Intracardiac thrombosis after congenital heart disease surgeries in neonates: a report of two cases.

BACKGROUND: Intracardiac thrombosis (ICT) is a rare complication after the cardiopulmonary surgery for interrupted aortic arch (IAA) or total anomalous pulmonary venous connection (TAPVC) without previous records. There are still no general guidelines regarding as the mechanism or management of postoperative ICT in neonates and younger infants. CASE PRESENTATION: We reported the conservative and surgical therapies in two neonates with intra-ventricular and intra-atrial thrombosis after the anatomical repair for IAA and TAPVC, respectively. There were no risk factors for ICT in both patients, except for the use of blood product and prothrombin complex concentrate. The surgery was indicated after TAPVC correction due to the worsening respiratory status and rapidly decreased mixed venous saturation. Anticoagulation combined with antiplatelet therapies was adopted in another patient. These two were both finally recovered, and three-month, six-month, and one-year follow-up echocardiography revealed no abnormality. CONCLUSIONS: ICT is uncommon in pediatric population after the surgery for congenital heart disease. Single ventricle palliation, heart transplantation, longer central line use, post-extracorporeal membrane oxygenation, and massive blood product use are major risk factors for postcardiotomy thrombosis. The causes of postoperative ICT are multifactorial, and the immaturity of thrombolytic and fibrinolytic system in neonates may serve as a prothrombotic factor. However, no consensus reached regarding as the therapies for postoperative ICT, and the large-scale prospective cohort study or randomized clinical trial is needed.

Non-obstructed supracardiac total anomalous pulmonary venous connection with giant superior vena cava aneurysm.

BACKGROUND: Giant superior vena cava (SVC) aneurysm in non-obstructed supracardiac total anomalous pulmonary venous connection (TAPVC) is even more rare than in obstructed one, and this combination has not been reported. CASE PRESENTATION: Here we reported a 29-year-old young lady with non-obstructed TAPVC complicated with a giant SVC aneurysm. Routine TAPVC correction and tricuspid valve repair were done. Additionally, venoctomy was carried out to seek for its histological etiology and to avoid potential complications. CONCLUSIONS: If confirmed by further and larger experiences, for patients with non-obstructed supracardiac TAPVC with giant SVC aneurysm, surgical treatment of SVC aneurysm could be more aggressive to prevent cardiovascular complications.

Percutaneous-perventricular device closure of ventricular septal defect: mid-term follow-up.

BACKGROUND: This report presents updated data and mid-term follow-up information to a former study introducing the novel technique of percutaneous-perventricular device closure of doubly committed subarterial ventricular septal defect. METHODS: Thirty-eight patients were added to the former series. There were 54 patients in total who had isolated doubly committed subarterial ventricular septal defects and underwent percutaneous-perventricular device closure. Closure outcomes and possible complications were measured in the hospital and during the 2.5-year follow-up. RESULTS: Surgery was successful in 53 patients (98.1%). There was no death, residual shunt, new valve regurgitation or arrhythmia either perioperatively or during the entire follow-up period. Only one patient developed pericardial effusion and tamponade in the former series. The mean hospital stay was 3.2 ± 0.6 days (range, 3.0 to 6.0 days), and only one unsuccessful case needed blood transfusion (1.9%). CONCLUSIONS: The percutaneous-perventricular device closure of isolated doubly committed subarterial ventricular septal defects appeared to be safe. Close monitoring for bleeding is essential postoperatively, especially in younger patients. This technique is generally safe with acceptable mid-term follow-up.

Giant right atrial aneurysm with atrial fibrillation.

Congenital right atrial aneurysm is a rare condition. Here we reported a 16-year-old male with giant right atrial aneurysm, atrial fibrillation, and atrial septal defect. Surgical resection of extensive right atrium, ASD repair, and maze procedure were performed. In the present case, we found extensive enlargement of right atrium protruding to the apex on the surface of the right ventricle. With the exist of atrial fibrillation, thrombus formation was always a lethal threat. Surgical treatment can provide excellent clinical results and further avoided life-threatening complications.

Fistula occlusion and ligation for a giant right coronary artery aneurysm concurrent with right atrial fistula: a case report.

