Mid-term outcomes of individualized surgeries in patients with Ebstein's anomaly.

The variable anatomy of Ebstein's anomaly leads to its various surgical procedures. The long-term outcomes of different operations were not well established. Thirty-five patients with Ebstein's anomaly who underwent operations from 2006 to 2018 in our department were retrospectively reviewed. Individualized surgical plans were performed according to the preoperative echocardiography and surgeons' preference. Tricuspid repair, either Danielson's or Carpentier's technique, was the primary choice in patients who had sufficient tricuspid leaflets and adequate right ventricle, while tricuspid replacement was used when a reliable repair is not achievable. Additional bidirectional cavopulmonary shunt was performed in those who had unstable hemodynamics despite of high central venous pressure after separation from cardiopulmonary bypass. The perioperative and follow-up data were collected. The age was 26.9 (0.6-54) years [16 children (age < 14, and 19 adults (age ≥ 14)]. Preoperative tricuspid regurgitation was severe in 30, moderate in 4, and mild in the remaining 1 patient. Preoperative cardiac-associated malformations include 20 atrial septal defects, 2 ventricular septal defects, 2 pulmonary stenosis, and 1 sub aortic ridge, and these were operated simultaneously. Among all the surgical patients, 2 needed additional reoperation during the same admission, and ultimately, 29 patients had biventricular repair, including 21 tricuspid repair and 8 replacements. The other 6 patients had cavopulmonary connection and achieved 1.5 ventricular repair (3 tricuspid repair and 3 replacements). In all the 24 tricuspid repair patients, Danielson's procedure was used in 17, while Carpentier's technique was used in the other 7 patients. The average cardiopulmonary bypass time was 90 ± 28 min and cross-clamp time was 48 ± 24min. There were 2 perioperative deaths (5.7%) and no third-degree atrioventricular block. The postoperative in hospital stay was 13.7 ± 9.6 days. In the 33 survivors who were followed up at a median of 29.2 months, 6 patients had severe tricuspid regurgitation, and 2 of them underwent tricuspid replacement. The 5-year freedom from severe tricuspid dysfunction or reoperation was 78.5%, and no difference was found between children and adults, neither between different surgical choices. The surgeries of Ebstein's anomaly were variable, and individualized operation achieved reasonable short- and mid-term results. However, severe tricuspid regurgitation during the follow-up was not neglectable, and reoperation in such cases also achieved good outcomes. New repair strategy such as cone repair may be considered.

Analysis of the Synergistic Effects of Fasting Plasma Glucose and Hypertension on Cardiovascular Autonomic Neuropathy.

BACKGROUND: The purpose of this study was to evaluate the associations of fasting plasma glucose (FPG) and hypertension (HTN) with cardiovascular autonomic neuropathy (CAN) and to estimate the extent to which the synergistic effects of FPG and HTN affect outcomes in a Chinese population. METHOD: We conducted a large-scale, population-based study to analyze the association and interaction of the two factors with CAN in a sample of 2,092 Chinese people. Univariate and multiple linear regression (MLR) analyses were employed to detect these relationships. Interaction on an additive scale can be calculated by using the relative excess risk due to interaction, the proportion attributable to interaction (AP), and the synergy index (S). RESULT: After adjusting for confounding factors, MLR showed that FPG and HTN were independently associated with CAN (p < 0.001 for both). A significant synergistic effect of FPG and HTN on CAN was detected (p = 0.046, RETI = 0.733, 95% CI 0.059-1.450; AP = 0.167, 95% CI -0.033 to 0.367; S = 1.275, 95% CI 0.140-2.410). CONCLUSION: Our findings suggest that FPG and HTN are independently associated with CAN, and they offer evidence to support the hypothesis that FPG and HTN have synergistic effects that influence the progression of CAN.

The early and mid-term results of mitral valve repair for mitral regurgitation in children.

