Resection of Cardiac Pheochromocytoma With Cardiopulmonary Bypass.

We report a case of a 21-year-old man with a cardiac pheochromocytoma involving the right atrium and extending to the right ventricular inflow tract, which was diagnosed by somatostatin receptor scintigraphy. For the preoperative evaluation, we chose multiple methods of imaging to accurately describe the anatomic extent and location of the tumor and its surrounding tissues, which showed that no major coronary artery ran through the tumor. The tumor was resected with disease-free margins effectively and safely with the use of cardiopulmonary bypass and with cardiac arrest. The patient remained asymptomatic at the 3-month follow-up.

[Sirolimus use in heart transplantation recipients with chronic renal dysfunction].

OBJECTIVE: To observe the effect of sirolimus-based immunosuppression administered on heart transplant recipients with chronic renal dysfunction. METHODS: From June 2004 to December 2008, standard calcineurin inhibitors (CNI)-based immunosuppressive regimen was changed to reduced-dose CNI plus sirolimus due to CNI-related chronic renal dysfunction in 20 out of 138 cardiac transplant recipients at Fuwai Hospital. The standard immunosuppressive regimen included steroid, CNI (cyclosporine or tacrolimus), and mycophenolate mofetil or azathioprine. Sirolimus was started at 0.75 - 1.50 mg/d with titration to achieve levels of 5 - 15 µg/L, and CNI dose was reduced gradually to 1/2-2/3 of the baseline level. Patients were followed for changes in renal function, lipid level and clinical side effects related to immunosuppressive therapy. Endomyocardial biopsy (EMB) was performed routinely at 3 weeks, 3, 6 and 12 months after transplantation. EMB was also performed at 3 months after regimen change within 1 year post-transplantation or when rejections were suspected in patients beyond 1 year post-transplantation. Echocardiography was performed for monitoring purpose. RESULTS: The mean follow-up after regimen change was (7.9 ± 6.3) months. Final sirolimus dose was (0.89 ± 0.22) mg/d and blood drug level was (7.6 ± 3.8)µg/L. Cyclosporine dose was reduced from (191.7 ± 60.0) mg/d to (123.6 ± 34.8) mg/d, with blood drug concentration reduced from (175.5 ± 58.0) µg/L to (111.9 ± 56.0) µg/L in 18 patients (P < 0.01). Tacrolimus average dose was reduced from 4.25 mg/d to 3.00 mg/d, with blood drug concentration reduced from 13.5 µg/L to 10.5 µg/L in 2 patients. Serum creatinine level fell from (160.4 ± 25.5) µmol/L to (134.4 ± 26.8) µmol/L (P < 0.01) and urea nitrogen fell from (13.8 ± 4.7) µmol/L to (10.4 ± 3.0) µmol/L (P < 0.01) at one month after regimen change. Twenty two EMBs were performed in 11 patients within 1 year post-transplant, there were 4 episodes of acute rejected (ISHLT grade 2). Twenty patients are all alive and cardiac function was normal. The most common side effect was hyperlipidemia, and triglycerides, total cholesterol and low density lipoprotein levels were significantly increased at 1 month post regimen change (P < 0.05 or P < 0.01). Leukocyte, hemoglobin and platelet as well as liver function remained unchanged at 1 month post regimen change (all P > 0.05). CONCLUSION: Our results show that change from CNI-based immunosuppressive regimen to reduced-dose CNI plus sirolimus is an effective and safe approach for the management of patients with CNI-related chronic renal dysfunction, leading to an improvement in renal function without compromise in anti-rejection efficacy and with tolerable side effects.

Does the expression of transforming growth factor ß-1: affect the outcome of the radiofrequency modified maze procedure in patients with rheumatic atrial fibrillation?

