Phytosterols in hull-less pumpkin seed oil, rich in ∆7-phytosterols, ameliorate benign prostatic hyperplasia by lowing 5α-reductase and regulating balance between cell proliferation and apoptosis in rats.

BACKGROUND: Pumpkin seed oil is widely used to treat benign prostatic hyperplasia (BPH), a common disease in elder men. However, its active components and mechanism have remained to be elucidated. OBJECTIVE: The objective of the present study was to investigate the active components of pumpkin seed oil and its mechanism against BPH. DESIGN: Total phytosterol (TPS) was isolated from hull-less pumpkin (Cucurbita pepo L. var. Styriaca) seed oil and analyzed by gas chromatography/mass spectrometry (GC/MS). Three phytosterols were purified by preparative HPLC (high performance liquid chromatography) and confirmed by NMR (nuclear magnetic resonance). TPS (3.3 mg/kg body weight, 1 mL/day/rat) was administered intragastrically to the testosterone propionate-induced BPH rats for 4 weeks. The structure changes of prostate tissues were assessed by hematoxylin & eosin (H&E) staining. The expression of androgen receptor (AR) and steroid receptor coactivator 1 (SRC-1) was analyzed by immunohistochemistry, while that of 5α-reductase (5AR), apoptosis, or proliferation-related growth factors/proteins was detected by real-time quantitative polymerase chain reaction or western blotting. RESULTS: The ∆7-phytosterols in TPS reached up to 87.64%. Among them, 24ß-ethylcholesta-7,22,25-trienol, 24ß-ethylcholesta-7,25(27)-dien-3-ol, and ∆7-avenasterol were confirmed by NMR. TPS treatment significantly ameliorated the pathological prostate enlargement and restored histopathological alterations of prostate in BPH rats. It effectively suppressed the expressions of 5AR, AR, and coactivator SRC-1. TPS inhibited the expression of proliferation-related growth factor epidermal growth factor, whereas it increased the expressions of apoptosis-related growth factor/gene transforming growth factor-ß1. The proliferation-inhibiting effect was achieved by decreasing the ERK (extracellular signal-regulated kinase) phosphorylation, while apoptosis was induced by Caspase 3 activation through JNK (c-Jun N-terminal kinase) and p38 phosphorylation. CONCLUSION: TPS from hull-less pumpkin seed oil, with ∆7-phytosterols as its main ingredients, is a potential nutraceutical for BPH prevention.

Portable pulsed xenon ultraviolet light disinfection in a teaching hospital animal laboratory in China.

An animal laboratory in a teaching hospital is a possible cause of cross infection. We aimed to assess the infection control in our animal laboratory and evaluate the disinfectant effects of a portable pulsed xenon ultraviolet (PX-UV) machine. Samples were taken from the surface of research tables, other high touch places, such as doorknobs, weighing scales, and handles of trolleys, and from air in the barrier system pre- and post-manual cleaning and post-PX-UV disinfection. The bacteria types were identified. We found that routine manual cleaning significantly reduced bacterial colony form unit (CFU)/cm2 (P = .02), and the median of CFU/cm2 reduced from 0.5 pre-cleaning to zero post-cleaning. PX-UV disinfection also significantly reduced residual bacterial counts (P = .002), with the highest counts 10 pre-PX-UV disinfection and 1 afterwards. Without manual cleaning, PX-UV disinfected surfaces significantly (P < .001), median count 6 pre-PX-UV disinfection and zero afterwards. PX-UV significantly reduced bacterial colony counts in the air with the median count falling from 6 to zero (P < .001). Some of the 21 species of pathogens we identified in the current study are pathogenic, resistant to antibiotics, and able to cause nosocomial infections and zoonosis. PX-UV reduced counts of most of the pathogens. PX-UV is an effective agent against these pathogens.

Evaluation of a pulsed xenon ultraviolet light device for reduction of pathogens with biofilm-forming ability and impact on environmental bioburden in clinical laboratories.

