Total thoracoscopic repair of ventricular septal defect: A single-center experience.

OBJECTIVES: To explore the safety and efficacy of total thoracoscopic repair of ventricular septal defects (VSD). We compared clinical outcomes of VSD via a total thoracoscopic approach with those of mini-sternotomy. METHODS: We retrospectively reviewed clinical data from patients with VSD from 2012 to January 2019. According to the surgical pattern, they were divided into two groups: the total thoracoscopic surgery group (36 patients, 27 females, aged 29 ± 9.52 years), and a mini-sternotomy group (31 patients, 12 females, aged 28 ± 8.67 years). RESULTS: There were no deaths in either group. In the thoracoscopic group, cardiopulmonary bypass (CPB) time and aortic cross-clamping (ACC) time were significantly longer than those of the mini-sternotomy group (CPB time: 112 ± 23.16 min vs. 78 ± 37.90 min, respectively, p < .001; ACC time: 65 ± 19.94 min vs. 50 ± 24.90 min, respectively, p < .001). postoperative hospital stay time (5.11 ± 2.48 days vs. 5.90 ± 6.27 days, p = .488) and chest drainage (139.86 ± 111.71 ml vs. 196.13 ± 147.34 ml, p = .081) tended to be lower in the thoracoscopy group, although there was no significant difference. No residual shunt or tricuspid regurgitation was found at follow-up. CONCLUSIONS: Total thoracoscopic repair is safe and effective in patients with VSD, with or without tricuspid regurgitation.

Outcomes of redo-isolated tricuspid valve surgery after left-sided valve surgery.

OBJECTIVES: To compare early and long-term outcomes of redo-isolated tricuspid surgery (RITS) after left-sided valve surgery. METHODS: We retrospectively reviewed 173 patients who underwent RITS for severe tricuspid regurgitation after previous left-sided valve surgery from January 1999 to December 2019. Patients were divided into two groups: RITS by median sternotomy (m-RITS; n = 78) and totally endoscopic approach (e-RITS; n = 95). Perioperative outcomes and follow-up results were analyzed. RESULTS: There were 19 (11%) in-hospital deaths (14.1% in m-RITS and 8.4% in e-RITS, p = .234) that decreased from 16.7% (1999-2014) to 6.9% (2015-2019) (p = .044). Tricuspid valve replacement (odds ratio [OR] = 4.989, 95% confidence interval [CI]: 1.133-29.790, p = .041) and NYHA function class IV (OR = 9.611, 95% CI: 2.102-43.954, p = .004) were independent risk factors for in-hospital mortality. The overall 1-, 5-, 10-, and 15-year survival rates were 97.2% (95% CI: 94.5%-99.9%), 80.3% (95% CI: 71.7%-88.9%), 59.2% (95% CI: 43.5%-75.5%), and 49.3% (95% CI: 27.2%-71.4%), respectively. CONCLUSION: Patients undergoing RITS carry a high risk of early mortality. There was no significant difference in early mortality or long-term survival between the endoscopy and median sternotomy, whereas the endoscopy approach was associated with shorter intensive care unit stays and fewer reoperations. Repair resulted in lower surgical mortality than replacement with acceptable residual tricuspid regurgitation.

Modified unicaval drainage in reoperative isolated tricuspid valve repair via totally thoracoscopic approach.

AIM: The aim of this study was to investigate the feasibility, safety, and clinical effect of modified unicaval drainage for thoracoscopic reoperative isolated tricuspid valve repair, compared with conventional bicaval drainage. METHODS: A total of 45 consecutive cases of patients who underwent thoracoscopic reoperative isolated tricuspid valve repair on beating-heart were enrolled and divided into two groups according to the different venous drainage (Group A: modified unicaval drainage, Group B: conventional bicaval drainage). A retrospective analysis of perioperative data and clinical outcomes were performed and all the surviving cases were followed up. Re-evaluation of echocardiography and electrocardiogram was performed prior to discharge, and at first month, sixth month, and every year follow-up. RESULTS: The overall postoperative 30-day mortality was 4.5% in Group A and 8.7% in Group B. The postoperative tricuspid valve regurgitation grade of both groups decreased significantly from preoperative regurgitation grade, p < 0.001, without intergroup significant difference, p = 0.815. Follow-up duration ranged from 6 to 38 months, there was one death at 24 months in Group A, and another at 9 months in Group B, respectively. Nobody from both groups experienced reintervention for residual tricuspid regurgitation. No significant difference could be identified about the incidence of postoperative morbidities and follow-up adverse events. CONCLUSION: Both strategies of caval venous drainage can provide satisfactory exposure for thoracoscopic reoperative isolated tricuspid valve repair and equivalent favorable postoperative outcome. And the modified unicaval drainage group may even preserve the anesthetic time and decrease the risk of iatrogenic jugular injury, achieving a more simplified procedure with better cosmetic outcome.

