The use of intra-aortic balloon pump in patients undergoing heart valve replacement: outcome and risk analysis.

BACKGROUND AND AIM OF THE STUDY: Intra-aortic balloon pump (IABP) in heart valve surgical patients is associated with a higher mortality than coronary artery bypass grafting (CABG). The study aim was to analyze the early outcome of heart valve surgical patients requiring IABP support, and to assess the risk factors for early mortality. METHODS: Among a cohort of 5,786 patients undergoing heart valve replacement without CABG, 81 (1.4%) required IABP support. Data from these latter patients were collected and analyzed retrospectively, and univariate and multivariate logistic regression were applied to identify risk factors for early mortality in patients requiring IABP support. RESULTS: IABP was inserted in 30 patients intraoperatively, and in 51 patients postoperatively. The overall mortality was 50.6%. Mortality in the intraoperative IABP subgroup was significantly lower than in the postoperative IABP subgroup (26.7% versus 64.7%, p = 0.001). The independent risk factors for early mortality were: age increasing by 10 years (OR 1.906, 95% CI: 1.165-3.116, p = 0.010) and pulmonary hypertension (OR 4.153, 95% CI: 1.380-12.499, p = 0.011). Intraoperative IABP insertion (OR 0.297, 95% CI: 0.100-0.876, p = 0.028) was identified as a protective factor compared to postoperative insertion. CONCLUSION: The mortality of patients requiring IABP support after heart valve replacement was high. The efficacy of intraoperative IABP insertion was better than a postoperative mandatory use. Clearly, more attention should be paid to older patients or those with pulmonary hypertension, who may benefit less from IABP.

Comparison of six risk scores for in-hospital mortality in Chinese patients undergoing heart valve surgery.

BACKGROUND: To compare six risk scores with regard to their validity to predict in-hospital mortality after heart valve surgery in a single-centre patient population of China. METHODS: From January 2006 to December 2011, 3479 consecutive patients who underwent heart valve surgery at our centre were collected and scored according to the EuroSCORE II, VA risk score, NNE risk score, Ambler risk score, NYC risk score, and STS risk score. Calibration of the six risk scores was assessed by the Hosmer-Lemeshow (H-L) test. Discrimination was tested by calculating the area under the receiver operating characteristic (ROC) curve. RESULTS: Observed mortality was 3.32% overall. The STS score showed good calibration in predicting in-hospital mortality (H-L: P = 0.126). The EuroSCORE II, VA score, NNE score, and NYC score underpredicted observed mortality (H-L: P < 0.0001, P < 0.0001, P = 0.001, and P < 0.0001, respectively) and the Ambler score overpredicted observed mortality (H-L: P = 0.005). The discriminative power (i.e. the area under the ROC curve) for in-hospital mortality was highest for the STS score (0.706), followed by the EuroSCORE II model (0.693), NNE score (0.684), NYC score (0.682), Ambler score (0.677) and VA score (0.643). CONCLUSION: Compared with the EuroSCORE II, VA score, NNE score, NYC score, and the Ambler score, the STS score gives an accurate prediction for individual operative risk in patients undergoing heart valve surgery at our centre. Therefore, the use of the STS score for risk evaluation maybe suitable in patients undergoing heart valve surgery at our centre in the future.

Risk model of prolonged intensive care unit stay in Chinese patients undergoing heart valve surgery.

