BACKGROUND: It is difficult to cover aneurysm-like ventricular septal defect (VSD) of large inlet and multiple outlets completely with symmetrical type occluders or eccentric type occluders. OBJECTIVE: To investigate the feasibility of A4B2 occluder devices for covering aneurysm-like VSD, and to observe the effects of proper occhiders selected according to pseudoaneurysm size on coveting aneurysm-like VSD. DESIGN: Case analysis.SETTING: the First Hospital of Hebei Medical University. PARTICIPANTS: From August 2004 to May 2006, 226 patients with the pseudoaneurysm of petimembranous VSD, who underwent interventional therapy in the First Hospital of Hehei Medical University, were recruited in the study. According to the results of the left ventricular angiography, 36 patients of pseudoaneurysm of petimembranous VSD with large inlet and multiple outlets were closured with A4B2 occluder devices. According to the results of the left ventricular angiography, the mean diameter of the left inlet of VSD was (10.6+8.7) mm (ranged from 8 to 21 mm), the mean diameter of the right outlet of VSD was (3.1 ± 2.9) mm (ranged from 2 to 8 ram). Main materials: Occluder device and delivery mechanism were offered by Shanghai Shape Memory Alloy Materials Company and Beijing Starway Medical Technology Inc. They were processed into double disks using nickel-titanium shape memory alloy wires by a special technology to close VSD by a transcatheter approach. The size of the occluder was denoted with the diameter of the waist, and the Size ranged from 4 to 16 mm in the present study. METHODS: All the occluders were transferred by a 7-10 F transferring sheath from right heart system, and the mean diameter of the occluders was (6.364-2.48) nun (ranged from 4 to 16 ram). Fifteen minutes after the procedure, left ventricular angiography and transthoracic echocardiography (TIE) were performed again to evaluate the efficacy. After the procedure, electrocardiogram (ECG) monitoring lasted for 5 successive days in all patients, and ECG and TIE were performed 1, 3, 6 and 12 months later. MAIN OUTCOME MEASURES: Residual shunt, arrhythmia and valve function as well as blood compatibility. RESULTS: Sixteen cases were closured by placing the occhiders into left inlet of VSD, 16 cases were closured by placing the occluders into the pseudoaneurysm completely, and 4 cases were closured at the outlet of the defects. The results of the left ventricular angiography and TTE that performed fifteen minutes after the procedure demonstrated that 32 cases were completely closured and slightly residual shunts (< 3 mm) was found in other 4 patients. And confirmed by TIE, the residual shunts completely disappeared in 2 of the 3 patients 24 hours later while in the other one in 1 month after the procedure. Temporary left bundle branch block was found in 3 cases while temporary right bundle branch block was found in 2 cases, and all of them recovered within one week. Without severe complications, all of the 36 patients were treated successfully with A4B2 (thin waist shape) occluder devices made in China. Critical appraisal in blood compatibility of the implantation materials used in this research had been performed. The hemolysis ratio was less than 5%, the platelet adhesion was less, and the blood coagulation function ,the immune system response( immunoglobulin and complement)and the re-endothelialization of material surface were all normal. CONCLUSION: Transcatheter interventional therapy with domestic A4B2 occluder devices for VSD with pseudoaneurysm is safe, effective, promising, and has fewer complications. The key to the procedure is to select suitable occluders and suitable positions where to plant them according to the size, morphologic characteristics, position, and maturity of the pseudoaneurysm.

AIM: To explore the predictive value of the combination of triglyceride-glucose(TyG)index, nesfatin-1, and retinol-binding protein 4(RBP4)for diabetic retinopathy, and provide evidence for early prediction of DR.METHODS: The clinical data of 164 patients with type 2 diabetes mellitus(T2DM)who admitted to the hospital between February 2022 and December 2023 were retrospectively collected. Based on the fundus examination results, these patients were divided into two groups: the DR group(n=43), including proliferative DR(PDR, n=19)and non-proliferative DR(NPDR, n=24), and the T2DM without DR group(n=121). The TyG index and the level of nesfatin-1 and RBP4 were measured after admission.RESULTS:T2DM patients with DR had a longer disease duration compared with T2DM patients without DR, and the DR group had higher fasting blood glucose, glycosylated hemoglobin, triglyceride, total cholesterol, low-density lipoprotein, TyG index, and RBP4 levels, while lower high-density lipoprotein and nesfatin-1 levels(all P<0.001). Multivariate Logistic regression analysis indicated that the duration of T2DM(OR=1.338, 95%CI: 1.059-1.690), glycosylated hemoglobin(OR=5.065, 95%CI: 1.659-15.470), low density lipoprotein(OR=12.715, 95%CI: 2.385-67.790), TyG index(OR=23.057, 95%CI: 2.936-181.073)and RBP4(OR=1.319, 95%CI: 1.028-1.692)were the independent risk factors for DR, while nesfatin-1(OR=0.007, 95%CI: 0.003-0.016)was an independent protective factor for DR. The ROC curves were drawn, and the results indicated that the TyG index, nesfatin-1, and RBP4 had certain predictive values for DR patients with T2DM, with areas under curve(AUC)of 0.804, 0.878 and 0.738, respectively. The combined AUC of the TyG index, nesfatin-1, and RBP4 was 0.946, sensitivity was 83.72%, and specificity was 92.56%. Patients with PDR had a higher TyG index, higher RBP4 level, and lower nesfatin-1 level than patients with NPDR(all P<0.05). Spearman's correlations indicated a positive association between the TyG index, RBP4 and DR degree, and a negative association between nesfatin-1 and DR degree(rs=0.557, 0.392, -0.359, repectively, all P<0.05). Pearson correlation analysis indicated a negative correlation between the TyG index and the levels of nesfatin-1, a positive correlation between the TyG index and the levels of RBP4, and a negative correlation between the levels of nesfatin-1 and RBP4 in DR patients with T2DM(r=-0.486, 0.538, -0.592, all P<0.05).CONCLUSION: The serum of TyG index and the levels of nesfatin-1 and RBP4 were early predictive markers for DR and were associated with the risk of the occurrence and severity of the disease. Besides, the combined prediction performance of TyG index, nesfatin-1, and RBP4 was better for DR.