Intraoperative Implantation of Temporary Endocardial Pacing Catheter During Thoracoscopic Redo Tricuspid Surgery.

BACKGROUND: The placement of a temporary epicardial pacing wire is a challenge during a minimally invasive redo cardiac operation. The aim of this study is to assess the application of temporary endocardial pacing in patients who underwent minimally invasive redo tricuspid surgery. METHODS: Perioperative data of consecutive patients who underwent thoracoscopic redo tricuspid surgery were collected. All the tricuspid surgeries and combined procedures were performed under peripheral cardiopulmonary bypass without aortic cross-clamping. A sheath was introduced into the right jugular vein beside the percutaneous superior vena cava cannula and a temporary endocardial pacing catheter was guided into the right ventricle via the sheath prior to the right atrial closure. The pacemaker was connected and run as needed during or after operation. RESULTS: A total of 33 patients who underwent thoracoscopic redo tricuspid surgery were enrolled. Symptomatic tricuspid valve regurgitation (93.9%) and tricuspid valvular prosthesis obstruction (6.1%) after previous cardiac operations were noted as indications for a redo surgery. The mean time from previous cardiac operation to this time redo surgery was 13.3±6.4years. Isolated tricuspid valve replacement was performed in 18 patients (54.5%) and tricuspid valve plasty combined with or without mitral valve replacement was performed in 15 patients (45.5%). A temporary endocardial pacing catheter was successfully placed in the right ventricle for all patients with good sensing and pacing. No temporary pacing related complications occurred from insertion to removal of pacing catheter in the patients. CONCLUSIONS: This application of temporary endocardial pacing provided a safe and effective substitute for epicardial pacing in patients who underwent minimally invasive redo tricuspid surgery.

Characteristics, Mechanism and Long-Term Ablation Outcome of Atrial Tachycardias After Mitral Valvular Surgery and Concomitant Cox-MAZE IV Procedure.

The incidence of atrial tachycardia (AT) after rheumatic mitral valvular (RMV) surgery has been well described. However, there have been few reports on the characteristics, mechanism, and long-term ablation outcome of ATs after RMV surgery and concomitant Cox-MAZE IV procedure.The present study reviewed consecutive patients who underwent AT ablation between May 2008 and July 2013. All patients were refractory to antiarrhythmic drugs (AADs) and had a history of RMV surgery and Cox-MAZE IV procedure. A total of 34 patients underwent AT ablation after RMV surgery and concomitant Cox-MAZE IV procedure, and presented 57 mappable and 2 unmappable ATs. The 57 mappable ATs included 14 focal-ATs and 43 reentry-ATs. Ten of the 14 focal-like ATs were located at the pulmonary vein (PV) antrum and border of a box lesion. Of the 43 reentry-ATs, 16 were marco-reentrant around the mitral annulus (MA) and 16 around the tricuspid annulus. There were 41 atypical ATs (non-cavotricuspid isthmus related) including 16 ATs related to the box lesion and 21 ATs related to other Cox-MAZE IV lesions. The AT were successfully terminated in 33 (97.1%) patients. After mean follow-up of 46.9 ± 15.7 months, 25 (73.5%) patients maintained sinus rhythm without AADs after a single procedure and 28 (82.4%) patients after repeated procedures.The recurrent ATs after RMV surgery and concomitant Cox-MAZE IV were mainly reentry mechanism, and largely related to LA. An incomplete lesion or re-conductive gaps in a prior lesion might be the predominant mechanisms for these ATs. Catheter-based mapping and ablation of these ATs seems to be effective and safe during a long-term follow-up.

Bilateral subclavian vein sheaths for superior vena cava drainage during thoracoscopic repair of atrial septal defects: cosmetic outcomes, safety and effectiveness.