BACKGROUND: Biofilm-forming organisms can persist on surfaces in hospital clinical laboratories and potentially lead to nosocomial infections. Therefore, effective decontamination procedures are essential for reducing infections. In this study, we investigated an alternative to often ineffective manual cleaning methods, a pulsed xenon ultraviolet (PX-UV) light device. We evaluated PX-UV effect on biofilm formation ability of pathogens and also evaluated PX-UV effectiveness on environmental bioburden in clinical laboratories. METHODS: We selected and identified P. aeruginosa PA47, Staphylococcus aureus B1, and K. pnenumoniae CR52 from clinic isolates. Biofilm-forming ability and effectiveness of PX-UV in killing these biofilm forming strains on surfaces was evaluated. The central laboratory, the clinical microbiology laboratory, and the clinical immunology laboratory were chosen for testing environmental bioburden. Air samples and high-touch surface specimens in the three laboratories were obtained before and after routine manual cleaning, and after 6 min of PX-UV disinfection. The cultured microbes were then identified with MALDI- TOF-MS. RESULTS: We found that P. aeruginosa PA47, Staphylococcus aureus B1, and K. pnenumoniae CR52 were able to form robust biofilms, and that PX-UV significantly reduced colony counts of these strains on all surfaces tested. PX-UV reduced the bioburden of air samples and eliminated bioburden on surfaces. All microbes identified in the clinical laboratories were pathogenic and consisted of cocci, rods, and fungi. CONCLUSIONS: The PX-UV device effectively reduced pathogens with biofilm-forming ability on surfaces, and the environmental bioburden was also significantly reduced by PX-UV. PX-UV is a viable option for protecting staff and decreasing rates of laboratory-acquired infections.

Pulsed xenon ultraviolet and non-thermal atmospheric plasma treatments are effective for the disinfection of air in hospital blood sampling rooms.

BACKGROUND AND OBJECTIVES: Non-thermal atmospheric plasma treatment and pulsed xenon ultraviolet (PX-UV) treatment are widely used in disinfection of hospital environments. However, their effectiveness has not been evaluated against a comparator. The objective of this study is to evaluate their effectiveness in the disinfection of pathogens in the air in hospital blood sampling rooms. METHODS: Samples were taken from the air before and after disinfection with PX-UV and non-thermal atmospheric plasma. We counted bacterial colonies and identified the types of bacteria. RESULTS: Non-thermal plasma treatment significantly reduced bacterial counts in the air, the median reduced from 1 before treatment to zero afterwards (p = 0.03). PX-UV treatment also significantly reduced bacterial counts in the air (p = 0.01), the median reduced from 1.5 before treatment to zero afterwards. Pathogens identified in the current study include nosocomial bacteria, such as Staphylococcus aureus, Staphylococcus epidermidis, and yeast. CONCLUSION: Disinfection of blood sampling sites is essential in a health service department. The efficiency of PX-UV and non-thermal atmospheric plasma treatment are comparable in air disinfection.

Peri-operative application of intra-aortic balloon pumping reduced in-hospital mortality of patients with coronary artery disease and left ventricular dysfunction.

BACKGROUND: There are few reports of peri-operative application of intra-aortic balloon pumping (IABP) in patients with coronary artery disease (CAD) and different grades of left ventricular dysfunction. This study aimed to analyze the early outcomes of peri-operative application of IABP in coronary artery bypass grafting (CABG) among patients with CAD and left ventricular dysfunction, and to provide a clinical basis for the peri-operative use of IABP. METHODS: A retrospective analysis of 612 patients who received CABG in the General Hospital of People's Liberation Army between May 1995 and June 2014. Patients were assigned to an IABP or non-IABP group according to their treatments. Logistic regression analysis was performed to investigate the influence of peri-operative IABP implantation on in-hospital mortality. Further subgroup analysis was performed on patients with severe (ejection fraction [EF] ≤ 35%) and mild (EF = 36%-50%) left ventricular dysfunction. RESULTS: Out of 612 included subjects, 78 belonged to the IABP group (12.7%) and 534 to the non-IABP group. Pre-operative left ventricular EF (LVEF) and EuroSCOREII predicted mortality was higher in the IABP group compared with the non-IABP group (P < 0.001 in both cases), yet the two did not differ significantly in terms of post-operative in-hospital mortality (P = 0.833). Regression analysis showed that IABP implantation, recent myocardial infarction, critical status, non-elective operation, and post-operative ventricular fibrillation were risk factors affecting in-hospital mortality (P < 0.01 in all cases). Peri-operative IABP implantation was a protective factor against in-hospital mortality (P = 0.0010). In both the severe and mild left ventricular dysfunction subgroups, peri-operative IABP implantation also exerted a protective role against mortality (P = 0.0303 and P = 0.0101, respectively). CONCLUSIONS: Peri-operative IABP implantation could reduce the in-hospital mortality and improve the surgical outcomes of patients with CAD with both severe and mild left ventricular dysfunction.

