Comparing the pRIFLE, AKIN, KDIGO, and modified KDIGO criteria in neonates after cardiac surgery.

BACKGROUND: While several standardized criteria for acute kidney injury (AKI) have been studied, there is no consensus on which criteria to use in neonates after cardiac surgery. The goal of this research was to compare the AKI incidence and outcomes according to the pediatric Risk, Injury, Failure and Loss, and End-Stage (pRIFLE), AKI Network (AKIN), Kidney Disease Improving Global Outcomes (KDIGO), and modified KDIGO (mKDIGO) criteria in neonates following congenital cardiac surgery. METHODS: A clinical database of all neonates undergoing congenital cardiac surgery admitted to the Cantonese cardiac center from 2014 to 2020 was retrospectively analyzed. AKI was based on the pRIFLE, AKIN, KDIGO, and mKDIGO classification. The predictive abilities for postoperative outcomes were compared by receiver operating curves, and multivariate logistic regression analysis was used to assess the association of AKI definitions with postoperative outcomes. RESULTS: In the study population of 522 patients, 177, 110, 131, and 114 neonates had AKI according to the pRIFLE, AKIN, KDIGO, and mKDIGO criteria, respectively. After multivariate analysis, all definitions were found to be significant predictors of increased mortality. The AUCs for mortality were substantially different with pRIFLE (AUC, 0.795), AKIN (AUC, 0.724), KDIGO (AUC, 0.819), and mKDIGO (AUC, 0.831) (P < 0.01) across the entire population, whereas the mKDIGO system was more accurate than the pRIFLE, AKIN, and KDIGO systems. CONCLUSIONS: The incidence of AKI varied across all definitions. However, the mKDIGO system was more accurate in predicting in-hospital mortality than the pRIFLE, AKIN, and KDIGO systems in neonates after heart surgery.

Macrophage-mediated regulation of catecholamines in sympathetic neural remodeling after myocardial infarction.

Sympathetic neural remodeling, which involves the inflammatory response, plays an important role in ventricular arrhythmias (VAs) after myocardial infarction (MI). Adrenergic receptors on macrophages potentially modulate the inflammatory response. We hypothesized that the increased level of catecholamines activates macrophages and regulates sympathetic neural remodeling after MI. We treated MI mice with either clodronate or metoprolol for 5 days following coronary artery ligation. Mice without treatment after MI and sham-operation mice served as the positive control and negative control, respectively. The norepinephrine levels in plasma and the peri-infarct myocardium increased by almost two-fold in the MI mice compared with the sham-operation mice. Both in vivo and ex vivo electrophysiology examinations showed that the vulnerability to VAs induced by MI was alleviated by macrophage depletion with clodronate and ß1-adrenergic blockade with metoprolol, which was in line with circulating and peri-infarct norepinephrine levels, sympathetic reinnervation, and the expression of nerve growth factor (NGF) 7 days after surgery. To further verify the interaction between catecholamines and macrophages, we preconditioned lipopolysaccharide-stimulated RAW 264.7 cells using epinephrine or epinephrine with selective adrenergic antagonists. The expression and release of inflammatory factors including NGF were enhanced by epinephrine. This effect was inhibited by metoprolol but not by other subtype antagonists. Our data suggested that the increased level of catecholamines, traditionally known as positive inotropes secreted from sympathetic nerve endings, might regulate cardiac sympathetic neural remodeling through ß1-adrenergic receptors on macrophages, subsequently inducing VAs after MI.

Targeting intestinal epithelial cell-programmed necrosis alleviates tissue injury after intestinal ischemia/reperfusion in rats.