OBJECTIVE: To investigate the cosmetic outcomes, safety and effectiveness of using bilateral subclavian vein sheaths for superior vena cava drainage during thoracoscopic repair of atrial septal defects. METHODS: Sixty-one consecutive adults scheduled for thoracoscopic repair of atrial septal defects between July 2012 and June 2013 were randomized into two groups: one group underwent placement of a 16 Fr percutaneous superior vena cava cannula (n = 30) and the other group underwent placement of bilateral 8 Fr subclavian vein sheaths (n = 31) for superior vena cava drainage during peripheral cardiopulmonary bypass. The perioperative data, central venous pressure during cardiopulmonary bypass, complications and the patient satisfaction scale scores for the incisions were compared between the two groups. RESULTS: The theoretical cardiopulmonary bypass flow rate was reached without complications in all patients. The average central venous pressure during cardiopulmonary bypass was not significantly different between the two groups [(6.9 ± 3.1) mmHg vs. (7.0 ± 3.5) mmHg, p=0.92]. The patient satisfaction scale scores for the incisions were significantly higher in the patients who underwent placement of bilateral subclavian vein sheaths than in the patients who underwent placement of a percutaneous superior vena cava cannula [(2.81 ± 0.75) vs. (2.07 ± 0.74), p<0.001]. CONCLUSIONS: Placement of bilateral subclavian vein sheaths is a safe and effective alternative to placement of a percutaneous superior vena cava cannula for superior vena cava drainage during thoracoscopic repair of atrial septal defects and results in greater patient satisfaction with the cosmetic outcome.

Transesophageal echocardiography for coronary sinus imaging in partially unroofed coronary sinus.

BACKGROUND: Partially unroofed coronary sinus (PUCS) is a rare congenital cardiac anomaly and prone to be misdiagnosed. The purpose of this study was to explore the value of transesophageal echocardiography (TEE) in CS imaging for the detection of PUCS and to develop a special two-dimensional TEE-based en face view of CS. METHODS: Twenty adult patients with suspected PUCS, showing a dilated coronary sinus and an enlarged right heart on transthoracic echocardiography (TTE), underwent TEE examination. In the mid-esophageal plane and close to an angle of 120°, the en face view of the CS successfully imaged the roof of the CS, which was beyond the realm of the atrial septum, and the interatrial septum was obtained simultaneously in the same view. Meanwhile, the 3D zoom mode could clearly display the comprehensive volume image and the adjacent structures of the PUCS. The results of TEE were compared with the findings of surgery or catheterization. RESULTS: En face view of the CS was obtained successfully by 2DTEE in 20 patients. In addition, 3DTEE was used for imaging of PUCS in 11 of the 20 patients. PUCS was ultimately confirmed in 13 patients either by surgery or catheterization. The TEE for PUCS diagnosis was consistent with the surgical findings. CONCLUSION: Transesophageal echocardiography can be successfully applied to obtain the comprehensive view of CS and its surrounding structures. The en face view of CS provided by 2DTEE may be helpful in better understanding PUCS and discriminating it from associated atrial septal defects.

IP3R2-mediated Ca2+ release promotes LPS-induced cardiomyocyte pyroptosis via the activation of NLRP3/Caspase-1/GSDMD pathway.

Pyroptosis plays a crucial role in sepsis, and the abnormal handling of myocyte calcium (Ca2+) has been associated with cardiomyocyte pyroptosis. Specifically, the inositol 1,4,5-trisphosphate receptor type 2 (IP3R2) is a Ca2+ release channel in the endoplasmic reticulum (ER). However, the specific role of IP3R2 in sepsis-induced cardiomyopathy (SIC) has not yet been determined. Thus, this study aimed to investigate the underlying mechanism by which IP3R2 channel-mediated Ca2+ signaling contributes to lipopolysaccharide (LPS)-induced cardiac pyroptosis. The SIC model was established in rats by intraperitoneal injection of LPS (10 mg/kg). Cardiac dysfunction was assessed using echocardiography, and the protein expression of relevant signaling pathways was analyzed using ELISA, RT-qPCR, and western blot. Small interfering RNAs (siRNA) and an inhibitor were used to explore the role of IP3R2 in neonatal rat cardiomyocytes (NRCMs) stimulated by LPS in vitro. LPS-induced NLRP3 overexpression and GSDMD-mediated pyroptosis in the rats' heart. Treatment with the NLRP3 inhibitor MCC950 alleviated LPS-induced cardiomyocyte pyroptosis. Furthermore, LPS increased ATP-induced intracellular Ca2+ release and IP3R2 expression in NRCMs. Inhibiting IP3R activity with xestospongin C (XeC) or knocking down IP3R2 reversed LPS-induced intracellular Ca2+ release. Additionally, inhibiting IP3R2 reversed LPS-induced pyroptosis by suppressing the NLRP3/Caspase-1/GSDMD pathway. We also found that ER stress and IP3R2-mediated Ca2+ release mutually regulated each other, contributing to cardiomyocyte pyroptosis. IP3R2 promotes NLRP3-mediated pyroptosis by regulating ER Ca2+ release, and the mutual regulation of IP3R2 and ER stress further promotes LPS-induced pyroptosis in cardiomyocytes.

Matrine inhibits disturbed flow-enhanced migration via downregulation of ERK1/2-MLCK signaling vascular smooth muscle cells.