We investigated whether the expression of transforming growth factor ß-1 in the left atrial appendage affected the outcome of the radiofrequency modified maze procedure in patients with rheumatic valve disease and long-standing persistent atrial fibrillation.Messenger RNA and protein expression of transforming growth factor ß-1 and volume fractions of collagen types I and III were measured in 80 patients with rheumatic valve atrial fibrillation who underwent valve surgery with the radiofrequency modified maze procedure; the same was done in a control group of 20 patients with rheumatic valve disease and sinus rhythm who underwent valve surgery alone.At 6 months' follow-up, atrial fibrillation recurred in 24 of the 80 patients in the study group. The messenger RNA and protein expressions of transforming growth factor ß-1, collagen type I volume fraction, and left atrial dimension had increased gradually in the control group and in the study subgroups that maintained sinus rhythm or relapsed into atrial fibrillation (P <0.05). The messenger RNA and protein expressions of transforming growth factor ß-1 correlated positively with collagen type I volume fraction (r=0.723, P <0.001 and r=0.745, P <0.001, respectively) and left atrial dimension (r=0.762, P <0.001 and r=0.765, P <0.001, respectively). In the sinus rhythm-maintained subgroup, the patients who regained functional atrial contraction had lower messenger RNA and protein expression of transforming growth factor ß-1 than did the patients who failed to retain such function (P <0.05).We conclude that the expression of transforming growth factor ß-1 in the resected left atrial appendage affects the recurrence of atrial fibrillation and restoration of functional left atrial contraction after the radiofrequency modified maze procedure.

Large right coronary artery to left ventricular fistula.

Right coronary to left ventricular fistulas are rare. We report a patient who presented with unstable angina and was found to have a large right coronary to left ventricular fistula.

Repair of a ventricular septal defect in a patient with left lung agenesis.

Congenital heart disease combined with lung agenesis is extremely rare. We report a case of a 5-year-old female with a ventricular septal defect (VSD) and left lung agenesis with severe pulmonary hypertension who underwent successful closure of the VSD.

Redoing a bioprosthetic tricuspid valve replacement with pacemaker wire through the ruined bioprosthetic valve orifice.

Severe tricuspid regurgitation with permanent pacemaker wire passing through the orifice of bioprosthetic tricuspid valve is extremely rare. We present a case of such kind of patient and redid bioprosthetic tricuspid valve replacement. A hawk mouth forceps for bone surgery was used to cut off the mental ring of ruined bioprosthetic tricuspid valve and the ruined valve was removed. A new bioprosthetic tricuspid valve was implanted and the wire of permanent pacemaker was left outside the ring of bioprosthetic tricuspid valve. This method may be helpful for such kind of patient.

Coronary artery bypass grafting for Kawasaki disease.

BACKGROUND: Kawasaki disease (KD) is the leading cause of pediatric ischemic heart disease. The incidence of serious coronary sequelae is low and about 2% - 3% of patients with KD, but once myocardial infarction occurs in children, the mortality is quite high and 22% at the first infarction.This study aimed to evaluate the efficacy of coronary artery bypass grafting (CABG) in patients with KD. METHODS: Eight patients with a history of KD underwent CABG between October 1997 and July 2005. The number of bypass grafts placed was 2 to 4 per patient (mean 2.5 +/- 0.8). Various bypass grafts were used in patients, i.e. the left internal mammary artery (LIMA) in 3 patients, bilateral internal mammary artery (IMA) in 2 patients, LIMA plus gastroepiploic artery (GEA) in 1 patient and total saphenous vein grafts (SVGs) in 2 patients. The combined procedures included ventricular aneurysmectomy in 1 patient, mitral valve plasty in 1 and right coronary aneurysmectomy in 1. One patient was not able to wean from cardiopulmonary bypass (CPB), after being supported with intra-aortic balloon pump (IABP), the patient was weaned from CPB successfully. RESULTS: One patient died of low cardiac output syndrome and acute renal failure 19 days after operation. Other patients recovered and were discharged uneventfully. During the follow-up that ranged from 3 to 57 months (mean 27 months), clincal angina disappeared or improved. Cardiac function was in Class I - II (NYHA). CONCLUSION: CABG is a safe and effective procedure for Kawasaki coronary artery disease. However long-term results need to be followed up.