BACKGROUND: The aim of this study was to develop a preoperative risk prediction model and an scorecard for prolonged intensive care unit length of stay (PrlICULOS) in adult patients undergoing heart valve surgery. METHODS: This is a retrospective observational study of collected data on 3925 consecutive patients older than 18 years, who had undergone heart valve surgery between January 2000 and December 2010. Data were randomly split into a development dataset (n=2401) and a validation dataset (n=1524). A multivariate logistic regression analysis was undertaken using the development dataset to identify independent risk factors for PrlICULOS. Performance of the model was then assessed by observed and expected rates of PrlICULOS on the development and validation dataset. Model calibration and discriminatory ability were analysed by the Hosmer-Lemeshow goodness-of-fit statistic and the area under the receiver operating characteristic (ROC) curve, respectively. RESULTS: There were 491 patients that required PrlICULOS (12.5%). Preoperative independent predictors of PrlICULOS are shown with odds ratio as follows: (1) age, 1.4; (2) chronic obstructive pulmonary disease (COPD), 1.8; (3) atrial fibrillation, 1.4; (4) left bundle branch block, 2.7; (5) ejection fraction, 1.4; (6) left ventricle weight, 1.5; (7) New York Heart Association class III-IV, 1.8; (8) critical preoperative state, 2.0; (9) perivalvular leakage, 6.4; (10) tricuspid valve replacement, 3.8; (11) concurrent CABG, 2.8; and (12) concurrent other cardiac surgery, 1.8. The Hosmer-Lemeshow goodness-of-fit statistic was not statistically significant in both development and validation dataset (P=0.365 vs P=0.310). The ROC curve for the prediction of PrlICULOS in development and validation dataset was 0.717 and 0.700, respectively. CONCLUSION: We developed and validated a local risk prediction model for PrlICULOS after adult heart valve surgery. This model can be used to calculate patient-specific risk with an equivalent predicted risk at our centre in future clinical practice.

[Clinical analysis of the edge-to-edge technique for mitral regurgitation due to myxomatous degeneration].

OBJECTIVES: To explore the feature of the edge-to-edge technique and its effect for mitral regurgitation due to myxomatous degeneration. METHODS: The in-patient data and follow-up outcomes of 58 patients after the edge-to-edge technique for mitral regurgitation due to myxomatous degeneration from January 2000 to January 2009 were analyzed retrospectively. Of the 58 patients, 32 patients were male and 26 patients were female, and the age range was from 43 years to 65 years with a mean of (56 ± 6) years, and moderate mitral regurgitation was observed in 18 patients and severe regurgitation in 40 patients, and the prolapse of the anterior leaflet was observed in 50 patients and the prolapse of the bileaflet in 8 patients. The edge-to-edge technique was performed in all patients and the annuloplasty was performed in 44 patients. RESULTS: There was no perioperative death and serious complication. Postoperative transthoracic echocardiography of all the survivors indicated that the dimensions of left atrial and left ventricular were obviously decreased (P < 0.05) and mitral insufficiency was obviously improved (no regurgitation was observed in 9 patients and trace regurgitation in 30 patients and mild regurgitation in 19 patients) and there was no mitral stenosis. Totally 58 patients were followed up from 24 months to 95 months with a mean of (58 ± 20) months. During the follow-up, there were 2 deaths for noncardiac factors. Freedom from recurrent moderate or severe mitral regurgitation at 5 years after operations was 91.9%. According to undergoing combined annuloplasty or not, 58 patients were divided into the edge-to-edge technique group (14 cases) and the edge-to-edge technique + annuloplasty group (44 cases), and the survival analysis shows there was significant difference on freedom from long-term recurrent moderate or severe mitral regurgitation after operations between two groups (χ(2) = 4.034, P = 0.045) and long-term effect of the latter group was better. CONCLUSIONS: The edge-to-edge technique can be conveniently used and bring about satisfactory perioperative and long-term effects for mitral regurgitation due to myxomatous degeneration. The combination of the edge-to-edge technique and the annuloplasty can improve the long-term effect significantly.

[Methods and results of surgical treatment for aortic root pathology due to Stanford A aortic dissection].