BACKGROUND: To investigate the effects of matrine on the vascular smooth muscle cell (VSMC) migration modulated by disturbed flow and their underlying molecular mechanisms in vitro. METHODS: Isolated rat aortic VSMCs were grown to confluence on 20- × 80-mm fibronectin-coated glass cover slides, and then, denuded zones were made at the position calculated to be the oscillating flow-reattachment zone and also in the downstream laminar flow region. VSMCs were treated with different doses of matrine (0, 10, 20, 30, and 40 mg/L), or PD98059 (30 µM), ML-7 (10 µM) combined with matrine (40 mg/L) for 30 minutes before and during the experiments. Then, the wounded monolayers were kept under static conditions or were subjected to laminar or disturbed flow for 21 hours or 10 hours. The VSMC migration was assessed by microscopic images. The extracellular signal-regulated kinase 1/2 (ERK1/2) and myosin light chain kinase (MLCK) proteins were determined by Western blot. RESULTS: Disturbed flow significantly increased phosphorylation of ERK1/2. Selective inhibition of ERK1/2 phosphorylation by inhibitor PD98059 and matrine significantly suppressed VSMC migration under disturbed flow. Disturbed flow significantly enhanced phosphorylation of MLCK, whereas both matrine and PD98059 inhibited the phosphorylation of MLCK under disturbed flow. The complete inhibition of MLCK phosphorylation using the selective MLCK inhibitor ML-7 significantly inhibited VSMC migration under disturbed flow. CONCLUSION: Matrine inhibits VSMC migration under disturbed flow, in part, by downregulation of ERK1/2-MLCK signaling pathway.

Mettl3-mediated m6A modification of Fgf16 restricts cardiomyocyte proliferation during heart regeneration.

Cardiovascular disease is the leading cause of death worldwide due to the inability of adult heart to regenerate after injury. N6-methyladenosine (m6A) methylation catalyzed by the enzyme methyltransferase-like 3 (Mettl3) plays an important role in various physiological and pathological bioprocesses. However, the role of m6A in heart regeneration remains largely unclear. To study m6A function in heart regeneration, we modulated Mettl3 expression in vitro and in vivo. Knockdown of Mettl3 significantly increased the proliferation of cardiomyocytes and accelerated heart regeneration following heart injury in neonatal and adult mice. However, Mettl3 overexpression decreased cardiomyocyte proliferation and suppressed heart regeneration in postnatal mice. Conjoint analysis of methylated RNA immunoprecipitation sequencing (MeRIP-seq) and RNA-seq identified Fgf16 as a downstream target of Mettl3-mediated m6A modification during postnatal heart regeneration. RIP-qPCR and luciferase reporter assays revealed that Mettl3 negatively regulates Fgf16 mRNA expression in an m6A-Ythdf2-dependent manner. The silencing of Fgf16 suppressed the proliferation of cardiomyocytes. However, the overexpression of ΔFgf16, in which the m6A consensus sequence was mutated, significantly increased cardiomyocyte proliferation and accelerated heart regeneration in postnatal mice compared with wild-type Fgf16. Our data demonstrate that Mettl3 post-transcriptionally reduces Fgf16 mRNA levels through an m6A-Ythdf2-dependen pathway, thereby controlling cardiomyocyte proliferation and heart regeneration.

Cardiovascular diseases are one of the world's biggest killers. Even for patients who survive a heart attack, recovery can be difficult. This is because ­ unlike some amphibians and fish ­ humans lack the ability to produce enough new heart muscle cells to replace damaged tissue after a heart injury. In other words, the human heart cannot repair itself. Molecules known as messenger RNA (mRNA) carry the 'instructions' from the DNA inside the cell nucleus to its protein-making machinery in the cytoplasm of the cell. These messenger molecules can also be altered by different enzymes that attach or remove chemical groups. These modifications can change the stability of the mRNA, or even 'silence' it altogether by stopping it from interacting with the protein-making machinery, thus halting production of the protein it encodes. For example, a protein called Mettl3 can attach a methyl group to a specific part of the mRNA, causing a reversible mRNA modification known as m⁶A. This type of alteration has been shown to play a role in many conditions, including heart disease, but it has been unclear whether m⁶A could also be important for the regeneration of heart tissue. To find out more, Jiang, Liu, Chen et al. studied heart injury in mice of various ages. Newborn mice can regenerate their heart muscle for a short time, but adult mice lack this ability, which makes them a useful model to study heart disease. Analyses of the proteins and mRNAs in mouse heart cells confirmed that both Mettl3 and m⁶A-modified mRNAs were present. The amount of each also increased with age. Next, experiments in genetically manipulated mice revealed that removing Mettl3 greatly improved tissue repair after heart injury in both newborn and adult mice. In contrast, mouse hearts that produced abnormally high quantities of Mettl3 were unable to regenerate ­ even if the mice were young. Moreover, a detailed analysis of gene activity revealed that Mettl3 was suppressing heart regeneration by decreasing the production of a growth-promoting protein called FGF16. These results reveal a key biological mechanism controlling the heart's ability to repair itself after injury. In the future, Jiang et al. hope that Mettl3 can be harnessed for new, effective therapies to promote heart regeneration in patients suffering from heart disease.