[Robotic surgery versus conventional open chest surgery for heart tumor: a propensity score matching analysis].

OBJECTIVE: To compare conventional open chest surgery and robotic surgery for their efficacy, short?term outcomes and patient selection in the treatment of heart tumors. Method The clinical data were collected from 225 patients (a total of 228 operations) who underwent cardiac neoplasm resection in our hospital between January, 1993 and April, 2016. A propensity score matching (PSM) was established according to the vital baseline data of the patients receiving conventional open chest surgery (n=125) and robotic surgery (n=60) after screening. The patients were matched for propensity into 60 pairs, and the efficacy, short?term outcomes and patient selection were compared between the two groups. RESULTS: Before PSM, the patients in conventional surgery group had significantly greater tumor size (P<0.001) and a higher proportion of patients with New York Heart Association functional class III and IV (P<0.001). The patients' baseline data were nearly balanced (P=0.982) between the two groups after matching. No significant differences were found between the two groups in cardiopulmonary bypass time (P=0.256), crossclamp time (P=0.862), in?hospital mortality (P=1.000), arrhythmia (P=1.000), delayed mechanical ventilation (>24 h; P=0.209), thoracic complications (P=0.611) or systemic embolism (P=1.000). The survival rates were 100% in both groups in the 6?month follow?up after the operation, and no significant difference was found between the two groups in the incidence of major adverse cardiac and cerebrovascular events within 6 months (P=0.438). CONCLUSION: Robotic heart tumor resection has a favorable efficacy with a good short?term prognosis, and can serve as an alternative for treatment of solitary lesions in low?risk patients receiving operations for the first time.

Optimal Timing of Surgical Revascularization for Myocardial Infarction and Left Ventricular Dysfunction.

BACKGROUND: The optimal timing of surgical revascularization for patients presenting with ST-segment elevation myocardial infarction (STEMI) and impaired left ventricular function is not well established. This study aimed to examine the timing of surgical revascularization after STEMI in patients with ischemic heart disease and left ventricular dysfunction (LVD) by comparing early and late results. METHODS: From January 2003 to December 2013, there were 2276 patients undergoing isolated coronary artery bypass grafting (CABG) in our institution. Two hundred and sixty-four (223 male, 41 females) patients with a history of STEMI and LVD were divided into early revascularization (ER, <3 weeks), mid-term revascularization (MR, 3 weeks to 3 months), and late revascularization (LR, >3 months) groups according to the time interval from STEMI to CABG. Mortality and complication rates were compared among the groups by Fisher's exact test. Cox regression analyses were performed to examine the effect of the time interval of surgery on long-term survival. RESULTS: No significant differences in 30-day mortality, long-term survival, freedom from all-cause death, and rehospitalization for heart failure existed among the groups (P > 0.05). More patients in the ER group (12.90%) had low cardiac output syndrome than those in the MR (2.89%) and LR (3.05%) groups (P = 0.035). The mean follow-up times were 46.72 ± 30.65, 48.70 ± 32.74, and 43.75 ± 32.43 months, respectively (P = 0.716). Cox regression analyses showed a severe preoperative condition (odds ratio = 7.13, 95% confidence interval 2.05-24.74, P = 0.002) rather than the time interval of CABG (P > 0.05) after myocardial infarction was a risk factor of long-term survival. CONCLUSIONS: Surgical revascularization for patients with STEMI and LVD can be performed at different times after STEMI with comparable operative mortality and long-term survival. However, ER (<3 weeks) has a higher incidence of postoperative low cardiac output syndrome. A severe preoperative condition rather than the time interval of CABG after STEMI is a risk factor of long-term survival.

[Long-term outcomes of off-pump coronary artery bypass grafting in patients aged over 75 years].