[Value of estimated glomerular filtration rate and serum creatinine for predicting long-term survival in Chinese patients after isolated coronary artery bypass graft surgery].

OBJECTIVE: To compare the predictive value of glomerular filtration rate (GFR) estimated by the Cockcroft-Gault formula or the modification of diet in renal disease (MDRD) equation and serum creatinine for in-hospital and long-term mortality post coronary artery bypass graft surgery (CABG). METHODS: Clinical data of 5559 consecutive patients undergoing isolated CABG were retrospectively analyzed. The main outcomes were in-hospital mortality and long-term mortality. Estimated GFR was calculated by the Cockcroft-Gault formula and MDRD equation respectively. Receiver-operating characteristic curves and Cox's analysis were used for the comparison. RESULTS: Follow-up was complete in 5485 patients (97.6%). Analysis of receiver-operating characteristic curves showed that GFR estimated by the Cockcroft-Gault formula had a maximal accuracy for predicting in-hospital mortality (area under the curve: 0.755, P < 0.01). Multivariate logistic analysis and the Cox's analysis results indicated estimated GFR < 60 mlxmin(-1)x1.73 m(-2) base on the Cockcroft-Gault formula was an independent risk factor for in-hospital and long-term mortality (hazard ratio 4.51 for in-hospital mortality, P < 0.01; hazard ratio 1.54 for long-term mortality, P < 0.01), both Cockcroft-Gault formula and MDRD equation were superior to serum creatinine for predicting in-hospital and long-term mortality post CABG. CONCLUSION: GFR estimated by the Cockcroft-Gault formula was superior to GFR estimated by the MDRD equation for predicting in-hospital mortality, and estimated GFR was superior to serum creatinine for predicting in-hospital and long-term mortality.

[Estimated glomerular filtration rate as a risk factor for long-term survival in Chinese renal insufficiency patients after isolated coronary artery bypass graft surgery].

OBJECTIVE: To investigate the eGFR as a risk factor for long-term (4-year) outcome in Chinese renal insufficiency patients after isolated coronary artery bypass grafting (CABG) at our institution. METHODS: From January 1999 to September 2003, 3371 consecutive patients who underwent isolated CABG were retrospectively reviewed. Of these patients, 549 (16.29%) patients were female, 1979 (58.71%) patients with hypertension, 866 (25.69%) patients with diabetes, 1130 (33.52%) patients with hyperlipidemia, 1011 (29.99%) patients with left main stenosis > 50%, and 1150 (34.11%) patients undergoing off-pump procedures. The mean age was (60 +/- 9) years old. Estimated GFR was calculated using the Cockcroft-Gault formula. The main outcomes were in-hospital mortality, in-hospital morbidity and long-term mortality. COX analysis was used in this study. RESULTS: There were 649 patients with glomerular filtration rate estimates < 60 ml/(min.1.73 m(2)) and 2722 patients with glomerular filtration rate estimates > 60 ml/(min.1.73 m(2)). The in-hospital mortality and follow-up mortality was higher in the estimated glomerular filtration rate < 60 ml/(min.1.73 m(2)) group (2.77% vs. 0.77%, P < 0.01), (6.81% vs. 2.63%, P < 0.01). The COX analysis result confirmed eGFR < 60 ml/(min.1.73 m(2)), derived using the Cockcroft-Gault formula (HR: 1.948, 95%CI: 1.357 to 2.797, P < 0.01) was an independent risk factor for long-term mortality in patients after coronary artery bypass grafting surgery. CONCLUSIONS: The estimated glomerular filtration rate < 60 ml/(min.1.73 m(2)) derived using the Cockcroft-Gault formula is an independent risk factor for long-term mortality in patients after coronary artery bypass grafting surgery.

Left ventricular reconstruction with no-patch technique: early and late clinical outcomes.