PURPOSE: To review the surgical techniques and mid-term results of mitral valve repair in children with moderate or severe mitral regurgitation (MR). METHODS: One hundred and seven children with moderate or severe MR, aged 19.6 ± 8.5 months, were enrolled in this study. The surgical techniques used for mitral valve repair varied according to the mitral valve morphology, and included annuloplasty, annuloplasty ring, cleft closure, reconstruction of the posterior leaflet, etc. The concomitant cardiac anomalies were treated simultaneously. The results of repair were evaluated by transesophageal echocardiography performed during the operation and by serial transthoracic echocardiography performed during the follow-up. RESULTS: One hundred and six cases had no more than mild regurgitation intraoperatively, whereas only one case had moderate regurgitation. This patient underwent redo repair immediately, and the subsequent regurgitation was trivial. The in-hospital mortality rate was 0.9 % (1/107). The average follow-up was 46.5 ± 8.2 months. One patient died of heart failure 10 months postoperatively. The freedom from moderate or severe regurgitation after mitral valve repair was 92.3 ± 3.3 %. CONCLUSION: Pediatric patients with moderate or severe MR require early surgical treatment. The early and mid-term results of mitral valve repair in pediatric patients were satisfactory.

Application of endovascular occlusion of both caval veins in minimally invasive isolated redo tricuspid surgery through right thoracotomy.

OBJECTIVE: To summarise the experiences of applying vena cava endovascular occlusion technique in minimally invasive isolated redo tricuspid surgery. METHODS: Forty-six consecutive patients received minimally invasive redo tricuspid surgery through right thoracotomy at our institute. All the patients had isolated significant tricuspid regurgitation after previous cardiac surgeries. Preoperative chest computed tomography showed high risk of conventional median sternotomy and vena cava exposure. A right anterolateral thoracotomy incision was made from the fourth intercostal space. The arterial cannula was placed in femoral artery, and balloon cannulas were used for bicaval cannulation. The venous cannulation was guided by transoesophageal echocardiography. Tricuspid valve operation was performed with heart beating after both venous cannulas were endovascularly occluded by inflating the balloons. RESULTS: There were no complications related to this cannulation technique. Two patients needed position adjustment or re-inflation of the balloon to obtain complete occlusion. The average time of cardiopulmonary bypass establishment was 55 ± 15 min and pump time was 58 ± 23 min. The length of stay was 8 ± 7 days. There was no early death in hospital. CONCLUSION: Endovascular occlusion of both vena cava in isolated redo tricuspid surgery was safe, effective and reliable. This approach significantly simplified the complexity of the surgery.

Antibiotic prophylaxis for surgical wound infections in clean and clean-contaminated surgery: an updated systematic review and meta-analysis.

BACKGROUND: The efficacy and necessity of prophylactic antibiotics in clean and clean-contaminated surgery remains controversial. METHODS: The studies were screened and extracted using databases including PubMed, Embase, Cochrane Library, Web of Science, and Clinical Trials.gov according to predefined eligibility criteria. Randomized controlled trials (RCTs) comparing the effect of preoperative and postoperative prophylactic antibiotic use on the incidence of surgical site infections (SSIs) in patients undergoing any clean or clean-contaminated surgery. RESULTS: A total of 16 189 participants in 48 RCTs were included in the primary meta-analysis following the eligibility criteria. The pooled odds ratio (OR) for SSI with antibiotic prophylaxis versus placebo was 0.60 (95% CI: 0.53-0.68). The pooled OR among gastrointestinal, oncology, orthopedics, neurosurgery, oral, and urology surgery was 3.06 (95% CI: 1.05-8.91), 1.16 (95% CI: 0.89-1.50), 2.04 (95% CI: 1.09-3.81), 3.05 (95% CI: 1.25-7.47), 3.55 (95% CI: 1.78-7.06), and 2.26 (95% CI: 1.12-4.55), respectively. Furthermore, the summary mean difference (MD) for patients' length of hospitalization was -0.91 (95% CI: -1.61, -0.16). The results of sensitivity analyses for all combined effect sizes showed good stability. CONCLUSION: Antibiotics are both effective, safe, and necessary in preventing surgical wound infections in clean and clean-contaminated procedures, attributed to their reduction in the incidence of surgical site infections as well as the length of patient hospitalization.

The involvement of AQP1 in heart oedema induced by global myocardial ischemia.