OBJECTIVE: To investigate the effectiveness of surgical approaches, outcomes and prognosis of aortic root pathology due to Stanford A aortic dissection. METHODS: Retrospective analysis the clinical data of 161 patients (122 male and 39 female, mean age of (44 ± 21) years) underwent surgical treatment for Stanford A aortic dissection between January 2001 and June 2011. There were 146 patients of acute aortic dissection and 15 patients of chronic aortic dissection. All the patients had aortic root pathologies that included commissural prolapsed in 140 cases, more than moderate aortic insufficiency in 75 cases, aortic sinus intima rupture in 15 cases, right and/or left coronary artery tearing in 8 cases, right and/or left coronary artery dissection in 16 cases, aortic root aneurysm in 31 cases. RESULTS: Aortic root replacement (Bentall procedures) were used in 72 cases, aortic root remodeling (including aortic valve replacement) in 80 cases, aortic root reimplantation (David procedure) in 9 cases. The cardiopulmonary bypass time was shorter in aortic root remodeling group ((193 ± 42) minutes) than the other two groups ((210 ± 61) minutes, (197 ± 34) minutes, F = 3.22, P = 0.04). The in-hospital mortality was 8.1% (13 cases), 5 cases (6.9%) in aortic root replacement group, 7 cases (8.8%) in aortic root remodeling group, 1 case in aortic root reimplantation. The cause of death included respiratory failure (4 cases), permanent neurological deficits (3 cases), multiple organ failure (4 cases), acute renal failure (2 cases). The survivors were followed up for 6 months to 6 years. There was no patient required reoperation for aortic root pathologies. There was no statistically significant difference between aortic root remodeling group and reimplantation group (P > 0.05). CONCLUSIONS: The surgical treatment for aortic root pathology due to Stanford A aortic dissection is challenging. Appropriate procedures according to the specialty of aortic root pathology can be performed with favorable functional results.

Congenital quadricuspid aortic valve: analysis of 11 surgical cases.

BACKGROUND: Congenital quadricuspid aortic valve is rarely seen during aortic valve replacement (AVR). The diagnosis and treatment of the disease were reported in 11 cases. METHODS: Eleven patients (nine men and two women, mean age 33.4 years) with quadricuspid aortic valve were retrospectively evaluated. Medical records, echocardiograms and surgical treatment were reviewed. RESULTS: In accordance with the Hurwitz and Roberts classification, the patients were classified as type A (n = 2), type B (n = 7), type F (n = 1) and type G (n = 1). Three patients were associated with other heart diseases, including infective endocarditis and mitral prolaps, left superior vena cava, aortic aneurysm. All had aortic regurgitation (AR) except two with aortic stenosis (AS), detected by color-flow Doppler echocardiography. The congenital quadricuspid aortic valve deformity in seven patients was diagnosed by echocardiography. All patients underwent successful aortic valve replacement. CONCLUSION: Quadricuspid aortic valve is a rare cause of aortic insufficiency, while echocardiography plays an important role in diagnosing the disease. Aortic valve replacement is the major therapy for the disease.

[Strategy of dealing with left subclavian artery in total arch replacement combined with stented elephant trunk implantation for Stanford type A aortic dissection].

OBJECTIVE: To summarize the experiences of ligating left subclavian artery (LSA) in total arch replacement and stented elephant trunk implantation for Stanford type A aortic dissection patients with difficulty in exposing the LSA. METHODS: Total arch replacement and stented elephant trunk implantation were performed on 79 consecutive patients from January 2008 to June 2010. Twenty-nine cases of the cohort undertook LSA ligation due to bad exposure. There were 21 males and 8 females patients, aged from 19 to 55 years with a mean of (44 ± 12) years. There were 12 acute dissections, 4 sub-acute dissections and 13 chronic dissections. Based on thoroughly evaluation of the Willis' circle and bilateral vertebral arteries through pre-operative imaging and intra-operative circulative parameters, if the collateral circulation was considered sufficient, LSA was ligated directly and only the innominate artery and carotid artery were reconstructed; if considered insufficient, an additional bypass from ascending aorta to left axillary artery was performed. RESULTS: All the 29 operations were completed successfully. There was one patient died from pulmonary infection and the others recovered well.Blood pressure of left arms were lower than right postoperatively [(78 ± 17) mmHg vs. (126 ± 24) mmHg, 1 mmHg = 0.133 kPa, P < 0.01], but oxygen saturation, skin temperature and strength of the left hand were normal compared to the right. All the survived patients have been followed 1 - 27 months and none of them presented with any symptoms of left subclavian artery steal syndrome and ischemia of left arms. CONCLUSIONS: Ligation of LSA under strict evaluation of collateral circulation could be safe in Type A dissection patients with bad exposure due to big ascending aortic aneurysm and will simplify the procedure significantly.