BACKGROUND: Few studies have evaluated late clinical outcome of no-patch technique in patients with large left ventricular aneurysms. The objectives of this study were to evaluate a no-patch surgical technique to reconstruct the left ventricle in patients with left ventricular aneurysm and to assess early and late clinical outcomes. METHODS: In 1995, we began using a no-patch technique in patients with dyskinetic left ventricular aneurysms. A total of 145 patients underwent left ventricular reconstruction with this technique and were followed up for (59 ± 29) months (range, 1 - 127 months). Risk factors for early mortality were analyzed by bivariate analyses. Cox's proportional hazards model was used to calculate risk factors for all-cause mortality and hospital readmission. Kaplan-Meier methodology was used to analyze late survival. RESULTS: One week after operation, left ventricular end-diastolic diameter had decreased from (61 ± 8) mm to (55 ± 8) mm, and geometry of the left ventricle was restored to a more normal conical shape. Early mortality was 3% and late mortality 11%. Over a 5-year follow-up period, hospital readmission was 28%. One-, 5-, and 10-year survival estimates were 95% (95% confidence interval (CI) 91% - 99%), 86% (95%CI 78% - 94%), and 74% (95%CI 60% - 88%). Readmission-free survival at 1 and 5 years after operation was 87% (95%CI 81% - 93%) and 60% (95%CI 50% - 70%), respectively. CONCLUSION: The no-patch technique for left ventricular reconstruction is an effective and simple procedure that can achieve satisfactory early and late clinical outcomes in patients with left ventricular aneurysms.

Extracorporeal membrane oxygenation for treatment of cardiac failure in adult patients.

This report reviews our experience in venoarterial extracorporeal membrane oxygenation (ECMO) support treatment in adult patients with cardiac failure, as well as analysis of the risk factors of early mortality. From February 2005 to June 2008, 45 patients undergoing cardiogenic shock required temporary ECMO support. They were divided into three groups: post-cardiotomy (n=31) and post-transplantation (n=5) heart failure, decompensated heart failure (n=9). ECMO implantation was performed through the femoral vessels, or axillary artery, or through the right atrium and ascending aorta. Average support duration was 126.7+/-104.3 h. Twenty-seven patients could be successfully weaned from support (60%); additionally, five were bridged to heart transplantation. The in-hospital mortality was 42% (19/45). Twenty-six patients (58%) could be successfully discharged. Additional intra-aortic balloon pumps were used in 11 patients, and six of them were successfully discharged. The mortality rate was obviously high for patients with acute renal failure treated by continuous renal replacement therapy (CRRT) under ECMO support (7/9 patients). The dominant mode of death was multisystem organ failure (9/19). ECMO offers effective cardiopulmonary support in adults. The better outcome requires a multidisciplinary approach to prevent complications unique to itself and limit organ injury before and during this support.

[Extracorporeal membrane oxygenation for treatment of cardiorespiratory function failure in adult patients].

OBJECTIVE: To explore the experience on venoarterial extracorporeal membrane oxygenation (ECMO) in adult patients with cardiac failure. METHODS: From February 2005 to June 2008, 45 patients (male 34, female 11) undergoing cardiogenic shock required temporary ECMO support. Average age was (49.0 +/- 14.1) years. Average body weight was (67.0 +/- 12.8) kg. Coronary heart disease occupied in 21 cases, valve disease occupied in 8 cases, and cardiomyopathy occupied in 7 cases. All the patients could be divided into 3 groups: post-cardiotomy (group 1, n = 31), post-transplantation (group 2, n = 5), decompensate of chronic heart failure (group 3, n = 9). Fourteen patients need cardiac resuscitation before ECMO support. ECMO implantation was performed through the femoral vessels or axillary artery or through the right atrium and ascending aorta. RESULTS: Average support duration of ECMO was (126.7 +/- 104.3) h. Twenty-seven patients could be successfully weaned from support (60.0%), additionally, 5 were bridged to heart transplantation. The in-hospital mortality was 42.2% (19/45). Twenty-six patients (57.8%) could be successfully discharged. The discharge rate was 58.1% in group 1, 4/5 in group 2 and was 4/9 in group 3. Twelve patients were re-operated for hemostasis. Three patients need femoral arterial thrombectomy because of ischemia of lower extremity. Additional intra-aortic balloon pumps were used in 11 patients, with 6 patients successfully discharged. The mortality rate for patients with acute renal failure treated by continuous renal replacement therapy under ECMO support was obviously high (7/9). The dominant mode of death was multisystem organ failure (9/19). CONCLUSION: Early indication, control of complications, and paying attention to the treatment after ECMO support could improve our results with increasing experience.