Aquaporin-1 (AQP1) is a member of aquaporin family that was previously proven to be involved in myocardial dysfunction; however, the role of AQP1 in myocardial stunning is less clear. To determine the change of AQP1 expression level in the heart and its effect on oedema after global myocardial ischemia, 40 adult goats underwent cardiopulmonary bypass (CPB) with an aortic cross-clamp time of 2 h and total bypass time of 6, 12, 24, 48 and 72 h followed by subsequent reperfusion. AQP1 function of eight goats was inhibited by HgCl(2) during the 24 h on CPB. All groups were compared with eight sham bypass control goats. Myocardial water content was measured, and the APQ1 mRNA and protein levels were detected by RT-PCR and immunoblotting, respectively. The results showed that the degree of myocardial oedema increased significantly at 6, 12, 24 and 48 h of reperfusion after CPB as compared with the control and recovered at 72 h of subsequent reperfusion. Expression levels of AQP1 mRNA and protein began to increase at 12 h and peaked at 24 h of CPB following reperfusion. Furthermore, myocardial oedema was reduced in the HgCl(2) group compared with the time-matched CPB and control groups. These data suggested that AQP1 expression increases in CPB and AQP1 plays an important role in myocardial oedema during CPB.

Physcion prevents high-fat diet-induced endothelial dysfunction by inhibiting oxidative stress and endoplasmic reticulum stress pathways.

High-fat diet (HFD)-induced obesity leads endothelial dysfunction and contributes to cardiovascular diseases. Palmitic acid (PA), a free fatty acid, is the main component of dietary saturated fat. Physcion, a chemical ingredient from Rhubarb, has been shown anti-hypertensive, anti-bacteria, and anti-tumor properties. However, the effects of physcion on endothelial dysfunction under HFD-induced obesity have not been reported. The purpose of the present study was to define the protective effect of physcion on HFD-induced endothelial dysfunction and its mechanisms involved. Obesity rat model was induced by HFD for 12 weeks. A rat thoracic aortic ring model was used to investigate the effects of physcion on HFD-induced impairment of vasorelaxation. Endothelial cell injury model was constructed in human umbilical vein endothelial cells (HUVECs) by treating with PA (0.25 mM) for 24 h. The results revealed that physcion reduced body weight and the levels of plasma TG, prevented impairment of endothelium-dependent relaxation in HFD-fed rats. In PA-injured HUVECs, physcion inhibited impaired viability, apoptosis and inflammation. Physcion also suppressed PA-induced both oxidative stress and ER stress in HUVECs. Furthermore, physcion increased PA-induced decrease in the activation of eNOS/Nrf2 signaling in HUVECs. These findings suggest that physcion has a significant beneficial effect on regulating HFD-induced endothelial dysfunction, which may be related to the inhibition of oxidative stress and ER stress through activation of eNOS/Nrf2 signaling pathway.

Prevalence of depression, anxiety in China during the COVID-19 pandemic: an updated systematic review and meta-analysis.

Background: Mental health risks associated with the aftermath of the COVID-19 pandemic are often overlooked by the public. The aim of this study was to investigate the effects of the COVID-19 pandemic on depression and anxiety disorders in China. Methods: Studies were analyzed and extracted in accordance with the PRISMA 2020 flowchart. The studies were screened and extracted using electronic databases including PubMed, Web of Science, Embase, Cochrane Library, and ClinicalTrials.gov according to the predefined eligibility criteria. The Cochrane Review Manager software 5.3.1 was used for data analysis and the risk of bias assessment. Results: As of 2023, a total of 9,212,751 Chinese have been diagnosed with COVID-19 infection. A total of 913,036 participants in 44 studies were selected following the eligibility criteria, the statistical information of which was collected for meta-analysis. The pooled prevalence of depression and anxiety were 0.31 (95% CI: 0.28, 0.35; I2 = 100.0%, p < 0.001) and 0.29 (95% CI: 0.23, 0.36; I2 = 100.0%, p < 0.001), respectively. After performing a subgroup analysis, the prevalence of depression among women, healthcare workers, students, and adolescents was 0.31 (95% CI: 0.22, 0.41), 0.33 (95% CI: 0.26, 0.44), 0.32 (95% CI: 0.26, 0.39), and 0.37 (95% CI: 0.31, 0.44), respectively. Conclusion: The prevalence of depression and anxiety among the Chinese was overall high. Monitoring and surveillance of the mental health status of the population during crises such as sudden global pandemics are imperative. Systematic review registration: https://clinicaltrials.gov/, identifier [CRD42023402190].