[Reoperative valve replacement in patients undergoing cardiac reoperation: a report of 104 cases].

OBJECTIVE: To review the experience of reoperative valve replacement for 104 patients. METHODS: From January 2002 to December 2009, 104 patients underwent heart valve replacement in reoperations, accounting for 2.92% of the total patient population (3557 cases) who had valve replacement during this period. In this group, 53 male and 51 female patients were included with a median age of 46 years (ranged from 13 to 72 years). The reasons of reoperation included 28 cases suffered from another valve lesion after valve replacement, 10 cases suffered from valve lesion after mitral valvuloplasty, 19 cases suffered from perivalvular leakage after valve replacement, 18 cases suffered from valve lesion after previous correction of congenital heart defect, 7 cases suffered from bioprosthetic valve decline, 10 cases suffered from prosthetic valve endocarditis, 9 cases suffered from dysfunction of machine valve, and 3 cases suffered from other causes. The re-operations were mitral and aortic valve replacement in 2 cases, mitral valve replacement in 59 cases, aortic valve replacement in 24 cases, tricuspid valve replacement in 16 cases, and Bentall's operation in 3 cases. The interval from first operation to next operation was 1 month-19 years. RESULTS: There were 8 early deaths from heart failure, renal failure and multiple organ failure (early mortality 7.69%). Major complications were intraoperative hemorrhage in 2 cases, re-exploration for mediastinal bleeding in 2 cases and sternotomy surgical site infection in 1 case. Complete follow-up (3 months-7 years and 2 months) was available for all patients. Two patients died, one patient died of intracranial hemorrhage, and another cause was unknown. CONCLUSION: Satisfactory short-term and long-term results can be obtained in reoperative valve replacement with appropriate timing of operation control, satisfactory myocardial protection, accurate surgical procedure and suitable perioperative treatment.

[Surgical treatment of congenital quadricuspid aortic valve].

OBJECTIVE: To improve the understanding of congenital quadricuspid aortic valve (QAV), explore its echocardiographic diagnostic value and summarize the methods and outcomes of surgical treatments. METHODS: The clinical data of 11 QAV patients from January 2000 to December 2008 were retrospectively analyzed. There were 9 males and 2 females with a mean operative age of (32±16) years (range: 4-55). RESULTS: In 766 patients undergoing aortic valve surgery, 11 were of congenital quadricuspid aortic valve (1.4%); cardiac pathology: infective endocarditis (n=1), left superior vena cava (n=1), aortic aneurysm (n=1), mitral prolapse (n=1) and tricuspid insufficiency (n=1). The patients of congenital QAV deformity was diagnosed by echocardiography (n=7), misdiagnosed as single valve (n=1), misdiagnosed as bicuspid valve (n=1) and misdiagnosed as rheumatic heart disease (n=2). Type B (n=7), Type A (n=2), Type F (n=1) and Type G (n=1). Eleven patients underwent the procedure of aortic valve replacement. And the concomitant procedures were aortic root broadening (n=1), ascending aortoplasty (n=1), mitral valvuloplasty (n=1) and tricuspid valvuloplasty (n=1). CONCLUSION: Quadricuspid aortic valve is rare in clinical practice. And echocardiography plays an important diagnostic role. Surgical replacement of aortic valve is the first-line therapy for these patients.

Association of TNFAIP3 polymorphism with rheumatic heart disease in Chinese Han population.