OBJECTIVE: To investigate the long-term outcomes of off-pump coronary artery bypass grafting (OPCAB) in patients aged over 75 years and analyze the risk factors affecting the outcomes of the procedure. METHODS: Clinical data were reviewed for 97 consecutive patients aged 75 years or above receiving OPCAB at our center between November, 2000 and November, 2013. The perioperative data including length of ICU stay, duration of mechanical ventilation, incidence of postoperative complications and mortality rate of the patients were analyzed. The follow-up data of the patients were also analyzed including all-cause mortality rate and major adverse cardiac and cerebral events (MACCE, including myocardial infarction, cerebrovascular event, and repeated revascularization). RESULTS: The perioperative mortality rate was 3.09% (3/97) in these patients. Of the 97 patients analyzed, 91 (93%) were available for follow-up for 29-192 months (with a median of 95.61∓34.07 months). The 10-year survival rate of the patients was 62% with a 10-year MACCE-free survival rate of 47.4%. During the follow-up, 6 (6.8%) patients underwent repeated revascularization procedures, 12 (12.37%) had cerebrovascular accidents and 5 (5.15%) had myocardial infarction. Logistic regression analysis showed that hypertension (OR=1.388, P=0.043) and diabetes (OR=1.692, P=0.017) were independent predictors of MACCE, and incomplete revascularization did not increase the risk of postoperative MACCE. CONCLUSION: OPCAB is safe and effective in elderly patients with good long-term outcomes. Hypertension and diabetes are independent risk factors of MACCE, and adequate control of blood pressure and blood glucose can reduce the incidence of postoperative MACCE. Incomplete revascularization is not detrimental to the long-term outcomes of OPCAB in elderly patients.

Tristetraprolin Down-Regulation Contributes to Persistent TNF-Alpha Expression Induced by Cigarette Smoke Extract through a Post-Transcriptional Mechanism.

RATIONALE: Tumor necrosis factor-alpha (TNF-α) is a potent pro-inflammatory mediator and its expression is up-regulated in chronic obstructive pulmonary disease (COPD). Tristetraprolin (TTP) is implicated in regulation of TNF-α expression; however, whether TTP is involved in cigarette smoke-induced TNF-α expression has not been determined. METHODS: TTP expression was examined by western blot analysis in murine alveolar macrophages and alveolar epithelial cells challenged without or with cigarette smoke extract (CSE). TNF-α mRNA stability, and the decay of TNF-α mRNA, were determined by real-time quantitative RT-PCR. TNF-α protein levels were examined at the same time in these cells. To identify the molecular mechanism involved, a construct expressing the human beta-globin reporter mRNA containing the TNF-α 3'-untranslated region was generated to characterize the TTP targeted site within TNF-α mRNA. RESULTS: CSE induced TTP down-regulation in alveolar macrophages and alveolar epithelial cells. Reduced TTP expression resulted in significantly increased TNF-α mRNA stability. Importantly, increased TNF-α mRNA stability due to impaired TTP function resulted in significantly increased TNF-α levels in these cells. Forced TTP expression abrogated the increased TNF-α mRNA stability and expression induced by CSE. By using the globin reporter construct containing TNF-α mRNA 3'-untranslated region, the data indicate that TTP directly targets the adenine- and uridine-rich region (ARE) of TNF-α mRNA and negatively regulates TNF-α expression at the post-transcriptional level. CONCLUSION: The data demonstrate that cigarette smoke exposure reduces TTP expression and impairs TTP function, resulting in significantly increased TNF-α mRNA stability and excessive TNF-α expression in alveolar macrophages and epithelial cells. The data suggest that TTP is a novel post-transcriptional regulator and limits excessive TNF-α expression and inflammatory response induced by cigarette smoke.

[Surgical ventricular restoration versus isolated coronary artery bypass grafting for left ventricular aneurysm: comparison of mid- to long-term outcomes].

OBJECTIVE: To compare the mid- to long-term outcomes of patients receiving isolated coronary artery bypass grafting (CABG) versus surgical ventricular restoration (SVR) plus CABG for left ventricular aneurysms. METHODS: The clinical data were retrospectively analyzed in 205 patients with left ventricular aneurysms admitted to our hospital between January, 1997 and December, 2012, including 115 patients receiving SVR plus CABG and 90 undergoing isolated CABG. By matching preoperative echocardiographic parameters including aneurysm size, left ventricular ejection fraction (LVEF), left ventricular end-systolic volume index (LVESVI) and EuroSCORE risk factors, 32 patients receiving SVR plus CABG and another 32 with isolated CABG were enrolled in this study. The patients were compared for survival rates, major adverse cardiac or cerebrovascular events (MACCEs), left ventricular geometry and function at 1, 3 and 5 years of follow-up. RESULTS: Compared with the patients receiving isolated CABG, those receiving SVR and CABG showed greater improvements in echocardiographic parameters and NYHA functional class. The differences in the echocardiographic parameters between the two groups gradually reduced with time and became comparable at 5 years after the operation (P>0.05). No significant difference was found in the mid- to long-term survival or the incidence of MACCEs between the two groups (P>0.05). CONCLUSION: Compared with isolated CABG, SVR plus CABG does not reduce the incidence of MACCEs or improve the mid- to long-term survival rate of patients with left ventricular aneurysm with a LVESVI <60 mL/m(2).