Individualized strategy of minimally invasive cardiac surgery in congenital cardiac septal defects.

BACKGROUND: Intracardiac septal defect is repaired using median sternotomy in most centers; however, there are several reports using minimally invasive surgery in both children and adults. This study summarized our strategy of minimally invasive therapy using various lateral mini-thoracotomies in patients with congenital septal defect. METHODS: In this study, 472 patients who underwent minimally invasive repair of intracardiac septal defects (atrial septal defect, (ASD), ventricular septal defect, (VSD), and atrioventricular septal defect, (AVSD)) from January 2012 to June 2020 were retrospectively reviewed. Those who underwent device closure were excluded. The minimally invasive strategy included three groups: the right sub-axillary vertical incision (RSAVI) group (N = 335, including192 ASDs, 135 VSDs and 8 AVSDs); the right anterolateral thoracotomy (RALT) group (N = 132, including 77 ASDs, 51 VSDs and 4 AVSDs); and the left anterolateral thoracotomy (LALT) group (N = 5, all subpulmonary VSDs). RESULTS: Concomitant surgeries included nine cases of right ventricular outflow tract obstruction relief, nine cases of mitral repairs and 37 cases of tricuspid repairs. There was one transition from thoracotomy to sternotomy. Three patients required second pump run for residual lesions (two residual VSD shunts and one mitral regurgitation). The age and body weight of the RSAVI group were significantly lower than those of the RALT and LALT groups (all P < 0.01). No postoperative death was observed. Postoperative complications included one case of chest exploration for bleeding, one case of reoperation due to patch dehiscence during the same admission, one case of transient neural dysfunction, three cases of diaphragmatic paresis and 13 cases of atelectasis. The median stay in the intensive care unit was two days, while the median postoperative hospitalization duration was six days. The echocardiography results before discharge indicated no significant residual lesions. No reoperation, no new onset of chest deformities and no sclerosis were observed during the follow-up. CONCLUSIONS: Intracardiac septal defects can be safely and effectively repaired by minimally invasive surgery with good cosmetic results. RSAVI is suitable in infants and children, while RALT is more commonly used in adolescents and adults. LALT is an alternative incision to repair subpulmonary VSD.

Losartan attenuates upstream vasculopathy in a modified piglet model of pulmonary vein stenosis: contribution of the Hippo pathway.

Background: Diffuse pulmonary vein stenosis (PVS) is an intractable congenital heart disease for which the underlying mechanism remains unclear. In this study, we investigated the effect of losartan and the role of the Hippo pathway in PVS. Methods: A total of 19 neonatal piglets were divided into 3 groups: a sham group (n=7), a banded group (n=6) with the left upper pulmonary vein and common trunk of both lower pulmonary veins banded, and a losartan group (n=6) with losartan treatment (1 mg/kg/d) after the banding operation. After 8 weeks, the piglets underwent hemodynamic measurement and harvesting. The upstream pulmonary veins were collected for histological staining and molecular biological analysis. Losartan and/or angiotensin II (stepwise concentrations from 0.1 to 100 µmol/L) were added to a human umbilical vein endothelial cell culture to investigate the potential mechanism in vitro. Results: The modified model demonstrated the main characteristics of patients with PVS, including pulmonary hypertension and intimal hyperplasia in the upstream veins. Upregulation of yes-associated protein (YAP) and angiotensin II type 1 receptor was observed in the neointima (P<0.01). Losartan treatment improved the pathological changes in piglets and decreased YAP expression in the neointima (P<0.01). In vitro, losartan suppressed angiotensin II-induced cell proliferation by inhibiting dephosphorylation and nuclear translocation of YAP in human umbilical vein endothelial cells (P<0.05). Conclusions: Losartan treatment ameliorates intimal hyperplasia and inhibits YAP activation. The activation of the Hippo-YAP pathway is involved in the vasculopathy of progressive PVS. These findings may contribute to the development of new approaches for treating PVS.

Modified Nuss procedure with a novel steel bar in patients with pectus excavatum post-congenital heart surgery.