Endoscopic repeat isolated tricuspid valve surgery after left-sided valve replacement: valvuloplasty or replacement.

BACKGROUND: The strategy of isolated tricuspid valve surgery has undergone innovations in recent years. This study aimed to summarize our experience using an endoscopic approach to repeat isolated tricuspid valve surgery (RITS) after left-sided valve replacement (LSVR). METHODS: From June 2013 to May 2019, 79 patients underwent endoscopic RITS after LSVR at our institution. Patients were divided into the tricuspid valvuloplasty (TVP) group (N.=49) and the tricuspid valve replacement (TVR) group (N.=30); perioperative outcomes and follow-up results were compared. RESULTS: There were seven postoperative deaths (8.9%). In-hospital mortality was higher in the TVR group than in the TVP group, although this difference was not statistically significant (13.3% vs. 6.1%, P=0.417). More patients experienced residual moderate-to-severe tricuspid regurgitation (TR) at discharge in the TVP group than in the TVR group (26.7% vs. 0%, P=0.003). Five patients died from heart, and multiorgan failure during follow-up; the overall 3- and 5-year survival rates were 93.8% [95% confidence interval (CI): (87.1-99.9%)] and 85.3% (95% CI: 73.3-99.2%), respectively, and no significant differences were found between the two groups (P=0.103). The overall rates of the 3- and 5-year freedom from severe recurrent TR were 93.2% (95% CI: 85.9-99.9%) and 89.0% (78.7-99.9%), respectively, and no significant difference was found between groups (P=0.176). CONCLUSIONS: Repeat isolated tricuspid valve surgery after left-sided valve replacement is associated with adverse perioperative outcomes. Endoscopic access offers an alternative approach for RITS after LSVR with acceptable results. TVP results in lower surgical mortality than TVR while carrying a higher risk of residual moderate-to-severe TR.

Early outcomes of mitral valvuloplasty by minimally invasive surgery or sternotomy.

BACKGROUND: Disagreement exists regarding methods for repair of the mitral valve. We compared early outcomes of mitral valvuloplasty by a minimally invasive technique and by a median sternotomy. METHODS: The data of 507 patients (mean age 47.9 ± 15.2 years) undergoing mitral valvuloplasty from January 2015 to June 2018 were analyzed retrospectively. In the study group (n = 225), mitral valvuloplasty via a totally thoracoscopic approach was performed by a single surgeon. In the control group (n = 282), mitral valvuloplasty via the traditional median sternotomy was carried out by other cardiac surgeons in our hospital. Clinical data, surgical results, and follow-up findings in the two groups were comparatively analyzed. RESULTS: In the study group, the blood transfusion rate (5.3% vs. 20.9%, p < 0.05) and incidences of poor wound healing (0 vs. 5.3%, p < 0.05) and respiratory tract infection (4.4% vs. 16.3%, p < 0.05) were lower, and postoperative hospitalization was shorter (5.9 ± 4.0 vs. 10.7 ± 8.4 days, p < 0.05). Within 30 days after surgery, no patient died in the study group while one died in the control group. The duration of follow-up was 12-36 months (mean 22.9 ± 8.8 months). During follow-up, there were 1 and 0 cases of redo surgery and 1 and 3 deaths in the study group and control group, respectively. CONCLUSION: Mitral valvuloplasty via a minimally invasive approach is superior to the traditional median sternotomy in terms of early outcomes, especially when performed by experienced surgeons.

The short-term pulsatile ventricular assist device for postcardiotomy cardiogenic shock: a clinical trial in China.