[Mechanical circulation support as emergency bridging for heart transplantation].

OBJECTIVE: To investigate the experience of patients in acute cardiogenic shock required insertion of mechanical circulation support devices (MCS) before undergoing standard pretransplant evaluations. METHODS: From February 2005 to August 2007, 10 patients including 7 male and 3 female required emergency bridging placement of MCS. Average age was (40 +/- 16.2) years old. Mean body weight was (70.8 +/- 18.1) kg. There were 5 patients of dilated cardiomyopathy, 2 patients of arrhythmic right ventricular cardiomyopathy, 2 patients of ischemic cardiomyopathy and 1 patient of end-stage valvular heart disease. All patients were accompanied with acute decompensation of congestive heart failure. Before implantation of MCS, all patients received treatment of three or more inotropic drugs at maximal dosages, 6 patients suffered from ventricular tachycardia, 4 patients required cardio-pulmonary resuscitation treatment and 3 patients suffered from definite function defect of liver and kidney. MCS included ECMO for 8 patients, BVS5000 and MEDOS for 1 patient respectively. RESULTS: The duration of MCS supporting was 3 to 44 d with a mean of (11.5 +/- 13.9) d. Four patients were successfully supported for getting heart transplantation, 1 patient received kidney transplantation simultaneously. Two patients recovered from acute heart failure, discharged and remained on regular heart transplantation list. One patient died from cerebral embolism after 44 days' support and 1 died from multiple organ failure after 3 days' support. Because of severe infection, MCS treatment of 2 patients was terminated ahead of schedule by their family and the patients were lost finally. CONCLUSIONS: The use of MCS devices for acute catastrophic situation appears warranted despite the abbreviated transplant evaluations. It is important for improving the outcomes with beginning MCS support before multiple organ system failure occurs, and accurately identifying individuals who can benefit from MCS.

Surgical outcome and clinical follow-up in patients with symptomatic myocardial bridging.

BACKGROUND: Myocardial bridging with systolic compression of the left anterior descending coronary artery (LAD) may be associated with myocardial ischaemia. The clinical outcome in patients with surgical treatment for symptomatic myocardial bridging remains undetermined. This study assessed the middle- and long-term results of surgical treatment for symptomatic myocardial bridging. METHODS: From 1997 to 2006, 37,463 patients received selective coronary angiography in the Fuwai Cardiovascular Hospital, Beijing, China. Of these, 484 patients had angiographic diagnosis of myocardial bridging. Of the 484 patients, 35 underwent surgery for treatment of myocardial bridging with significant systolic arterial compression. Among the surgical treatment patients, 24 presented with other cardiac disorders, and the remaining 11 symptomatic patients with isolated myocardial bridging were included in the follow-up study. RESULTS: The angiographic prevalence of myocardial bridging was 1.3% in this study. The coronary angiographies of the 11 patients revealed myocardial bridging in the middle segment of LAD causing systolic compression > or = 75% (ranging from 75% to 90%). The mean age of patients was 48.4 years. Surgical myotomy was performed in 3 patients and coronary artery bypass grafting (CABG) in 8 patients. Eight patients were operated on with an off-pump approach and 3 with a cardiopulmonary bypass technique after median sternotomy. Conversion to on-pump CABG surgery was necessary in 1 patient because of perforation of the right ventricle. The left internal mammary artery was used in all patients with CABG. The acute clinical success rate was 100% with respect to the absence of myocardial infarction, death or other major in-hospital complications. All of the patients were followed up clinically. The median follow-up was 35.3 months (range: 6 to 120 months). Nine patients were free from symptoms and one of them continued taking beta blockers. The remaining 2 patients with myotomy had atypical chest pain. One received coronary angiography again and no stenosis was found two years after operation; while exercise testing was performed in the other patient and revealed no evidence of myocardial ischaemia. None of the patients sustained a myocardial infarction or other major adverse cardiac events (death or vessel revascularization) during follow-up. CONCLUSIONS: Myocardial bridging is a relatively common angiographic finding. Surgical myotomy or CABG should be limited to patients who are refractory to oral medication. Surgical relief of myocardial ischaemia due to systolic compression of intramyocardial coronary arteries can be accomplished with low operative risk and excellent middle- and long-term results.