In a pair-matched case-control study (239 versus 478) conducted in Chinese Han population, we investigated the association between tumor necrosis factor-alpha-induced protein 3 (TNFAIP3) gene, tumor necrosis factor receptor-associated factor 1 (TRAF1) gene, complement component 5 (C5) gene, and rheumatic heart disease (RHD). We observed no association with RHD for the five tagging single nucleotide polymorphisms (tSNP) in the C5 gene, the three tSNPs in the TNFAIP3 gene, or the two tSNPs in the TRAF1 gene. However, we determined that the tSNP, rs582757, located at intron_5 of the TNFAIP3 gene, associated with RHD in Chinese Han population. Both the distribution of genotype and allele frequencies differed significantly between case and control subjects (p = 0.001 and p = 0.0004, respectively). The minor C allele reduced the risk of RHD with a per-allele odds ratio of 0.57 (0.42-0.78) for the additive model in univariate analysis (p = 0.000). Under a dominant model, CC/CT carriers had a 0.54-fold reduced risk of RHD (95% confidence interval 0.38-0.75, p = 0.000) than TT carriers. Therefore, we report a new genetic variant (rs582757) in the TNFAIP3 gene that associated with the prevalence of RHD in Chinese Han population. Further genetic and functional studies are required to identify the etiological variants in linkage disequilibrium with this polymorphism.

[Evaluation of surgical technique and indication on descending aortic aneurysms].

OBJECTIVE: To evaluate the surgical technique and indication on descending aortic aneurysms. METHODS: From January 1996 to June 2006, 41 patients with descending aortic aneurysm underwent operation, including DeBakey type III dissection in 26, false aneurysm in 6, true aneurysm in 4, and residual or newly complicated type III dissection after the surgery of Marfan syndrome in 5. Operations were performed by left heart bypass in 9, femoral-femoral bypass in 7, pulmonary-femoral bypass in 2, and deep hypothermic circulatory arrest in 23. The whole thoracic descending aorta was replaced in 15, and intercostal arteries were reimplanted in 12. RESULTS: One patient died of acute renal failure with the hospital mortality 2.4%. Main complications: respiratory dysfunction in 6, renal dysfunction in 6, recurrent nerve injuries in 4, chylothorax in 2, and no paraplegia. CONCLUSIONS: Surgical intervention of descending aortic aneurysm still has its unique advantages and indications; surgical safety is markedly improved by the use of deep hypothermic circulatory arrest.

Defective expression of transforming growth factor beta type II receptor (TGFBR2) in the large cell variant of non-small cell lung carcinoma.

Large cell carcinoma (LCC) of the lung is defined as an undifferentiated carcinoma without the characteristic features of squamous cell (SqC), small cell, or adenocarcinomas (AdC). In the present study, the expression level of the important tumor suppressor, transforming growth factor beta type II receptor (TGFBR2), was examined both in LCC and non-LCC tumors, which include AdC, SqC and adenosquamous carcinoma (Ad-SqC). Immunohistochemical staining with TGFBR2 antibody revealed statistically significant or near significant differences in the reduced expression in LCC (80% of cases) versus AdC (42.1% of cases, P=0.0288) and SqC (47.1% of cases, P=0.0589), or LCC versus non-LCC (45% of cases, P=0.02). The differences in the expression level of TGFBR2 between LCC and non-LCC were consistent with the histopathologic classification of these tumors, suggesting that the defective TGFBR2 expression might contribute to the carcinogenesis and/or development of LCC.

[Impact of different brain protection techniques upon postoperative temporary neurological dysfunction in aortic surgery with the aid of deep hypothermic circulatory arrest].