Despite the recent advances in myocardial protection, surgical techniques, intra-aortic balloon therapy, and maximal pharmacological support, postoperative ventricular dysfunction continues to occur in 0.5-1.0% of all patients undergoing cardiac surgery. Ventricular assist device (VAD) is an important therapeutic adjunct in treating patients with profound ventricular dysfunction with postcardiotomy cardiogenic shock. The purpose of this report was to describe the clinical results with the China-made Luo-Ye VAD as a short-term circulatory support. From May 1998 to December 2006, 17 patients with postcardiotomy cardiogenic shock were supported by the Luo-Ye VAD. Of these patients, 10 were males and seven were females with a mean age of 49.6 years (range 36-68 years). All cases were supported by left VAD (LVAD). Mean duration of support was 46.3 h (range 13-113 h). A criteria of insertion was established to standardize implantation criteria. Among the 17 patients treated with LVAD, eight (47.1%) patients were weaned from support and seven (41.2%) patients were discharged from hospital. Ten (58.8%) patients died while on LVAD support (nine cases) or shortly after weaning (one case). The causes of death in the entire group were cardiac (40%), renal failure (20%), neurologic (10%), sepsis (10%), and multiple organ system failure (20%). The complications were represented by bleeding, renal failure, neurologic event, infection, ventricular arrhythmias, etc. The Luo-Ye VAD functioned well and proved to be useful in patients with postcardiotomy cardiogenic shock. It carries a less-postoperative anticoagulant and a low incidence of VAD-related complications. The survival rate was encouraging in our small cohort of patients.

A comparative study of three-dimensional high-definition and two-dimensional high-definition video systems in totally endoscopic mitral valve replacement.

BACKGROUND: Three-dimensional vision with improved depth perception and spatial orientation has already proved its superiority to the two-dimensional vision in endoscopic surgery. However, those benefits remain unidentified in cardiac surgery. For the first time, we compare performance of a three-dimensional high-definition video system with a two-dimensional high-definition video system in patients undergoing totally endoscopic mitral valve replacement. METHODS: We enrolled 90 patients with mitral valve disease in a single institution, from June 2013 to June 2016. Totally endoscopic mitral valve replacement was performed by the same surgeon using either a three-dimensional high-definition (n=43) or a two-dimensional high-definition (n=47) video system with the same surgical technique. Short-term outcomes were compared between the two groups. All medical records were retrieved from a prospectively maintained database of minimally invasive cardiac surgery. RESULTS: All surgeries were successfully completed under totally endoscopic guidance. There were no intraoperative complications in either group. The use of three-dimensional video system reduced aortic cross-clamp time by approximately 10% (3D vs. 2D: 65.74±14.32 vs. 72.67±14.67 min, P=0.027). No significant differences were observed in cardiopulmonary bypass time, postoperative ventilation duration, length of surgical intensive care unit stay, length of hospital stay, and major complications between the two groups. There were no perioperative deaths in either group. CONCLUSIONS: Compared with the two-dimensional video system, the three-dimensional high-definition video system provided a better surgical experience with the same operative safety for totally endoscopic mitral valve replacement.

Mitral valve replacement via minimally invasive totally thoracoscopic surgery versus traditional median sternotomy: a propensity score matched comparative study.

BACKGROUND: To compare surgical outcomes after mitral valve replacement via either minimally invasive thoracoscopic (MIs) or traditional median sternotomy (MS) surgery and determine the short- and mid-term clinical outcomes of the MI approach. METHODS: All patients who received either MIs (n=405) or MS (n=691) mitral valve replacement surgery at the Guangdong Cardiovascular Institute between January 2012 and July 2015 were analyzed for outcome differences due to surgical approach using propensity score matching. The best 202 matches from the MI group and the MS group were analyzed. The clinical data of the two groups were collected, including preoperative cardiac function, operative data, postoperative complications, and follow-up. RESULTS: A final total of 404 patients were included in this study after propensity score matching; the MIs group and the MS group each contained 202 patients. The two groups were similar in age, weight, pathological changes, and surgical approach. Compared with the MS group, the MIs group had a longer cardiopulmonary bypass time (P<0.001), aortic cross-clamping time (P<0.001), and total procedure time (P<0.001). There were no significant differences between the groups regarding in-hospital mortality, stroke, pneumonia, acute renal failure, arrhythmia, and chylothorax. The MS group had significantly more patients with poor wound healing than the MIs group (P=0.004). The MI group had a lower rate of transfusion (P=0.037), shorter ventilation time (P=0.041), shorter ICU stay (P=0.033), reduced chest tube drainage and length of chest tube stay (P<0.001), and shorter hospital stay (P<0.001). There was no significant difference between the groups in hospital re-admission for bleeding, but the total hospitalization cost was higher in the MIs group (P=0.002). The mean follow-up was 26.59±12.33 months, the 1-year postoperative survival rate was 98.86%, and the overall survival rate was 97.44%. Compared with the MS group, the MIs group recovered earlier (P<0.05), and returned to work or study earlier (P<0.05). More patients in the MIs group were satisfied with the wound (P<0.001). The MS group had a higher incidence of postoperative osteomyelitis than the MIs group (P=0.028). There were no significant differences between groups in rates of mortality, stroke, pacemaker, reoperation, or 36-item Short Form Health Survey score. CONCLUSIONS: Compared with the MS approach, the MIs method of mitral valve replacement has longer cardiopulmonary bypass time and aortic cross-clamp time; however, it does not increase the risk of mortality and complications. Furthermore, MIs causes less trauma, fewer transfusions, less wound infection, faster recovery, faster return to work or study, and greater satisfaction with the incision in the mid-term. MI cardiac surgery is safe, effective, and feasible.