Repair of anomalous origin of right coronary artery from the pulmonary artery.

Anomalous origin of the right coronary artery from the pulmonary artery is a rare cardiac malformation. Between July 2002 and July 2005, we operated on 4 patients with this defect. There were 2 males and 2 females, aged from 18 months to 42 years. Three patients underwent direct re-implantation of the right coronary artery into the aorta, and one had an intrapulmonary tunnel repair (intrapulmonary artery baffle with an autologous pericardial patch for tunneling to the anomalous right coronary ostium). Cardiopulmonary bypass was used in 2 patients, and an off-pump technique in the other 2. One patient had an atrial septal defect that was closed with an Amplatzer septal occluder through the right atrium under transesophageal echocardiography, without cardiopulmonary bypass. All patients survived and recovered uneventfully. Follow-up ranged from 3 to 39 months (mean, 17 months). All patients were doing well and free from symptoms, with normal exercise tolerance. Surgical correction of anomalous right coronary artery shows good early and midterm results.

[Early and middle outcomes of total arterial revascularization using exclusively internal mammary artery and radial artery].

OBJECTIVE: To evaluate the early and mid-results of the use of the radial artery alongside the internal mammary artery for complete arterial revascularization in coronary bypass surgery. METHODS: From January 1999 to January 2005, 123 patients with coronary artery disease with lesions in more than one branch (target vessel), 114 males and 9 females, aged 51.9 +/- 9.4 (32 approximately 74) underwent coronary artery surgery after the complete arterial revascularization pattern. Before the operation the left ventricular ejection fraction (EF) value ranged 30% approximately 78%, and 24 patients (21.1%) had poor ejection fraction (with the EF < 50%). Sixty-four patients (52%) had previous myocardial infarction. Four patients with unstable angina received urgent operation. 36 patients (29.3%) had disease of the left main trunk. 74% of the patients underwent off-pump bypass technique. The mean number of distal anastomoses was 2.6 +/- 0.4 per patient. 20 patients were followed up for 62 +/- 12.8 months (36 approximately 80 months). RESULTS: The early mortality was 0.8%. Postoperative complications included arterial fibrillation in seven patients (5.7%). One patient underwent IABP insertion because of low cardiac output, 3 patients were re-admitted because of heart failure, angina and arrhythmias. Three patients died of cardiac events. One patient underwent redo-CABG due to recurrent myocardial infarction and one patient underwent percutaneous coronary intervention because of stenosis of the arterial graft. CONCLUSIONS: Complete arterial revascularization using radial and mammary arteries provides excellent early results, showing a low mid-term complication rate and surgical morbidity.

Transplantation of mesenchymal stem cells from human bone marrow improves damaged heart function in rats.