BACKGROUND: Intestinal dysfunction, especially acute pathologies linked to intestinal ischemia/reperfusion (I/R) injury, is profoundly affected by inflammation and improper execution of cell death. Few studies have examined the efficacy of combined strategies in regulated intestinal epithelial necrosis after intestinal I/R. Here, we evaluated the functional interaction between poly (adenosine diphosphate-ribose) polymerase 1 (PARP-1)-induced parthanatos and receptor-interacting protein 1/3 (RIP1/3) kinase-induced necroptosis in the pathophysiological course of acute ischemic intestinal injury. METHODS: Anesthetized adult male Sprague-Dawley rats were subjected to superior mesenteric artery occlusion consisting of 1.5 h of ischemia and 6 h of reperfusion. The PARP-1-specific inhibitor PJ34 (10 mg/kg) and the RIP1-specific inhibitor Necrostatin-1 (1 mg/kg) were intraperitoneally administered 30 min before the induction of ischemia. RESULTS: Intestinal I/R was found to result in PARP-1 activation and RIP1/3-mediated necrosome formation. PJ34 or Necrostatin-1 treatment significantly improved the mucosal injury, while the combined inhibition of PARP-1 and RIP1/3 conferred optimal protection of the intestine. Meanwhile, results from terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate-biotin nick end labeling assay showed a decrease in intestinal epithelial cell death. Interestingly, we further showed that PARP-1 might act as a downstream signaling molecule of RIP1 in the process of I/R-induced intestinal injury and that the RIP1/PARP-1-dependent cell death signaling pathway functioned independently of caspase 3 inhibition. CONCLUSIONS: The results of our study provide a molecular basis for combination therapy that targets both pathways of regulated necrosis (parthanatos and necroptosis), to treat acute intestinal I/R-induced intestinal epithelial barrier disruption.

Development and external validation of a perioperative clinical model for predicting myocardial injury after major abdominal surgery: A retrospective cohort study.

Purpose: We aimed to develop and validate a predictive model for myocardial injury in individuals undergoing major abdominal surgery. Methods: This multicenter retrospective cohort analysis included 3546 patients aged ≥45 years who underwent major abdominal surgeries at two Chinese tertiary hospitals. The primary outcome was myocardial injury after noncardiac surgery (MINS), defined as prognostically relevant myocardial injury due to ischemia that occurs during or within 30 days after noncardiac surgery. The LASSO algorithm and logistic regression were used to construct a predictive model for postoperative MINS in the development cohort, and the performance of this prediction model was validated in an external independent cohort. Results: A total of 3546 patients were included in our study. MINS manifested in 338 (9.53 %) patients after surgery. The definitive predictive model for MINS was developed by incorporating age, American Society of Anesthesiologists (ASA) classification, preoperative hemoglobin concentration, preoperative serum ALB concentration, blood loss, total infusion volume, and operation time. The area under the curve (AUC) of our model was 0.838 and 0.821 in the derivation and validation cohorts, respectively. Conclusions: Preoperative hemoglobin levels, preoperative serum ALB concentrations, infusion volume, and blood loss are independent predictors of MINS. Our predictive model can prove valuable in identifying patients at moderate-to-high risk prior to non-cardiac surgery.

Antibacterial Hybrid Hydrogels.

Bacterial infectious diseases and bacterial-infected environments have been threatening the health of human beings all over the world. In view of the increased bacteria resistance caused by overuse or improper use of antibiotics, antibacterial biomaterials are developed as the substitutes for antibiotics in some cases. Among them, antibacterial hydrogels are attracting more and more attention due to easy preparation process and diversity of structures by changing their chemical cross-linkers via covalent bonds or noncovalent physical interactions, which can endow them with various specific functions such as high toughness and stretchability, injectability, self-healing, tissue adhesiveness and rapid hemostasis, easy loading and controlled drug release, superior biocompatibility and antioxidation as well as good conductivity. In this review, the recent progress of antibacterial hydrogel including the fabrication methodologies, interior structures, performances, antibacterial mechanisms, and applications of various antibacterial hydrogels is summarized. According to the bacteria-killing modes of hydrogels, several representative hydrogels such as silver nanoparticles-based hydrogel, photoresponsive hydrogel including photothermal and photocatalytic, self-bacteria-killing hydrogel such as inherent antibacterial peptides and cationic polymers, and antibiotics-loading hydrogel are focused on. Furthermore, current challenges of antibacterial hydrogels are discussed and future perspectives in this field are also proposed.

Dexmedetomidine Attenuates LPS-Induced Monocyte-Endothelial Adherence via Inhibiting Cx43/PKC-α/NOX2/ROS Signaling Pathway in Monocytes.

