or in combination, in hypercholesterolemic patients. Forty-eight hypercholesterolemic patients (23 had metabolic syndrome) were given pravastatin 40 mg and placebo, pravastatin 40 mg and valsartan 160 mg, or valsartan 160 mg and placebo daily during each 2-month treatment period in a randomized, single-blind, placebo-controlled, crossover trial with three treatment arms and two washout periods (each 2 months). Brachial artery flow-mediated dilation and C-reactive protein improved to a greater extent with combined therapy compared with either monotherapy. Importantly, we also observed simultaneous improvement in metabolic phenotypes, with all three treatments causing increased plasma adiponectin levels, reduced fasting insulin levels, and increased insulin sensitivity relative to baseline measurements. For the first time in a statin combination trial, pravastatin combined with valsartan therapy increased plasma adiponectin, lowered fasting insulin levels, and improved insulin sensitivity in an additive manner when compared with monotherapy alone. In contrast to other statins, hydrophilic pavastatin may be combined with other drugs to safely reach lipid target levels while simultaneously improving the metabolic and cardiovascular phenotype of patients at high risk.

Rosuvastatin and pravastatin have differential hydrophilicity and potency to inhibit hydroxymethylglutaryl-CoA reductase that may be relevant to changes in adiponectin levels, insulin resistance, and the rate of new onset diabetes in large clinical studies. Therefore, we hypothesized that rosuvastatin and pravastatin may have differential metabolic effects in hypercholesterolemic patients.This was a randomized, single-blind, placebo-controlled, parallel study. Age, gender, and body mass index were matched. Fifty-four patients were given placebo, rosuvastatin 10mg, or pravastatin 40mg, respectively once daily for 2 months.When compared with pravastatin therapy, rosuvastatin therapy significantly reduced total, LDL cholesterol, and apolipoprotein B levels (P0.05 by post-hoc comparison), but comparably improved flow-mediated dilation after 2 months. Interestingly, rosuvastatin therapy significantly increased fasting insulin (mean % changes; 28%, P=0.005). and HbA1c (1%, P=0.038) while decreasing plasma adiponectin levels (9%, P=0.010) and insulin sensitivity (assessed by QUICKI; 2%, P=0.007) when compared with baseline. By contrast, pravastatin therapy significantly decreased fasting insulin (8%, P=0.042), and HbA1c levels (1%, P=0.019) while increasing plasma adiponectin levels (36%, P=0.006) and insulin sensitivity (3%, P=0.005) when compared with baseline. Moreover, these differential effects were evident when outcomes of rosuvastatin and pravastatin therapy were directly compared (P=0.002 for insulin levels by ANOVA on Ranks, P=0.003 for adiponectin, P=0.003 for QUICKI, and P=0.010 for HbA1c by ANOVA).While significantly reducing lipoprotein profiles, rosuvastatin therapy had unwanted metabolic effects in hypercholesterolemic patients when compared with pravastatin therapy, that may be clinically relevant in patients prone to metabolic diseases.

Background: Recently introduced dichotomous phenotypic classification of bicuspid aortic valve (BAV) showed potential association between BAV phenotype and patterns of valvulopathy or aortopathy. However its potential advantage needs to be compared with the conventional BAV classification in a large patient population. Methods: In 486 consecutive patients (309 male, 58±14 years) who underwent aortic valve (AV) surgery (n=483) or aortic surgery (n=146), BAV phenotype was classified using echocardiography. Dichotomous classification was based on the orientation of coronary arteries: AP (both coronary arteries originating from the anterior cusp) and RL (each coronary artery originating from each cusp). Conventional classification (type 1 - 4) was based on the fused cusp (Figure). We analyzed the associations between the BAV phenotype and 1) indication of AV surgery (aortic stenosis [AS] vs. regurgitation [AR]), and 2) implementation of aortic surgery. Results: BAV-AP (n=271, 56%) was more common than BAV-RL (n=215, 44%). Using conventional classification, fused cusps were indistinguishable in 15% (type 4). Indications of AV surgery included dominant AS (n=352), AR (n=96), and infective endocarditis (IE; n=35). Aortic surgeries were performed for aortic aneurysm (n=135), IE with abscess (n=9), dissection (n=1), and coarctation (n=1). Patients with BAV-RL type presented lower frequency of male (55% vs. 70%, P=0.001), AV surgery for dominant AS (82% vs. 66%, P Conclusions: New classification can overcome the ambiguity of the conventional classification and shows better association with type of valvulopathy and combined aortopathy.