OBJECTIVES: Pectus excavatum (PE) can be secondary in patients who underwent sternotomy for cardiac surgery. Retrosternal adhesions increase the complexity and risk of traditional Nuss repair. Thus, we summarized the outcomes of our modified Nuss procedure using a newly designed bar. METHODS: A retrospective analysis was performed on 35 patients who underwent modified PE repair after open heart surgery from January 2011 to July 2019. The surgery was performed using a novel bar with no need for intraoperative reshaping and rotation, assisted by thoracoscopy and subxiphoid incision when necessary. RESULTS: There were 19 males and 16 females with a median age of 5.3 years (interquartile range, 4.1-10.9) at PE repair. All patients underwent the modified procedure uneventfully with no death. The median operating time was 70 min. Twenty-nine (82.9%) patients required subxiphoid incision assistance. There was 1 case (2.8%) with unexpected sternotomy due to intraoperative bleeding. The median length of postoperative hospital stay was 4 days. During the median 3.5 years of follow-up, no bar dislocation was found and 30 (85.7%) patients had their bars removed with no recurrence recorded. After PE repair, the Haller index improved significantly (2.6 ± 0.4 vs 4.9 ± 1.3, P < 0.05) and further decreased till the time of bar removal (2.5 ± 0.4 vs 2.6 ± 0.4, P < 0.05). All patients were satisfied with the cosmetic outcome. CONCLUSIONS: The novel bar can be placed and removed easily with a low rate of adverse events. This modified Nuss procedure seems to be a safe, effective and convenient approach for the management of PE after cardiac surgery.

Photosensitizer-loaded cell membrane biomimetic nanoparticles for enhanced tumor synergetic targeted therapy.

Photodynamic therapy (PDT) has the advantages of low toxicity and specificity, but photosensitizers usually fail to accumulate efficiently at the tumor site. In this study, a new multifunctional nano-drug delivery system was exploited by a biomimetic strategy to improve the PDT effects. The self-assembled methoxy poly(ethylene glycol)-poly(lactide-co-glycolide) (mPEG-PLGA) nanoparticles encapsulated with the photosensitizer chlorin e6 (Ce6) by microfluidics were employed as the nano-core, followed by coating red blood cell (RBC) membranes as the biomimetic agent to prolong the circulation time in vivo. In order to boost the therapeutic effect, doxorubicin (Dox) was preloaded into RBC nanovesicles. The cell membrane surface was modified with folic acid (FA) to further enhance the tumor targeting efficiency. The prepared biomimetic nanoparticles with a homogeneous size (70 nm) can trigger sufficient reactive oxygen species (ROS), leading to significant tumor ablation without side effects. In addition, the system had high tumor targeting efficiency, with an increase of 25% compared with no FA-modified nanoparticles. Therefore, this biomimetic multifunctional nanodrug delivery system possesses a prolonged circulation time and higher tumor targeting efficiency and can exert better tumor cytotoxicity for improved PDT due to homophilic targeting in vivo.

Minimally invasive and conventional surgical treatment of primary benign cardiac tumors.

BACKGROUND: Primary cardiac tumors are rare and the majorities are benign. Conventional surgical treatment uses median sternotomy, while minimally invasive surgery from right anterolateral minithoracotomy has become an alternative method in recent years. In this study, we summarized the surgical outcomes of both approaches. METHODS: From January 2008 to August 2018, 50 patients with primary benign cardiac tumors underwent either conventional or minimally invasive surgery in our department. The baseline data were collected. The peri-operative data and follow up results were compared between the two groups. RESULTS: There were19 men and 31 women enrolled in this study with a mean age of 55.0 ± 17.5 years. The most common site of the tumor was left atrium (n = 40, 80%), followed by right atrium (n = 8, 16.0%), right ventricle (n = 1, 2.0%) and left ventricle (n = 1, 2.0%). All patients underwent surgery uneventfully, including 33 cases (66.0%) of median sternotomy and 17 cases (34.0%) of right anterolateral minithoracotomy. No significant differences were found between the two groups in terms of cardiopulmonary bypass time, aortic cross-clamp time, postoperative intubation time, intensive care unit days and length of the hospital stay. Patients with right anterolateral minithoracotomy had less post-operative chest drainage (536 ± 159 vs 773 ± 255 ml, P < 0.01) and transfusion rate (5.9% vs 33.3%, P = 0.033) than those who had sternotomy. There was no peri-operative death, and all the patients were alive and free of recurrence at the latest follow-up. CONCLUSIONS: Surgical resection of primary benign cardiac tumors is safe, effective and durable. The right anterolateral minithoracotomy provides the same postoperative recovery as standard median sternotomy, but less transfusion. It can be considered as a promising alternative approach.