BACKGROUND: Coronary artery aneurysms in most cases require surgical treatment once diagnosed. Lifelong anticoagulation is often needed after surgery. We herein describe a 55-year-old man who was asymptomatic and diagnosed with right giant coronary artery aneurysm combined with right atrial fistula. CASE PRESENTATION: This is a case of asymptomatic giant right coronary artery aneurysm concurrent with coronary artery fistula. Because the aneurysm was in the distal right posterior descending coronary artery, right coronary artery ligation and fistula occlusion through the right atrium were performed in the absence of cardiopulmonary bypass. The aneurysm was excluded without impacting the myocardial blood supply, and the patient was exempted from lifelong anticoagulation regimen. The follow-up revealed favorable outcomes and the patient's life expectancy was improved. CONCLUSION: Decompression and exclusion without cardiopulmonary bypass can be adopted for distal coronary artery aneurysms that do not involve or only have a limited impact on distal blood supply. This procedure can exempt the patient from the lifelong anticoagulation regimen. In addition, the risk for myocardial ischemia caused by the thrombus in the aneurysm can also be avoided. The whole procedure is comparatively easy to perform.

[The Establishment of Tunica Media-induced Systemic Inflammatory Responses Animal Model].

OBJECTIVE: To establish animal model of tunica media-induced systemic inflammatory responses and verify the stability of established model. METHODS: Tunica media of aorta was captured from C57/BL6 mouse donor, followed by the intervention of homogenization. After centrifugation, the supernatant was harvested and injected into the acceptor of C57/BL6 mouse to mimic the featured pathological changes induced by the exposure of tunica media with circulation. ELISA assay was used to detect the levels of tumor necrosis factor-α (TNF-α) and interleukin-6 (IL-6). RESULTS: The levels of TNF-α, IL-6 in the model group were significant higher than those in the control group (P<0.05). There were two peak values of both TNF-α and IL-6 identified at 3 h and 24 h after the injection of supernatant in the model group. CONCLUSION: The exposure of tunica media to circulation may induce systemic inflammatory responses.

Modified Warden procedure for partial anomalous pulmonary venous return to the superior vena cava.

BACKGROUND: We report the long-term outcomes of our modified Warden cavoatrial technique, originally reported in 2010, for the treatment of anomalous pulmonary veins, which insert into the superior vena cava (SVC). METHODS: This study was conducted between 2007 and 2015 in 26 patients (18 females, eight males) with a mean age of 22 years (range, 4-70 years). Twenty-four patients had a sinus venosus atrial septal defect and one patient had two partial anomalous pulmonary venous connections to the SVC. Two patients with persistent left SVC underwent right SVC division without reimplantation. RESULTS: There were no short- or long-term mortalities. The mean follow-up was 4.6 years (range, three months to eight years). All patients had unobstructed caval and pulmonary venous flow and no long-term arrhythmias. CONCLUSIONS: The modified cavoatrial anastomosis technique has shown excellent results with unobstructed pulmonary and systemic venous flow without long-term arrhythmias.

[The Association Between Bone Morphogenic Protein-4 and in-situ Saphenous Vein Graft Pathology in Diabetic Patients Undergoing Coronary Revascularization].

OBJECTIVES: This study was designed to assess the expression levels of bone morphogenic protein-4 (BMP4) in saphenous veins harvested from diabetic patients undergoing coronary artery bypass grafting (CABG), and to investigate its association with in-situ morphological and pathological changes within the venous wall. METHODS: From January 2013 to December 2014, forty patients with type 2 diabetes mellitus (DM) and risk factors matched non-DM controls (n =40) were enrolled prospectively. Of the 40 DM patients, 24 had noninsulin-dependent diabetes (NIDM) and the remaining 16 had insulin-dependent diabetes (IDM). Segments of saphenous vein without surgical dilatation from these 80 patients were obtained. Vessel wall characteristics were evaluated by hematoxylin-eosin (HE) staining, and the expression and distribution of BMP4 was assessed by Western blot assay and immunohistochemistry analysis. RESULTS: The intimal and medial thickness of the saphenous veins harvested from DM patients were higher than those from non-DM controls. Compared with non-DM patients, the expression level of BMP4 was significantly elevated in diabetic veins ( P<0.05), and BMP4 was highly expressed in smooth muscle cells located in the medial layer. Moreover, the expression levels of BMP4 in diabetic veins were significantly correlated with intimal thickness (r =0.655, P<0.01), intimal area (r =0.684, P<0.01), medial thickness (r =0.642, P<0.01) and medial area (r =0.692, P<0.01). CONCLUSIONS: The pre-existing intimal and medial hyperplasia were significantly correlated with the high expression levels of BMP4 in saphenous veins harvested from diabetic patients, implying a potential role of BMP4 in the progression of vein graft stenotic diseases in this cohort of post-CABG patients. Future studies were warranted in investigating novel therapeutic strategy targeting at BMP4 for improving long-term vein graft patency.