Tricuspid leaflet resection in an open beating heart for the creation of a canine tricuspid regurgitation model.

OBJECTIVES: Outcomes of tricuspid valve replacement are poor, partly due to right heart remodelling. The research on its underlying mechanisms is hampered by a lack of animal models of tricuspid regurgitation (TR). Our objective was to create a reproducible and clinically compatible TR animal model to study right heart remodelling caused by TR. METHODS: Fourteen juvenile male Beagle dogs were divided randomly into an intervention group (n = 11) and a sham-operated control group (n = 3). The intervention group underwent thoracotomy and right atrial incision following superior and inferior vena caval occlusion. The anterior leaflet, together with the chordae, of the tricuspid valve was resected in eight dogs ('one leaflet' group), whereas both anterior and posterior leaflets, together with the chordae, were resected in three dogs ('two leaflets' group). The right atrium and chest were then closed. The control group underwent the same procedure, except leaflet resection. One dog from the 'two leaflets' group and one control dog were sacrificed and autopsy was performed at 12 months post-surgery. RESULTS: All dogs survived over the 1-year observation period postoperatively. TR grade IV occurred immediately postoperatively in the 'one leaflet' group, and TR grade IV plus in the 'two leaflets' group. The overall procedure lasted 30-40 min, and the mean time of vena caval occlusion was 87 ± 10 s. Central venous pressure increased from 6 ± 1.2 at baseline to 13 ± 1.7 mmHg (P < 0.01). By 12 months after TR creation, both in the 'one leaflet' group and in the 'two leaflets' group, the right atrial area, tricuspid annular diameter and right ventricular index of myocardial performance increased significantly, right ventricular fractional area change and tricuspid annular plane systolic excursion decreased significantly. Autopsy of the intervention dog revealed oedema, ascites and cirrhosis. CONCLUSIONS: Our surgical technique to create a TR animal model was reproducible with high success and survival rates. This animal model would prove suitable to investigate the mechanisms of right heart remodelling.

Five-year epidemiological survey of valvular heart disease: changes in morbidity, etiological spectrum and management in a cardiovascular center of Southern China.

OBJECTIVE: The objective of the present study is to analyze the epidemiological profile of patients with abnormal valvular structure and function and highlight the etiological spectrum and management of valvular heart disease (VHD) in a single cardiovascular center of Southern China in five years. METHODS: The retrospective study included 19,428 consecutive patients (9,441 men and 9,987 women with a mean age of 52.03±20.50 years) with abnormal valvular structure and function who were screened by transthoracic echocardiography (TTE) or transesophageal echocardiography (TEE) at the in-patient department of Guangdong General Hospital from January 2009 to December 2013. Data on baseline characteristics, potential etiology, treatment strategies and discharge outcomes were collected from electronic medical records. RESULTS: There were 13,549 (69.7%) patients with relatively definite etiology for VHD. VHD was rheumatic in 7,197 (37.0%) patients, congenital in 2,697 (13.9%), degenerative in 2,241 (11.5%), ischemic in 2,460 (12.7%). The prevalence decreased significantly in rheumatic VHD from 2009 to 2013 (from 42.8% to 32.8%, P<0.001), but increased markedly in congenital VHD (from 9.0% to 12.3%, P<0.001), ischemic VHD (from 9.2% to 11.3%, P=0.003) and degenerative VHD (from 8.8% to 14.5%, P<0.001). Meantime, the prevalence of ischemic VHD increased after the age of 45, similar to that of degenerative VHD. From 2009 to 2013, the proportion of patients with VHD undergoing open cardiac valvular surgery decreased (from 49.5% to 44.3%, P<0.001) and that of patients treated with general medication increased (from 49.2% to 54.1%, P<0.001). However, there was markedly increment in video-assisted thoracoscopic surgery (VATS) from 2009 to 2013 (from 0.3% to 4.4%, P<0.001). Increasing tendencies were showed in aortic mechanical valve replacement (from 32.1% to 34.5%, P=0.001) and double mechanical valve replacement (from 20.9% to 22.3%, P=0.035), especially in mitral valvuloplasty (from 8.5% to 15.7%, P<0.001). However, the proportion of patients undergoing bioprosthetic valve replacement decreased from 2009 to 2013 (from 26.3% to 15.5%, P<0.001). CONCLUSIONS: Despite a significant shift from rheumatic towards degenerative etiology from 2009 to 2013, rheumatic VHD remains the leading etiology in Southern China, with a significant increase in the prevalence of ischemic, congenital and degenerative VHD. General medication and cardiac valvular surgery remain the main treatment options. The proportion of VATS increased markedly from 2009 to 2013, and mechanical valve replacement and mitral valvuloplasty showed an increasing tendency.