Correlates of haemodynamic flow characteristics of sequential saphenous vein grafts in coronary artery bypass grafting.

OBJECTIVES: A sequential bypass technique has been widely used in the saphenous vein grafts (SVGs) during coronary artery bypass grafting (CABG) surgery. The aim of the present study was to investigate the correlates of haemodynamic flow characteristics of sequential SVGs using transit-time flow measurement. METHODS: From January 2013 to December 2016, 235 patients underwent isolated CABG using 1 aortosequential SVG to non-left anterior descending targets and the left internal mammary artery to the left anterior descending coronary artery. Among them, 212 patients have completed computed tomography angiography at 1-year follow-up and were included in the present study. The intraoperative flow rate and pulsatility index (PI) of sequential SVGs were assessed with transit-time flow measurement. The univariable and multivariable stepwise linear regression analyses of the possible correlating variables, including distal-end coronary artery (DECA) characteristics, were performed. RESULTS: For sequential SVGs, the mean proximal flow rate was 45.8 ± 19.2 ml/min, and the mean PI was 3.17 ± 1.00. We assessed the following correlates for proximal flow rate and PI: patient characteristics and DECA characteristics. Independent correlates of proximal flow rate were triple sequential SVG (by 21.0 ± 2.5 ml/min; P < 0.001), the DECA with more severe proximal stenosis (3.6 ± 1.3 ml/min per 10% increase; P = 0.007) and the DECA with larger diameter (≥1.5 mm) (by 4.8 ± 2.3 ml/min; P = 0.038). For PI, independent correlate was triple sequential SVG (by -0.55 ± 0.15; P < 0.001), and the DECA with larger diameter (≥1.5 mm) showed a strong trend (P = 0.069). The flow rate plotted against the logarithmic transformation of PI showed a significant inverse relationship in the linear regression analysis (P < 0.001). At 1-year follow-up, the patency of the proximal segment (between the aorta and the first side-to-side anastomosis) was 99.5% (211 of 212). CONCLUSIONS: Triple sequential SVG, the DECA with a larger diameter and more severe proximal stenosis were associated with higher proximal flow rate, whereas triple sequential SVG was associated with lower PI. These findings provide new data on flow characteristics and may guide subsequent studies towards improving sequential SVG patency.

Exogenous melatonin ameliorates hepatic injury in a rat cardiopulmonary bypass model.

Hepatic injury after cardiac surgery was considered to be a consequence of cardiopulmonary bypass (CPB). This study tested the hypothesis that melatonin could attenuate the hepatic injury in a rat CPB model. Male Sprague-Dawley rats were randomly divided into four groups: sham-operation group, control group (given an equal volume of vehicle), low dose melatonin (10 mg/kg) treated group and high dose melatonin (20 mg/kg) treated group. Blood samples were collected at the beginning, at the cessation of CPB, and at 30 min, 1, 2, 3 and 24 h post-operation. Liver samples were harvested at 24 h after operation. The serum indices of the liver enzymes and systemic inflammation, as well as oxidative stress indices and the Ca++-ATPase activity of liver tissues were determined. In the control animals, the indices of liver enzymes, tumor necrosis factor-alpha (TNF-alpha) increased after operation, and liver inducible nitric oxide synthase (iNOS), malondialdehyde (MDA), myeloperoxidase (MPO) increased as well. However, the activities of liver antioxidative enzymes and the concentration of glutathione (GSH) decreased remarkably. Results in melatonin group showed that melatonin reversed all the biochemical changes, but there was no significant difference between the melatonin-treated groups. In addition, histological findings further supported these results. All results indicated that application of exogenous melatonin during operation preserves liver function by reducing oxidative stress and the systemic inflammatory response.