[Different approaches to revascularization for complex coronary artery disease and left ventricular dysfunction: analysis of perioperative outcomes].

OBJECTIVE: To compare the perioperative outcomes of coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) for treatment of complex coronary artery disease and left ventricular dysfunction. METHDOS: The clinical data of 966 patients admitted to our hospital from January 2003 to December 2013 with coronary artery disease and left ventricular dysfunction (ejection fraction ≤50%) were retrospectively reviewed. Among the patients, 386 underwent CABG and 580 received PCI. After matching for EuroSCORE risk factors and preoperative echocardiographic parameters, 135 patients with CABG and 135 with PCI were enrolled in this study. With hospital mortality and perioperative major complications as the endpoints, the early outcomes of the procedures were evaluated. Perioperative echocardiography was performed to evaluate the change of left ventricular geometry and function. RESULTS: Compared with CABG group, PCI group had significantly higher incidences of chronic lung disease (8.1% vs 0.7%, P=0.003) and recent myocardial infarction (64.4% vs 31.9%, P=0.000) but significantly lower left-main disease (12.6% vs 23.7%, P=0.018); the other baseline characteristics were comparable between the two groups. Patients with CABG had a greater number of treated target vessels than those with PCI (2.90±0.81 vs 1.67±0.73, P=0.000), and complete revascularization was more common in CABG group (94.8% vs 51.8%, P=0.000). No significant difference was found in perioperative variations of LVEF between the two groups, but patients with CABG had a greater variation in LVEDD than those with PCI. The hospital mortality and other major complications were similar between the two groups. CONCLUSION: Both CABG and PCI are safe and reliable revascularization strategies for complex coronary artery disease and left ventricular dysfunction, but CABG can achieve a higher rate of complete revascularization and better improves the left ventricular function.

Establishment of a chronic left ventricular aneurysm model in rabbit.

OBJECTIVES: To establish a cost-effective and reproducible procedure for induction of chronic left ventricular aneurysm (LVA) in rabbits. METHODS: Acute myocardial infarction (AMI) was induced in 35 rabbits via concomitant ligation of the left anterior descending (LAD) coronary artery and the circumflex (Cx) branch at the middle portion. Development of AMI was confirmed by ST segment elevation and akinesis of the occluded area. Echocardiography, pathological evaluation, and agar intra-chamber casting were utilized to validate the formation of LVA four weeks after the surgery. Left ventricular end systolic pressure (LVESP) and diastolic pressure (LVEDP) were measured before, immediately after and four weeks after ligation. Dimensions of the ventricular chamber, thickness of the interventricular septum (IVS) and the left ventricular posterior wall (LVPW) left ventricular end diastolic volume (LVEDV), systolic volume (LVESV), and ejection fraction (EF) were recorded by echocardiogram. RESULTS: Thirty one (88.6%) rabbits survived myocardial infarction and 26 of them developed aneurysm (83.9%). The mean area of aneurysm was 33.4% ± 2.4% of the left ventricle. LVEF markedly decreased after LVA formation, whereas LVEDV, LVESV and the thickness of IVS as well as the dimension of ventricular chamber from apex to mitral valve annulus significantly increased. LVESP immediately dropped after ligation and recovered to a small extent after LVA formation. LVEDP progressively increased after ligation till LVA formation. Areas in the LV that underwent fibrosis included the apex, anterior wall and lateral wall but not IVS. Agar intra-chamber cast showed that the bulging of LV wall was prominent in the area of aneurysm. CONCLUSIONS: Ligation of LAD and Cx at the middle portion could induce development of LVA at a mean area ratio of 33.4% ± 2.4% which involves the apex, anterior wall and lateral wall of the left ventricle.

Increasing patients' ability to identify their physicians with a photo album: a prospective study.