Real-time three-dimensional transesophageal echocardiography to predict artificial chordae length for mitral valve repair.

BACKGROUND: Artificial chordae replacement is an effective technique for mitral valve repair, however, it is difficult to accurately determine the length of artificial chordae. This study aimed to assess the reliability and accuracy of real-time three-dimensional transesophageal echocardiography (TEE) to predict the length of artificial chordae preoperatively. METHODS: From December 2008 to December 2010, 48 patients with severe mitral regurgitation successfully underwent mitral valve repair using artificial chordae replacement. The patients were divided into a TEE pre-measurement group (n = 26) and a direct measurement group (n = 22), according to the method used to determine the length of artificial chordae. Cardiopulmonary bypass time, aortic cross-clamp time, and the recurrence rate of moderate or severe mitral regurgitation were compared between the two groups. RESULTS: There were no operative deaths in either group. The mean cardiopulmonary bypass time was 113.0 ± 18.7 min and 127.0 ± 28.9 min (p < 0.05), and the aortic cross-clamp time was 70.0 ± 16.6 min and 86.0 ± 20.7 min (p < 0.05) in the TEE pre-measurement group and direct measurement group, respectively. The difference between the pre-measured artificial chordal length and actual constructed artificial chordal length was not significant in the TEE pre-measurement group (p > 0.05). Although the difference in the incidence of moderate or severe mitral regurgitation between the two groups was not significant (p > 0.05), the incidence in the TEE pre-measurement group (3.8%) was lower than that in the direct measurement group (18.2%). CONCLUSIONS: Real-time three-dimensional transesophageal echocardiography can accurately predict the length of artificial chordae required for mitral valve repair, and shortens cardiopulmonary bypass time and aortic cross-clamp time while improving the results of mitral valve repair.

Surgical treatment of late tricuspid regurgitation after left cardiac valve replacement.

BACKGROUND: The development of late tricuspid regurgitation (TR) following left cardiac valve replacement is an important complication, as it is associated with a severe impairment of exercise capacity and a poor symptomatic outcome. The pathogenesis of this condition remains poorly defined. It is still a challenge in terms of its prevention, treatment and indications for surgical correction. AIMS: To investigate the possible pathogenesis and report the surgical results of the late TR after left cardiac valve replacement. METHODS: There were 56 patients with moderate to severe TR after left cardiac valve replacement, divided into normal prosthesis group (10 patients with normal prosthetic valve function) and dysfunctional prosthesis group (46 patients with prosthetic valve dysfunction). In the normal prosthesis group, 4 patients underwent mitral valve replacement (MVR) and 6 patients underwent combined mitral and aortic valve replacement (DVR). Patients in the dysfunctional prosthesis group included MVR in 36, aortic valve replacement (AVR) in 4 and DVR in 6, with bioprosthetic valve dysfunction occurring in 18, mechanical prosthetic valve obstruction in 22 and periprosthetic valve leakage in 6 patients. At the initial operation, 10 patients underwent DeVega's tricuspid annuloplasty and 46 patients' tricuspid valves were normal. At the second operation, the surgical treatment of TR included tricuspid valve replacement (TVR) in 9 and tricuspid annuloplasty in 47. RESULTS: Two patients died postoperatively giving a 3.6% hospital mortality. The 54 survivors were followed up for 6-132 months (mean of 79.4 months). Heart function improved significantly in 8 with TVR and in 40 with tricuspid annuloplasty. Echocardiography showed moderate TR in 5 and severe TR in 1 patient with tricuspid annuloplasty who need a further surgical treatment. CONCLUSION: Pulmonary hypertension, myocardial dysfunction, and atrial fibrillation might be responsible for the development of late TR after left cardiac valve replacement. Tricuspid annuloplasty, as the surgical method of first choice, resulted in improvement in 87% of patients with late TR after left cardiac valve replacement. TVR can also be safely applied to repair organic disease and the extremely dilated tricuspid valve annulus. If the TR area is more than 25cm(2), the TVR is recommended.