Dietary n-3 fatty acids attenuate cardiac allograft vasculopathy via activating peroxisome proliferator-activated receptor-gamma.

Recent in vitro data suggested that n-3 fatty acids could inhibit the activation of PPAR gamma. This study was designed to test the hypothesis that fish oil ameliorates CAV development via activating PPAR gamma in an inbred rat model of heart transplantation. Animals were divided into four groups: isograft, control (CsA + vehicle), LFO-treated group (CsA + 0.3% v/w fish oil), and HFO-treated group (CsA + 0.6% v/w fish oil). CsA was administered at 1.5 mg/kg/day for two wk postoperatively. Recipients were treated with fish oil or vehicle daily for eight wk. The histopathological and immunohistochemical examination, activity of NF-kappaB and PPAR gamma, intragraft chemokine levels, and chemokine receptor expression were analyzed. Both LFO and HFO significantly decreased the CAV score, inhibited recruitment of T lymphocytes and macrophages, elevated the activity of PPAR gamma, inhibited the activity of NF-kappaB, reduced levels of intragraft MCP-1 and IP-10 as well as downregulated expression of chemokine receptors CCR2. CXCR3 expression was not affected. Our results demonstrated that fish oil might attenuate CAV development, possibly through activating PPAR gamma and subsequently inhibiting the NF-kappaB activation, the chemokines secretion, as well as the CCR2 expression.

Endocardial Changes in Nonvalvular Atrial Fibrillation Without Atrial Thrombus-Thrombomodulin and Tissue Factor Pathway Inhibitor.

Atrial fibrillation (AF) is a well-known cause for thromboembolism. Although blood stasis in the left atrium and hypercoagulable state of the blood have been emphasized as important mechanisms, limited attention has been paid to the endocardial changes in maintaining the balance of local coagulation, which may also contribute to the thrombus formation in AF. In the present study, left atrial appendage samples were obtained at heart surgery from nonvalvular AF and non-AF patients without atrial thrombus. Immunohistochemistry for endocardial markers including thrombomodulin (TM) and tissue factor pathway inhibitor (TFPI) was performed and semiquantitatively graded. In immunohistochemistry analysis, decreased expression of TM was found in patients with nonvalvular AF compared with those without AF ( P < .001). There was no difference in TFPI expression between the 2 groups ( P = .213). Patients with TM score of 0 or 1 seemed to have larger left atrial diameter (LAD) than those with TM score of 2 or 3 (44.0 (7.9) vs 40.6 (3.9); P = .009), while no relationship between LAD and TFPI expression was found (43.4 (7.0) vs 42.9 (7.8); P = .485). In conclusion, TM expression in the atrial endocardium is decreased in nonvalvular AF without atrial thrombus, while TFPI expression is not. Downregulated TM expression might be associated with enlarged LAD.

Predictive risk factors for recurrent atrial fibrillation after modified endoscopic ablation: A 2-year follow-up.

BACKGROUND: Our previous study reported a modified endoscopic procedure for nonvalvular atrial fibrillation (AF) that requires only 3 ports in the left chest wall. HYPOTHESIS: Certain preoperative variables might be predictive risk factors for AF recurrence among patients who underwent this procedure. METHODS: From October 2010 to April 2014, 114 patients with either paroxysmal AF (PAF) or nonparoxysmal AF (non-PAF) underwent the procedure and completed postoperative cardiac-rhythm measurement via electrocardiography and Holter monitoring. Univariate and multivariate analyses of the possible AF-related risk factors were conducted. RESULTS: During 2-year follow-up, 99 of 114 patients (86.8%) were free from atrial tachyarrhythmia. Results from univariate analyses showed that AF duration, left atrial diameter (LAD), left atrial minimum volume, left atrial empty fraction, left atrial expansion index, and left atrial active empty fraction (LAAEF) were significantly associated with postoperative AF recurrence. Results from multivariate analyses showed that AF duration (odds ratio [OR]: 1.194, 95% CI: 1.063-1.340, P = 0.003), LAD (OR: 1.101, 95% CI: 1.005-1.205, P = 0.039), and LAAEF (OR: 0.490, 95% CI: 0.277-0.865, P = 0.014) were independent risk factors. There was no difference in AF recurrence between patients with PAF and non-PAF (P = 0.250). CONCLUSIONS: Our 2-year follow-up study suggested that low LAAEF, long AF duration, and large LAD might be potential predictive risk factors for AF recurrence. Patients with PAF and non-PAF had a similar AF recurrence rate after modified endoscopic ablation.