OBJECTIVES: Patients in teaching hospitals often encounter difficulty in correctly identifying their physicians. We hypothesized that a photo album of physicians might increase the ability of patients to correctly identify their physicians and hence conducted this study to test the hypothesis. DESIGN: A prospective study was conducted. SETTING: Department of Surgery, The Third XiangYa Hospital. PARTICIPANTS: THE PATIENTS WERE DIVIDED INTO TWO GROUPS ON ADMISSION: group A as intervention group (n = 75) and group B as control group (n = 94). All the patients were verbally informed of their medical team but only the patients in group A (the intervention group) were also shown the photos of their medical team. MAIN OUTCOME MEASURES: One day before being discharged, the patients in group A (the intervention group) were asked to return the photo albums, and all the patients from both groups were asked to give the names of their caring physicians prior to departure from the hospital. RESULTS: Only 53% of the patients (50 out of 94) in group B (the control group) could give at least one of their physicians' name, while 85% of the patients (64 out of 75) in group A (the intervention group) could tell at least one of their physicians' name; there is a significant difference (p < 0.005, 95% CI, 17.4-44.7%). CONCLUSION: Patients' ability to identify their physicians can be significantly increased with a photo album.

Ultrasound-guided cannulation of the internal jugular vein in robotic cardiac surgery.

BACKGROUND: Robotic assisted minimally invasive cardiac sugery is a new technique that uses small port sites and peripheral vessel cannulation for cardiopulmonary bypass (CPB) has been used. The right internal jugular vein (IJV) is commonly used for intraoperative venous access to the central circulation and identified with an external landmark. Previous studies have demonstrated the superiority of ultrasound guidance over external landmark technique in anaesthetic and intensive care settings. The aim of the present study was to delineate the utility of ultrasound-guided cannulation of the IJV during establishment of peripheral CPB in robotic cardiac surgery. METHODS: We prospectively studied 296 adult patients undergoing ultrasound-guided right IJV cannulation during establishment of peripheral CPB in robotic cardiac surgery at our institute from January 2007 to October 2012 (ultrasound group). The success rate, the first attempt success rate, access time and the complication rate of ultrasound-guided method were compared with the landmark-guided method used for 302 historical control patients (landmark group). RESULTS: In the ultrasound group, 296 consecutive adult patients underwent ultrasound-guided right IJV cannulation during establishment of peripheral CPB in robotic cardiac surgery. In the landmark group, 302 patients underwent right IJV cannulation using the landmark-guided technique. The success rate and the frst attempt success rate in the ultrasound group were significantly higher than that in the landmark group (100% vs. 88.1%, P < 0.000 and 98.6% vs. 38.4%, P < 0.000). Average access time in the ultrasound group was shorter than that in the landmark group ((6.3 ± 13.6) seconds; interquartile range (4 - 62) seconds vs. (44.5 ± 129.5) seconds; interquartile range (5 - 986) seconds). The complication rate in the ultrasound group was significantly lower than that in the landmark group (0.3% vs. 8.3%, P < 0.000). CONCLUSION: Compared with the landmark-guided approach, ultrasound-guided cannulation of the right IJV significantly improves success rate, decreases access time and reduces complication rate during establishment of peripheral CPB in robotic cardiac surgery.

[Robotic internal thoracic artery harvesting and the mid-term follow up of arterial graft patency].

OBJECTIVE: To summarize our experience of robotic internal thoracic artery (ITA) skeletonized harvesting in Asian patients and evaluate the learning curves of robotic ITA harvesting and ITA graft patency. METHODS: A total of 200 patients underwent totally robotic ITA takedown at our department from April 2007 to August 2012. ITA was harvested in a skeletonized fashion and learning curve estimated. Coronary artery bypass grafting was completed in minimally invasive direct coronary artery bypass graft (MIDCAB) or totally endoscopic coronary bypass graft on beating heart (BH-TECAB) manners after robotic ITA harvesting. The coronary angiography or 64-MSCT was performed to evaluate the patency of ITA graft before discharge and at Year 1-5 postoperatively. RESULTS: One patient underwent median sternotomy for severe plural adhesion. Left ITA (LITA, n = 190), right ITA (RITA, n = 5) and double-ITA (n = 4) were harvested. The mean duration of single ITA harvesting was 18-70 (35.8 ± 10.7) min. A significant learning curve was observed: y (min) = 58.0 - 5.3×ln(x) (r(2) = 0.33, P < 0.01). ITA patency was 98.1% at Year 1 and 97.8% at Year 2 postoperatively respectively. And there was no recurrence of ITA occlusion at Years 3-5. CONCLUSIONS: Robotic ITA takedown is a prerequisite for totally endoscopic coronary bypass graft and can be performed safely and within an acceptable time after overcoming a learning curve. ITA graft patency has comparable outcomes of conventional surgery.