OBJECTIVE: To assess impact of different brain protection techniques upon postoperative temporary neurological dysfunction in aortic surgery with the aid of deep hypothermic circulatory arrest. METHODS: From January 2003 to December 2005, 78 patients who met the inclusion criteria entered the present cohort, 43 of whom were under the aid of deep hypothermic circulatory arrest plus retrograde cerebral perfusion (RCP group) and the other 35 under deep hypothermic circulatory arrest plus selective antegrade cerebral perfusion (SCP group). The present and grades of postoperative temporary neurological dysfunction were assessed by independent observers with the same criterion. The impact of duration of deep hypothermic circulatory arrest upon the postoperative temporary neurological dysfunction was also evaluated. RESULTS: The incidence of postoperative temporary neurological dysfunction was significantly higher in the RCP group than in the SCP group (15, 34.9% vs. 4, 11.4%, P<0.05). And long duration of deep hypothermic circulatory arrest (more than 50 min) has a negative impact on the postoperative temporary neurological dysfunction rate. CONCLUSIONS: Applying selective antegrade cerebral perfusion as the brain protection technique and shortening the duration of deep hypothermic circulatory arrest can reduce the incidence of temporary neurological dysfunction and preserve cerebral function more effectively.

Novel microdeletion in the transforming growth factor beta type II receptor gene is associated with giant and large cell variants of nonsmall cell lung carcinoma.

Mutations in the tumor suppressor gene transforming growth factor beta (TGFB) Type II receptor (TGFBR2) are frequently found in many cancers with microsatellite instability, but are less common in lung cancer. In the present study, we looked for mutations in TGFBR2 in nonsmall cell lung carcinoma (NSCLC) cells and tissues. A novel homozygous microdeletion (c.492_507del) was identified in two cell lines derived from the same giant cell carcinoma (GCC) and was confirmed in the corresponding tumor tissues. Furthermore, a heterozygous c.492_507del was found in the germ-line of one patient, as well as in the other GCC cases and some large cell carcinomas (LCC) but not in other subtypes of NSCLC. The 16 bp-microdeletion introduced a premature stop codon at positions 590-592 of the cDNA, resulting in a truncated TGFBR2 protein with a mutated transmembrane domain and loss of kinase domain. The GCC cells were characterized as being unresponsive to TGFB induction both in growth inhibition and stimulation of extracellular matrix protein. Moreover, after the reconstitution of wild-type TGFBR2 expression, the sensitivity to TGFB was restored. Therefore, mutated TGFBR2 seems to play an important role in the abrogation of TGFB signal transduction in GCC cells.

[Surgical interventions for complex native valve endocarditis].

OBJECTIVE: To elucidate the early and long-term results of surgical treatment for complex infective endocarditis with prosthetic valve replacement. METHODS: Fifty-seven patients of complex native valve endocarditis, including 25 cases of aortic valve, 16 of mitral valve and 16 of double valves, who underwent operative interventions with prosthetic valve replacement between December 1988 and June 2002, were analyzed retrospectively. Intraoperative findings demonstrated aortic annular abscesses (n = 19), root abscesses (n = 4), mitral posterior annular abscesses (n = 11), myocardial abscesses (n = 6), massive leaflet destruction (n = 32) and valvular vegetations (n = 55). Complex reconstruction of the aortic and mitral annulus was required in 35 patients. Associated procedures included Bentall's procedure (n = 4), aortic valve replacement (n = 21), mitral valve replacement (n = 16) and double valve replacements (n = 16). RESULTS: The operative mortality was 11%. Complications included low cardiac output syndrome, recurrence of endocarditis, multiple organ failure, ventricular arrhythmia, bleeding, mediastinal infection, respiratory insufficiency and heart block. Follow-up was 100% complete at a mean of 5.93 years. There were five late deaths (3 prosthetic valve endocarditis, 2 valve-related). The NYHA functional status recovered to Class I in 17 patients, Class II in 27 and Class III in 2 at 1 year follow-up. Kaplan-Meier analysis showed the 5-year actuarial freedom from reoperation was (84 +/- 3)%, and actuarial survivorship at 5 years was (61 +/- 9)%. CONCLUSIONS: Urgent or even emergency operation is advocated for complex infective endocarditis. Proper intraoperative reconstruction of the aortic and mitral annulus and optimized perioperative management, especially the strategy for prevention of recurrent endocarditis, are of great importance in achieving satisfied early and long-term clinical outcomes.