A Novel Hybrid Approach for Balloon Dilation of Pulmonary Vein Stenosis Following Total Anomalous Pulmonary Venous Connection Repair with Atrial Septal Patching.

Pulmonary venous obstruction after the repair of total anomalous pulmonary venous connection is a serious complication. Transcatheter interventional treatment is a palliative choice to defer the timing of surgery; however, penetrating through the patched atrial septum may be difficult. We report a technique for pulmonary venous obstruction after mixed-type total anomalous pulmonary venous connection repair using balloon dilatation of the pulmonary veins through a novel hybrid approach.

Surgical restoration of left ventricular diastolic function: possible treatment for noncompaction cardiomyopathy.

Noncompaction of the left ventricle is a rare congenital cardiomyopathy characterized by prematurely arrested compaction of the endocardial and myocardial fibers resulting in impaired systolic and diastolic ventricular function. Nontransplant surgical treatment is lacking and limited to correction of accompanied valve problems or arrhythmias. We present a technique for surgical restoration of ventricular diastolic function in a patient with noncompaction of the left ventricle.

Hybrid perventricular device closure of doubly committed subarterial ventricular septal defects: mid-term results.

BACKGROUND: Doubly committed Subarterial ventricular septal defect (VSD) is a specific anatomic type of VSD located just beneath the aortic valve. The purpose of this study was to evaluate the safety and feasibility of using minimal invasive perventricular device closure in managing this type of VSD. METHODS: During Dec 2008 and Aug 2010, 34 Pediatric patients with doubly committed subarterial VSD who met the inclusion criteria for device closure were enrolled in this study. Perventricular closure was attempted using a unique design eccentric device under the guidance of real-time transesophageal echocardiography. Complications such as residual shunt, valve regurgitation, arrhythmias were all recorded in postoperative period and during follow-up. RESULT: Perventricular device closure was successfully done in 28 patients (82%). 6 patients converted to open surgical repair due to residual shunt >3mm (1 patient), more than mild degree aortic regurgitation (3 patients) and device mal-position (2 patients). Complete closure rate was achieved in 93% at discharge and 100% during 20 months follow-up. No severe complications such as device embolism, significant arrhythmias and noticeable valve regurgitation were noted during follow-up. Procedure induced trivial grade aortic valve regurgitation was noted in five (18%) patients after procedure while only one (4%) persisted during midterm follow-up. CONCLUSION: Perventricular closure of doubly committed subarterial VSDs appears to be a safe and effective minimally invasive technique with good mid-term outcomes.

Perventricular device closure of perimembranous ventricular septal defect in pediatric patients: technical and morphological considerations.

BACKGROUND: We report our experience of using perventricular device closure (PVDC) in treating perimembranous ventricular septal defect (pm-VSD) with emphasis on technical and morphological considerations. METHOD: Thirty-one pediatric patients with pm-VSD who underwent successful PVDC were enrolled in this study. The pm-VSDs were divided into three different types (type I: tunnel shape; type II: with subaortic rim < 2 mm; type III: membranous aneurysm formation). Four closure strategies were utilized, corresponding to the morphology of the pm-VSD. RESULTS: Mean age of the patients was 2.1 years with mean VSD diameter 5.8 mm. Seven patients had type I VSD, nine presented with type II, and 15 had type III. Twenty-two concentric and nine eccentric devices were used with mean device size 7.3 mm. Complete closure was achieved in 97% of cases during follow-up. Procedure-induced tricuspid regurgitation (TR) was noted in nine patients at discharge; four resolved. Multivariable analysis showed that the procedure-induced TR was associated with the device size (odds ratio = 5.059; 95% confidence interval = 1.431-17.880). CONCLUSION: Different closure strategies allow for PVDC of various types of pm-VSDs in selected pediatric patients.

[Establishment and evaluation of extracorporeal circulation model in rats].