[Values of computed tomography angiogram in non-cardiac surgery planning and cardiac risk assessment of coronary atherosclerosis during perioperative period].

OBJECTIVE: To explore the values of detecting coronary atherosclerosis by computed tomography angiogram (CTA) on non-cardiac surgery planning and cardiac risk assessment of coronary atherosclerosis during perioperative period. METHODS: A total of 89 patients with suspected coronary heart disease (CHD) scheduled for non-cardiac surgery underwent coronary CTA to evaluate luminal stenosis and calculate calcification score. There were 56 males and 33 females with a mean age of 65.1 years. Operative sites included chests (n = 29), abdomens and pelvis (n = 26), large vessels (n = 3), bones and joints (n = 19) and other regions (n = 12). Reasons of abandoned or postponed surgery were documented to analyze the influence of CTA results on surgery planning. Cardiac events were recorded to assess the correlation with coronary atherosclerosis. RESULTS: Among them, 75 patients (84.27%) were diagnosed as atherosclerosis while 10 patients (11.24%) were negative; 2 patients had coronary artery bypass and another 2 had stent implantation. According to the results of CTA, 12 operations (13.48%) were canceled and 8 (8.98%) postponed after interventions. Severe stenosis of coronary lumen had significant effects on surgery planning (P = 0.003) while calcification score did not. In patients undergoing surgery as scheduled or after intervention, 1 had atrial fibrillation at post-operation. CONCLUSION: For the patients with suspected CHD scheduled for non-cardiac surgery, severity of coronary stenosis may greatly influence surgery planning. Preoperative coronary CTA may decrease the incidence of cardiac events during perioperative period.

Combined treatment of ulinastatin and tranexamic acid provides beneficial effects by inhibiting inflammatory and fibrinolytic response in patients undergoing heart valve replacement surgery.

OBJECTIVE: To investigate the effect of ulinastatin and tranexamic acid administered alone or in combination on inflammatory cytokines and fibrinolytic system in patients undergoing heart valve replacement surgery during cardiopulmonary bypass (CPB). BACKGROUND: CPB-induced fibrinolytic hyperfunction and systemic inflammatory response syndrome (SIRS) are the leading causes responsible for the occurrence of postsurgical complications such as postsurgical cardiac insufficiency and lung injury, which may lead to an increase in postsurgical bleeding, prolongation of hospital stay, and increased costs. METHODS: One hundred twenty patients undergoing heart valve replacement surgery during CPB were randomly assigned into 4 groups of 30 patients each: blank control group (Group C), tranexamic acid group (Group T), ulinastatin group (Group U), and tranexamic acid-ulinastatin combination group (Group D). Physiological saline, tranexamic acid, ulinastatin, and a combination of tranexamic acid and ulinastatin were given to each group, respectively. Arterial blood was collected from the radial artery at 4 time points: after induction of anesthesia (T1), unclamping the ascending aorta (T2), and at 1 hour (T3) and 24 hours (T4) after CPB. The levels of plasma tumor necrosis factor alpha (TNF-α), interleukin 6 (IL-6), neutrophil elastase (NE), and the concentrations of tissue plasminogen activator (t-PA) and α2-antiplasmin (α2-AP) were detected. The changes in the volume of pericardial mediastinal drainage after surgery were observed and recorded. RESULTS: The plasma TNF-α, IL-6, and NE levels significantly increased in patients from all 4 groups at time points of T2, T3, and T4 in comparison to those before CPB (P < .05), and the plasma TNF-α and IL-6 levels in groups U and D were significantly lower than those in the other 2 groups (P < .05). The plasma t-PA, α2-AP, and D-dimer concentrations significantly increased in patients from all 4 groups at T2 and T3 compared with those before CPB (P < .05), and the plasma t-PA and D-dimer concentrations were significantly lower in groups T and D than those in groups U and C (P < .05) at T2 and T3. The plasma α2-AP concentrations in groups T and D were significantly higher than those in Group C at T3 (P < .05). The volumes of pericardial mediastinal drainage per body surface area were significantly lower in groups T and D than those in Group C 6 hours after the surgery (P < .05). CONCLUSIONS: Ulinastatin inhibits the release of inflammatory medium and reduces the inflammatory response during CPB. Tranexamic acid can effectively inhibit the fibrinolytic hyperfunction caused by CPB and thus decreases postsurgical bleeding. In addition, it exhibits a minor anti-inflammatory response. As a consequence, a combined treatment of ulinastatin and tranexamic acid reduces postsurgical bleeding and shortens postoperative hospital stay in patients undergoing heart valve replacement surgery.