BACKGROUND: Bone marrow-derived mesenchymal stem cells (MSCs) are of great therapeutic potential after myocardial ischemic injury. However, little is known about the biological characteristics of MSCs in patients with coronary artery disease and their effects on infracted myocardium. The present study evaluated the biological characteristics of MSCs from patients with coronary artery disease and their effects after being transplanted into infarcted myocardium using a rat model. METHODS: Sternal bone marrow aspirates were taken at the time of coronary artery bypass graft surgery. Mononuclear cells isolated from bone marrow were cultured based on plastic adherence. The morphology and growth characteristics of MSCs were observed in primary and successive passages. A myocardial infarction model was created in 27 adult rats. Two weeks later, animals were randomized into two groups: culture medium (group I, n=13) or MSCs (2x10(6)) from early passages labeled with BrdU (group II, n=14) were injected into the infarcted myocardium. Echocardiography, histological examination, and reverse transcription-polymerase chain reaction (RT-PCR) were performed four weeks after cell transplantation. RESULTS: Flow cytometry analyses demonstrated that adherent spindle cells from bone marrow are mesenchymal stem cells (positive for CD29 and CD44, but negative for CD34 and CD45). Growth curves showed that MSCs have great proliferative capability especially at early passages. MSCs implantation in the infarcted border zone improved left ventricular function significantly in group II compared with group I. However, despite improved left ventricular function, we did not observe significant regeneration of cardiac myocytes. Immunohistochemistry revealed only the expression of desmin in the engrafted MSCs, a marker of premature myocyte. Moreover, the improved left ventricular function in this study seemed to be secondary to the beneficial reverse remodeling induced by the increase of collagen in infarcted zone, the decrease in the adjacent myocardium, and the increase of neovascularization (capillary density: 192+/-7.8/mm2 in group II vs. 165+/-5.9/mm2 in group I, P<0.05). Reverse transcription-polymerase chain reaction (RT-PCR) results showed the expression levels of collagen I, collagen III, SDF-1 (stromal cell-derived factor-1), and VEGF (vascular endothelia growth factor) in the infarcted border zone were significantly higher in the MSCs treated group. CONCLUSIONS: The MSCs from patients with coronary artery disease have a typical phenotype with highly proliferative potential and the engrafted MSCs may regulate extracellular collagens and cytokines to prevent the ventricular scar from pathologic thinning and attenuate the contractile dysfunction of the infarcted heart.

[Results of surgical correction in patients with anomalous origin of the coronary artery from the pulmonary artery].

OBJECTIVE: To evaluate effectiveness of surgical correction in patients with anomalous origin of the coronary artery from the pulmonary artery. METHODS: Between April 1999 and August 2005, 12 patients with anomalous origin of the coronary artery from the pulmonary artery underwent surgical correction. There were 8 patients with anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA), and 4 patients with anomalous origin of the right coronary artery from the pulmonary artery (ARCAPA). Eight patients underwent direct aortic reimplantation, and 4 patients underwent a Takeuchi procedure (intrapulmonary artery baffle with an autologous pericardial patch). Simultaneous mitral annuloplasty was performed in 7 patients of ALCAPA with moderate and severe mitral regurgitation. One patient of ARCAPA was associated with an atrial septal defect (ASD) which was closed with an amplatzer septal occluder through right atrium under transesophageal echocardiography (TEE) without CPB. RESULTS: There were neither early and late deaths nor postoperative complications. Follow-up of all patients ranged from 7 to 83 months (mean, 32 +/- 24 months). The left ventricular function after operation improved from a preoperative fractional shortening (FS) of 0.21 +/- 0.09 to 0.35 +/- 0.06 (P = 0.006) for patients with ALCAPA. Preoperative mitral regurgitation decreased in 7 patients of ALCAPA after mitral annuloplasty at the follow-up. All patients were doing well and their exercise tolerance improved to normal. They were free from symptoms. CONCLUSIONS: Reestablishment of a two-coronary system is necessary for patients with anomalous origin of the coronary artery from the pulmonary artery. The left ventricular function improved after 2-coronary repair. We recommend that the simultaneous mitral annuloplasty should be performed at the time of operation for patients who have moderate and severe mitral regurgitation with ALCAPA. Surgical correction of ARCAPA and ARCAPA show good early and mid-term results, long-term results need to be followed up.