Atrial endocardial expression of von Willebrand factor and thrombomodulin is associated with recurrence after minimally invasive surgical atrial fibrillation ablation.

OBJECTIVES: We retrospectively analysed data from non-valvular atrial fibrillation (AF) patients who underwent minimally invasive surgical AF ablation at our centre. Our purpose was to explore the atrial endocardial expression of von Willebrand factor (vWF) and thrombomodulin (TM) and their association with rhythm results after the procedure. METHODS: From January 2014 to May 2015, 60 patients underwent minimally invasive surgical AF ablation at our centre. Left atrial appendage samples were obtained during the procedure and immunohistochemistry for endocardial markers including vWF and TM was performed and semi-quantitatively graded. All patients underwent postoperative rhythm documentation at 3, 6, 12 and 24 months. RESULTS: At the 2-year interval, 49 (82%) patients maintained sinus rhythm, and all patients were asymptomatic. Univariate analysis shows that patients with AF recurrence have higher vWF score 2/3 and longer AF duration (P < 0.05). In the multivariate analysis, AF duration, vWF score, TM score, left atrial diameter (LAD) and non-paroxysmal AF are included. The result suggests that higher vWF score 2/3, lower TM score 0/1 and non-paroxysmal AF are statistically significant (P < 0.05). In addition, higher vWF score 2/3 is associated with larger LAD (45.2 ± 5.6 mm vs 41.2 ± 7.6 mm, P = 0.032), while higher TM score 2/3, on the other hand, is associated with smaller LAD (44.6 ± 6.1 mm vs 39.9 ± 7.8 mm, P = 0.032). The Kaplan-Meier analysis shows that higher vWF score 2/3 and lower TM score 0/1 appear to be accompanied with higher recurrence rate (vWF: P = 0.021; TM: P = 0.036). CONCLUSIONS: Atrial endocardial expression of vWF and TM might be associated with recurrence after minimally invasive surgical AF ablation. Patients with AF recurrence seem to have elevated vWF expression and decreased TM expression.

Fontan Failure and Death in Contemporary Fontan Circulation: Analysis From the Last Two Decades.

BACKGROUND: We sought to evaluate the incidence of Fontan failure or complication and its relation to death in patients having contemporary Fontan strategies over 2 decades. METHODS: Five hundred patients who underwent Fontan completion (extracardiac, n = 326; lateral tunnel, n = 174) from 1985 to 2012 were reviewed. Patient characteristics, modes of Fontan failure/complication and death, and predictors for Fontan failure/complication and death were analyzed. RESULTS: There were 23 early deaths (4.6%) and 17 late deaths (3.4%), with no early death since 2000. Survival has improved over time (p < 0.001). Twenty-three of 40 patients who died were identified as Fontan failure before death, including ventricular dysfunction (n = 14), pulmonary vascular dysfunction (n = 4), thromboembolism (n = 2), and arrhythmia (n = 4). Mode of death was circulatory failure (n = 18), multiorgan failure (n = 6), pulmonary failure (n = 3), cerebral/renal (n = 5), and sudden death (n = 4). Modes of failure/complication were directly (65%) or conceivably (10%) related to death in 30 of 40 patients (75%). Forty-eight percent of survivors had late Fontan complication(s). Five-year freedom from late Fontan complication was lower among patients who died compared with patients who survived (29.4% versus 53.3%, p < 0.001). Ventricular dysfunction (p = 0.001) and higher pulmonary artery pressures (p < 0.001) after Fontan were predictors for death. Longer cardiopulmonary bypass time (p = 0.032) and reinterventions (p < 0.001) were predictors for late Fontan complication. CONCLUSIONS: Early death in the early era has been overcome. Yet the incidence and causes of late death remain unchanged. There was a strong causative relationship between the mode of Fontan failure/complication and death, indicating the importance of early recognition and treatment of Fontan failure/complication.