[Clinical factors influencing surgical approach selection of robotic-enhanced minimally invasive coronary artery bypass grafting].

OBJECTIVE: To investigate clinical factors that influence the selection of minimally approach between minimally invasive direct coronary artery bypass (MIDCAB) and totally endoscopic coronary artery bypass (TECAB). METHODS: From February 2007 to January 2013, patients were selected under uniform criteria. A total of 202 patients including 142 male and 60 female patients with age range from 33 to 80 years and average age of (59 ± 10) years were included and were all routinely prepared for TECAB. Either TECAB or MIDCAB was performed based on the intraoperative condition. There were 90 patients who underwent TECAB (TECAB group) and 112 patients who received MIDCAB surgery (MIDCAB group). Univariate analysis was used to compare preoperative, intraoperative and early postoperative parameters. Logistic multivariate regression analysis was used to discuss independent influencing factors of minimally invasive approach selection. RESULTS: All of the patients successfully received TECAB or MIDCAB surgery without mortality, severe complications or conversion to sternotomy. The early and midterm follow up of graft patency (by computed tomography angiography) was satisfactory. The mean operative time was (160 ± 64)minutes, mean graft flow was (27 ± 18) ml/min. Univariate analysis showed that sex ratio (3.5 vs.1.8, t = 4.350, P = 0.037), weight [(69 ± 11)kg vs.(72 ± 11)kg, t = -1.979, P = 0.049], multivessel coronary disease (43.3% vs.60.7%, t = 6.051, P = 0.014), and learning curve case (4.4% vs.14.3%, t = 5.418, P = 0.02) were significant predictors of conversion to MIDCAB. By multivariate analysis, multivessel coronary disease (HR = 1.964, 95%CI: 1.049-3.680, P = 0.035) and learning curve case (HR = 4.538, 95%CI: 1.219-16.891, P = 0.024) were independent influencing factors of MIDCAB approach. CONCLUSIONS: Robotic-assisted minimally invasive coronary artery bypass grafting can be performed safely and effectively either by TECAB or MIDCAB. Multivessel coronary disease and early learning curve cases are independent influencing factors of minimally invasive approach selection.

[Clinical experiences on correction of congenital heart diseases with robotic technology: a report of 160 cases].

OBJECTIVE: To summarize the clinical experiences on correction of congenital heart disease with robotic technology at a single center. METHODS: Between January 2007 and May 2012, this retrospective study recruited 160 consecutive patients undergoing robotic surgery for congenital heart diseases. There were 74 males and 86 females with a median age of 35 years (range: 11-62). The procedures included secundum-type atrial septal defect repair (n = 130), ostium primum defect repair (n = 1), perimembranous ventricular septal defect repair (n = 21), mitral valve repair for anterior leaflet cleft (n = 7) and mitral valve repair plus left atrial myxoma resection (n = 1). Cardiopulmonary bypass graft was established through cannulation of right femoral artery, vein and right internal jugular vein under the guidance of transesophageal ultrasound. Myocardial protection was performed with cold blood cardioplegic solution or HTK solution and a transthoracic Chitwood clamp was used to occlude ascending aorta. Via three 8-mm ports and one 15-mm port in right chest, the microscopic instruments were manipulated to complete defect closure or mitral valve plasty, utilizing da Vinci S or da Vinci SI robotic system. Echocardiography was performed intraoperatively and at pre-discharge. Routine follow-ups were conducted. The clinical data of operating time, cardiopulmonary bypass time and follow-up examinations were retrospectively analyzed. RESULTS: All cases were treated successfully without a conversion into median sternotomy. No operative mortality or severe surgical complications were observed. Seventy-six cases of secundum-type atrial septal defect were completed on beating heart. The learning curves were noted for operating time of beating heart group and cross clamp time of arrest heart group. No residual shunt, malignant arrhythmia or mitral valve regurgitation was detected on intraoperative or postoperative echocardiography and during a median follow-up period of (29.1 ± 16.3) months. CONCLUSION: Robotic minimal access is technically feasible and it may be applied in selective patients with atrial septal defect, perimembranous ventricular septal defect and mitral valve cleft.