OBJECTIVE: To establish an extracorporeal circulation (ECC) rat model, and evaluate the inflammatory response and organ injury induced in the model. METHODS: SD rats were anesthetized and cannulated from right common carotid artery to left femoral vein to establish the bypass of extracorporeal circulation. Then the rats were randomly divided into ECC group and sham group. The rats in ECC group were subjected to extracorporeal circulation for 2 hours and then rest for 2 hours, while the rats in sham group were only observed for 4 hours without extracorporeal circulation. After that, blood routine examination, blood gas analysis, the measurement of pro-inflammatory factors in bronchoalveolar lavage fluid and lung tissue were performed to evaluate the lung injury induced by ECC. Circulating endothelial cells were also calculated by flow cytometry to assess the vascular endothelial injury. RESULTS: At 2 hours after ECC, red blood cell counts in both groups kept normal, while leukocyte and neutrophil counts, plasmatic tumor necrosis factor-a level and neutrophil elastase level, circulating endothelial cells in the rats of ECC group were significantly higher than those in sham group. Tumor necrosis factor-alpha in bronchoalveolar lavage fluid and water content in lung of the ECC rats were also significantly higher, while the oxygenation index was significantly lower. Neutrophil infiltration was also observed in lung tissues with increased thickness of alveolar membrane in ECC group. CONCLUSION: The ECC model established from right common carotid artery to left femoral vein in our study can successfully induce systemic inflammatory response, and acute lung injury associated with inflammation.

Management of a giant aortic root aneurysm in a young patient with Marfan syndrome: a case report.

INTRODUCTION: Marfan syndrome (MFS) is a common heritable connective tissue disease involving multiple organs. Even though the clinical manifestations of MFS can be various, aortic root aneurysm is estimated as one of the most serious complications. We herein describe an individualized treatment decision-making process for a 23-year-old male with MFS, suffering from a giant but stable aortic root aneurysm which is extremely rare at his age. CASE: The patient, a 23-year-old male with a family history of MFS, presented to our cardiovascular department because of progressive exertional chest distress, fatigue and occasional precordial pain. Physical examinations revealed 190.5 cm of height, high myopia, and a diastolic murmur at the aortic valve area. Laboratory examinations for systemic vasculitis and infectious diseases were negative. Transthoracic echocardiography and enhanced thoracic computed tomography (CT) scan revealed the existence of a giant aortic root aneurysm (125.1 mm in short-axis), severe aortic valve regurgitation, cardiac dilatation (LV; 99 mm in diastolic diameter) and a poor ejection fraction (EF; 18%). Considering the risk of rupture or dissection of the dilated aortic root, we performed Bentall procedure based on the results of multidisciplinary team discussion and intraoperative exploration. Postoperative thoracic CT scan revealed a normal sized reconstructed aortic root, and the patient was discharged uneventfully 7 days later. CONCLUSION: It is extremely rare to report such a giant aortic root aneurysm in a young patient. In the treatment decision-making process, the patient's specific situation should be taken into consideration. A mechanical Bentall procedure seems to be an acceptable option for some selected cases.

Physical Predictors of Cognitive Function in Individuals With Hypertension: Evidence from the CHARLS Basline Survey.

The purpose of the study was to examine the independent associations of each individual physical performance measure (i.e., grip strength, walking speed, repeated chair stands, and balance test) with subdomains of cognitive function and to determine predictors for each subdomain of cognitive function. A secondary data analysis was performed using a nationally representative middle-aged and older sample of hypertensive population. The findings showed that after adding all four physical performance measures, stronger grip strength was significantly associated with better visuospatial abilities, episodic memory, orientation/attention, and overall cognitive function. In addition, faster walking speed and faster repeated chair stands were strongly associated with better episodic memory and overall cognitive function, respectively. Because grip strength was significantly associated with several subdomains of cognitive functioning, it seems conceivable that increasing physical activity would improve both grip strength and cognitive function in patients with hypertension.

The influence of medical abortion compared with surgical abortion on subsequent pregnancy outcome.

Seven prospective cohort studies (12484 cases) were included in this review of the respective effects on the next pregnancy of medical and surgical abortion in early pregnancy. The incidence of miscarriage and postpartum hemorrhage was significantly lower in the pregnancy following a medical abortion. No other significant differences were found. With respect to the outcome of the next pregnancy, first-trimester medical abortions may thus be safer than the surgical option.