Patent foramen ovale (PFO) is a remnant of the fetal circulation, with a prevalence of 27% of general population [1]. The condition can allow right-to-left blood flow that bypasses the pulmonary circulation when right atrial pressure excels left atrial pressure [2]. In patients with venous thrombus, when there is a favorable pressure gradient such as pulmonary hypertension, emboli from the venous system can enter the arterial circulation through an abnormal intracardiac shunt like a PFO and may lead to a systemic manifestation, such as stroke [2,3]. We herein report a case of multiple concurrent paradoxical embolisms resulting in mesenteric infarction, which is very rare, and concurrent occlusion of the peripheral arteries in a patient with PFO, who suffered deep vein thrombosis (DVT) and massive pulmonary thromboembolism (PTE). A 73-year-old Asian man who was physically inactive presented with sudden onset abdominal pain. He also complained of claudication and mild dyspnea that had lasted for one month. He had a medical history of hypertension controlled with medication for two years. Vital signs were notable for fever (38.4 °C) and tachycardia. On physical examination, he appeared tachypneic, and abdominal rigidity and tenderness were remarkable. Concurrently, both legs were cold, and pulses on both posterior tibial arteries and dorsalis pedis arteries

Background: Although aortic stenosis (AS) is a prototype of left ventricular hypertrophy (LVH) due to pressure overloading, patterns of LV geometric changes in patients with tight AS and their potential impact remain to be established. Methods: LV mass index (LVMI), LV end-diastolic volume (LVEDV) and regional LV wall thickness in 16 segments were measured in 147 patients with tight AS (indexed aortic valve area [AVA] < 0.6 cm 2 /m 2 ) using multi-detector computed tomography and compared with those of 32 normal controls. LVH was defined as LVMI >95 th percentile of normal controls and LV remodeling as increased LVM/LVEDV with normal range of LVMI. Asymmetric remodeling or hypertrophy were used for patients with septal wall thickness >1.5 fold compared to the opposite segment. Patients with increased LVMI but normal range of LVM/LVEDV were classified to have eccentric LVH and those with eccentric LVH and decreased LV systolic function were defined to have de-compensation. Results: AS patients with mean indexed AVA of 0.36 ± 0.08 cm 2 /m 2 showed 7 different patterns of LV geometry including normal LV geometry (n=44), remodeling (n=7), asymmetric remodeling (n=7), concentric hypertrophy (n=16), asymmetric hypertrophy (n=23), eccentric hypertrophy (n=38), and de-compensation (n=12). Peak transaortic velocity (r=0.31, p2 , p=0.005). Conclusions: Various remodeling patterns of LV geometry were observed in tight AS and individual variation in LVH severity under similar LV pressure overloading could explain different severity of diastolic dysfunction.

Introduction: The risks and benefits of long-term dual antiplatelet therapy (DAPT) beyond 12 months in patients receiving drug-eluting stents (DES) and with high-risk clinical and angiographic features are unclear. Hypothesis: We try to determine whether extended use of DAPT is beneficial among patients with off-label use of DES. Methods: A total of 5,045 patients were included in the DES LATE trial and stratified according to randomized treatments (aspirin-alone or dual-therapy) and whether use was standard or off-label. Off-label was defined as use in renal insufficiency, ejection fraction ≤30%, acute myocardial infarction (MI), multivessel stenting, total stent length ≥36 mm, or ostial, bifurcation, grafts, left main, restenotic, thrombus, or totally occluded lesions. The primary endpoint was a composite of death from cardiac causes, MI, or stroke at 24 months after randomization. Results: Off-label use occurred in 68.6% of all patients. Among patients with off-label use, the risk of primary endpoint at 2 years was similar between aspirin-alone and dual-therapy group (2.6% vs. 3.1%; hazard ratio: 0.89; 95% confidence interval: 0.59 to 1.34, P = 0.59). In addition, no significant differences were observed between 2 treatment groups for individual and combined risks of efficacy and safety endpoints (death, MI, stroke, stent thrombosis, repeat revascularization, or major bleeding). These findings were consistent in patients with on-label use of DES (Figure). Conclusions: Extended use of DAPT beyond 12 months was not significantly more effective than aspirin monotherapy in reducing the risk of death from cardiac causes, MI, or stroke, regardless of off-label or on-label use of DES.

There are limited data on the optimal antithrombotic therapy for patients with atrial fibrillation (AF) who undergoing coronary stenting. We reviewed 203 patients (62.6 % men, mean age 68.3 ± 10.1 years) between 2003 and 2012, and recorded clinical and demographic characteristics of the patients. Clinical follow-up included major adverse cardiac and cerebrovascular events (MACCE) (cardiac death, myocardial infarction, target lesion revascularization, and stroke), stent thrombosis, and bleeding. The most commonly associated comorbidities were hypertension (70.4 %), diabetes mellitus (35.5 %), and congestive heart failure (26.6 %). Sixty-three percent of patients had stroke risk higher than CHADS2 score 2. At discharge, dual-antiplatelet therapy (aspirin, clopidogrel) was used in 166 patients (81.8 %; Group I), whereas 37 patients (18.2 %) were discharged with triple therapy (aspirin, clopidogrel, warfarin; Group II). The mean follow-up period was 42.0 ± 29.0 months. The mean international normalized ratio (INR) in group II was 1.83 ± 0.41. The total MACCE was 16.3 %, with stroke in 3.4 %. Compared with the group II, the incidence of MACCE (2.7 % vs 19.3 %, P = 0.012) and cardiac death (0 % vs 11.4 %, P = 0.028) were higher in the group I. Major and any bleeding, however, did not differ between the two groups. In multivariate analysis, no warfarin therapy (odds ratio 7.8, 95 % confidence interval 1.02–59.35; P = 0.048) was an independent predictor of MACCE. By Kaplan–Meier survival analysis, warfarin therapy was associated with a lower risk of MACCE (P = 0.024). In patients with AF undergoing coronary artery stenting, MACCE were reduced by warfarin therapy without increased bleeding, which might be related to tighter control with a lower INR value.