[Surgical treatment of giant coronary artery aneurysm].

OBJECTIVE: To discuss the clinical features and surgical treatments of giant coronary artery aneurysm (CAA). METHODS: From July 1996 to October 2004, 6 giant CAA patients were underwent surgery at Fuwai hospital. Three cases were underwent CAA resection, 2 concomitant coronary bypass, 3 reconstruction. The giant CAA was often combined with other cardiac diseases. Four cases underwent additional procedures of fistula closure, 3 aortic valve replacements, 2 aortoplasty and 1 thrombus cleaning at the same time. RESULTS: All patients recovered uneventfully. The mean of cardiopulmonary bypass time was (144 +/- 26) min (range 67 to 207 min). Aortic cross clamping time was (104 +/- 21) min (range 56 to 172 min). Patients follow-up time occurred from 8 to 87 months (mean of 48 months). All patients were free of symptoms during follow-up. None of the patients died during the follow-up period and none of the CAA recurred. CONCLUSIONS: The giant CAA is a serious cardiovascular disease, early diagnosis and surgical treatment are mandatory.

[The safety and efficacy of basiliximab as induction agent in preventing early acute rejection in Chinese cardiac transplantation receipts].

OBJECTIVE: To investigate the safety and efficacy of basiliximab as induction agent in preventing early acute rejection post heart transplantation. METHODS: Basiliximab (20 mg, iv) was administered one hour before and 4 days post operation to patients (n = 47) underwent heart transplantation between June 2004 and Feb 2005 in our department. Intravenous methylprednisolone (500 mg at operation beginning and repeated immediately post operation, followed by 125 mg every 8 hours for the first day). Prednisone was then initiated at 1 mg.kg(-1).d(-1) tapered 10 mg every 3 days to 10 mg/d. Mycophenolate mofetil (MMF, 0.5 - 1.0 g twice daily) was also administered post intubation, oral Cyclosporine A (CsA, 3 to 6 mg.kg(-1).d(-1)) was prescribed after transplantation if serum creatinine was < 150 micromol/L. The dose of CsA was individually adjusted to achieve a target serum concentration of 180 - 300 ng/ml. Endomyocardial biopsies were performed 3 weeks (19.7 +/- 9.6) d post heart transplantation. Biopsy specimens were graded according to the standardized criteria of the International Society for Heart and Lung Transplantation (ISHLT). Echocardiograms were routinely performed weekly within the first 3 weeks post-operation. RESULTS: All 47 consecutive patients [mean age (44.9 +/- 13.4) years, range 13 - 63 years, 38 men] survived the operation and the underlying diseases was idiopathic cardiomyopathy (42.5%), ischemic heart disease (25.5%), arrhythmogenic right ventricular cardiomyopathy (17.0%), hypertrophic cardiomyopathy (4.2%), heart tumor (4.25%), valve heart disease (2.1%), hypertensive cardiomyopathy (2.1%) and giant cell myocarditis (2.1%). There were 4 patients with pre-operation PRA > 10% and CDC was less than 5% in all patients. The grades of the acute rejection in biopsy specimens were as follow: Grade (G) 0 in 30 (63.8%), G IA in 11 (23.4%), G IB in 3 (6.3%) and GII in 3 (6.3%) patients. The average dose of MMF was (1.2 +/- 0.3) g/d. The initial time of receiving CsA was (3.4 +/- 2.1) day post operation. The average cumulative dose of CsA was (4.1 +/- 1.2) mg.kg(-1).d(-1) before endomyocardial biopsy. The average serum concentration of CsA was (237.0 +/- 76.2) ng/ml. Left ventricular ejection fraction assessed by echocardiogram was normal in all patients within the first 3 weeks. Five patients suffered from respiratory infections and recovered post antibiotic and symptomatic therapies. CONCLUSION: Basiliximab as induction agent in combination with conventional triple immunosuppressive therapy is safe and effective in preventing acute rejection in Chinese cardiac transplantation receipts.