Dexmedetomidine is widely used for sedating patients in operation rooms or intensive care units. Its protective functions against oxidative stress, inflammation reaction, and apoptosis have been widely reported. In present study, we explored the effects of dexmedetomidine on monocyte-endothelial adherence. We built lipopolysaccharide- (LPS-) induced monocyte-endothelial adherence models with U937 monocytes and human umbilical vein endothelial cells (HUVECs) and observed the effects of dexmedetomidine on U937-HUVEC adhesion. Specific siRNA was designed to knock-down Connexin43 (Cx43) expression in U937 monocytes. Gö6976, GSK2795039, and NAC were used to inhibit PKC-α, NOX2, and ROS, respectively. Then, we detected whether dexmedetomidine could downregulate Cx43 expression and its downstream PKC-α/NOX2/ROS signaling pathway activation and ultimately result in the decrease of U937-HUVEC adhesion. The results showed that dexmedetomidine, at its clinically relevant concentrations (0.1 nM and 1 nM), could inhibit adhesion of molecule expression (VLA-4 and LFA-1) and U937-HUVEC adhesion. Simultaneously, it also attenuated Cx43 expression in U937 monocytes. With the downregulation of Cx43 expression, the activity of PKC-α and its related NOX2/ROS signaling pathway were reduced. Inhibiting PKC-α/NOX2/ROS signaling pathway with Gö6976, GSK2795039, and NAC, respectively, VLA-4, LFA-1 expression, and U937-HUVEC adhesion were all decreased. In summary, we concluded that dexmedetomidine, at its clinically relevant concentrations (0.1 nM and 1 nM), decreased Cx43 expression in U937 monocytes and PKC-α associated with carboxyl-terminal domain of Cx43 protein. With the downregulation of PKC-α, the NOX2/ROS signaling pathway was inhibited, resulting in the decrease of VLA-4 and LFA-1 expression. Ultimately, U937-HUVEC adhesion was reduced.

Revising ventricular septal defect residual shunts without aortic re-cross-clamping: a safe and effective surgical procedure.

BACKGROUND: The conventional approach to revising a residual shunt following ventricular septal defect (VSD) closure is to re-occlude the aorta and repair the residual shunt under cardioplegic arrest. The present study evaluated the safety and effectiveness of a new approach for revising residual shunts following VSD repair without re-occluding the aorta. This approach is known as on beating heart surgery. METHODS: This retrospective study included 80 pediatric patients who underwent surgical closure of a simple VSD. Residual shunts larger than 2 mm were intraoperatively detected by transesophageal echocardiography (TEE) and these patients received immediate reintervention. Of the patients, 37 received on beating heart surgery without aortic cross-clamping (Group A) and 43 patients were operated on with aortic cross-clamping and cardioplegia (Group B). RESULTS: Residual VSD closures were successfully performed in all patients. Group A had significantly shorter aortic cross-clamp times (P<0.0001), significantly shorter CPB times (P<0.01), a lower incidence of prolonged ventilation (>6 hours) (P=0.04), a lower incidence of prolonged intensive care unit (ICU) stay (ICU stay >1 day) (P=0.02), and reduced in-hospital expenses (P<0.0001) compared with Group B. There was no significant difference in the incidence of recurrent residual shunts (P=0.96), prolonged postoperative hospital stay (>5 days) (P=0.24), or the incidence of perioperative complications (P=0.81) between the groups. CONCLUSIONS: On beating heart surgery is a safe and effective approach for the closure of residual VSDs and is significantly associated with a lower incidence of prolonged ventilation, a lower incidence of prolonged ICU stay, and reduced in-hospital expenses.

Real-time three-dimensional transesophageal echocardiographic guidance versus fluoroscopic guidance for transvenous temporary cardiac pacemaker implantation during transcatheter aortic valve implantation surgeries.

BACKGROUND: Fluoroscopic guidance is the traditional method for the implantation of transvenous temporary cardiac pacemakers (TVTPs). This study aimed to compare the time, effectiveness, and safety of real-time three-dimensional transesophageal echocardiography (3D TEE) with those of fluoroscopy in guiding TVTP implantation. METHODS: The records of patients who underwent transcatheter aortic valve implantation (TAVI) guided by real-time 3D TEE or fluoroscopy between July 1, 2016, and June 30, 2020, were retrospectively analyzed. TVTPs were implanted by anesthesiologists via the right internal jugular vein (IJV) in the real-time 3D TEE-guided group (3D TEE group), and by interventional cardiologists via the femoral vein in the fluoroscopy-guided group (fluoro group). RESULTS: A total of 143 patients (3D TEE-group n=79, and fluoro group n=64) were included. No statistical differences were observed in the baseline characteristics of the two groups. TVTPs were successfully implanted in all of the patients. The needle-to-pace time was significantly shorter in 3D TEE group than in fluoro group (5.2±2.9 vs. 8.5±4.6 min, P<0.001). Further, the incidence of access complications was significantly lower in 3D TEE group than in fluoro group (3.8% vs. 12.5%, P<0.05). One patient in fluoro group who suffered cardiac perforation underwent drainage via pericardiocentesis. No patients in either group died because of TVTP placement. The total complication rates were significantly lower in 3D TEE group than in fluoro group (19.0% vs. 39.1%, P<0.05). No statistically significant differences existed between groups in terms of pacing threshold, the incidence of permanent pacemaker insertion after surgery, the length of postoperative intensive care unit (ICU) stay, or the duration of postoperative hospitalization. CONCLUSIONS: Real-time 3D TEE-guided can be used to effectively, quickly, and safely guide TVTP implantation. The procedure can be performed by properly trained anesthesiologists. Therefore, real-time 3D TEE is a suitable option for guiding perioperative TVTP implantation in patients undergoing cardiac surgery.

Propensity-matched analysis of two port approach versus three port approach for totally thoracoscopic mitral valve replacement.

BACKGROUND: To objectively evaluate the feasibility, safety, effectiveness and short-term outcome of totally thoracoscopic mitral valve replacement via two port approach, we conducted a retrospective study comparing two port approach with three port approach for mitral valve replacement. METHODS: Data for all thoracoscopic mitral valve replacement were analyzed from Guangdong Cardiovascular Institute between January 1, 2016 and December 31, 2017. To account for selection bias between two port approach and three approach, one-to-one propensity score caliper matching without replacement was performed. The clinical data of the two groups were collected, including preoperative cardiac function, operative data, postoperative complications, and short-term outcome. RESULTS: A total of 330 patients who underwent totally thoracoscopic mitral replacement via two port or three port from January 1, 2016 to December 31, 2017 were enrolled (two-port group: n=103; three-port group: n=227). Propensity score matching resulted in 71 matched pairs with improved balance post matching in baseline covariates. The baseline differences between two groups were eliminated (P>0.05 for all baseline variables). The cardiopulmonary bypass time (min) (154.27±57.02 vs. 142.68±51.33 P=0.183) and the aortic cross-clamp time (min) (106.99±106.98 vs. 90.16±31.63 P=0.206) in the two-port group were not significantly different from those in the three-port group. No significant difference was observed between the two groups in mechanical ventilation time, duration of intensive care unit stay, or amount of postoperative chest drainage. No perioperative death or re-exploration for bleeding was found in either group. As for other postoperative complications, two groups had the similar rate of lung infection lung infection (1.41% vs. 1.33% P=1.000) or acute renal failure (1.41% vs. 1.41% P=1.000). CONCLUSIONS: No significant differences in cardiopulmonary bypass time, aortic cross-clamp time, overall operative time, perioperative mortality, or complications were observed between two-port and three-port totally thoracoscopic mitral valve replacement. Two-port totally thoracoscopic mitral valve replacement is a safe, effective, and feasible procedure for mitral valve replacement.

Stand-alone surgical ablation for atrial fibrillation: a novel bilateral double-port approach.

BACKGROUND: To explore an effective, reproducible and less invasive surgical approach for lone atrial fibrillation (AF). METHODS: A modified "mini-maze" including pulmonary vein isolation (PVI), box-lesion and left atrial appendage (LAA) resection was applied for AF patients in our center from January 2016 to June 2017. A 2.5 cm thoracotomy extended with tissue retractor was made as working port in the fourth intercostal space on each anterior side of the chest. The thoracoscope was inserted in another port lateral to main port for observing. During PVI, the tip of the clamp could be adjusted to reach as superior as the roof of left atrium for transmural lesions. The floor line was made by linear ablation pen. The LAA was removed by stapler before PVI for better exposure of the roof. RESULTS: This modified "mini-maze" was successfully completed in 53 non-paroxysmal AF patients except 1 was converted to sternotomy due to intraoperative hemorrhage. All patients recovered uneventfully. Seven-day Holter was accessed in 3, 6 and 12 months respectively in all patients. The mean follow-up was 14 (range, 3-30) months. Sinus rhythm was achieved in 48.1%, 64.8% before discharge and 3 months after surgery respectively, Twenty-eight patients in sinus rhythm or not, underwent catheter mapping and ablation three months after the operation to conform the lesion set made by this procedure. Sinus rhythm reached 87.0% after subsequent catheter ablation without any anti-arrhythmia treatment at 12 months. All patients survived without stroke, hemorrhage and pulmonary vein stenosis. CONCLUSIONS: Modified "mini-maze" procedure is safe, less invasive and highly reproducible for lone AF. Sequential hybrid procedure will shape the treatment of non-paroxysmal AF.