Hirsutella sinensis fungus improves cardiac function in mouse model of heart failure.

Cordyceps sinensis, including Hirsutella sinensis, is a highly valuable traditional Chinese medicine and is used to treat patients with pulmonary heart disease in clinical practice. However, the underlying mechanisms of its effects remain unclear. In this study, a mouse model of heart failure established by non-thoracic, transverse aortic constriction (TAC) was developed to determine the underlying mechanisms of therapeutic effects of Hirsutella sinensis fungus (HSF) powder. The results showed that HSF treatment remarkably ameliorated myocardial hypertrophy, collagen fiber hyperplasia, and cardiac function in mice with heart failure. Using transcriptional and epigenetic analyses, we found that the mechanism of HSF mainly involved a variety of signaling pathways related to myocardial fibrosis and determined that HSF could reduce the levels of TGF-ß1 proteins in heart tissue, as well as type I and III collagen levels. These data suggest that HSF alleviates heart failure, inhibits irreversible ventricular remodeling, and improves cardiac function through the regulation of myocardial fibrosis-related signaling pathways, which can provide novel opportunities to improve heart failure therapy.

The effect of Guanxin Shutong capsule on alleviating the myocardial fibrosis in heart failure rats.

ETHNOPHARMACOLOGICAL RELEVANCE: Guanxin Shutong (GXST) capsule is a renowned traditional Chinese medicine widely used for the treatment of cardiovascular diseases in the clinic. However, no pharmacological experimental studies of GXST has been reported on the treatment of pressure overload-induced heart failure. This study aimed to investigate the effects of GXST capsule on ameliorating myocardial fibrosis conditions in pressure overload-induced heart failure rats. MATERIAL AND METHODS: Rats were randomly divided into 6 groups: Normal group, Model group, GXST-treated group at a dose of 0.5 g/kg, 1 g/kg, 2 g/kg, respectively, and digoxin positive control group at a dose of 1 mg/kg. After 4 weeks of administration, cardiac function was evaluated by echocardiography. Cardiac injury and fibrotic conditions were evaluated by H&E staining, Masson staining, and Sirius Red staining. Myocardial fibrosis was evaluated by immunohistochemistry staining and Western blot. RESULTS: GXST significantly inhibited cardiac fibrosis, reduced the excessive deposition of collagen, and finally improved cardiac function. GXST reversed ventricular remodeling might be through the TGF-ß/Smad3 pathway. CONCLUSION: GXST capsule demonstrated a strong anti-fibrosis effect in heart failure rats by inhibiting the TGF-ß/Smad3 signaling pathway.

Chimney reconstruction provides a wider subaortic space and reduces the risk of pulmonary artery compression in the Norwood-type aortic arch reconstruction without patch supplementation.

OBJECTIVES: Pulmonary artery (PA) compression by the neoaorta is a serious complication after the Norwood-type palliation (NP) for hypoplastic left heart syndrome. Either excess patch tailoring or limited use of autologous tissue may cause narrowing of the subaortic space. The chimney technique could theoretically provide a wide subaortic space. METHODS: Twenty-nine patients with both pre- and post-NP computed tomography data available of the 37 consecutive patients who underwent NP in our institution were reviewed. Arch height, arch width, sinus of Valsalva diameter, area under the neoaortic arch and arch angle were measured. These patients were divided according to the neo-arch reconstruction technique, chimney reconstruction technique (CR) or conventional direct reconstruction technique (DR). RESULTS: Median age and weight at NP were 2.1 months and 3.5 kg, respectively. Twenty-two patients underwent previous bilateral PA banding. During NP, 17 CR and 12 DR were performed. Four patients in the DR group developed PA compression. No neoaortic arch dilatation was found in either group. Post-NP arch width, area under the neo-arch and the arch angle were significantly larger in the CR group. Pre-NP arch height was significantly smaller in DR patients with PA compression than in those without. CONCLUSIONS: The chimney technique decreased the risk of PA compression and provided a wider subaortic space and a less acute arch angle. This technique had no short-term effect on the neoaortic root. Small preoperative arch height is a potential risk factor for PA compression in DR, and the chimney technique could be an effective solution.

Effect of Autotransfusion Using Intraoperative Predonated Autologous Blood on Coagulopathy during Thoracic Aortic Surgery: A Randomized Controlled Trial.

BACKGROUND: Intraoperative predonated autologous blood transfusion is thought to replenish platelets and coagulation factors and ameliorate coagulopathy. This study aimed to evaluate whether intraoperative predonated autotransfusion improves coagulopathy during thoracic aortic surgery. METHODS: Patients who underwent thoracic aortic surgery were randomized into two groups as follows: those who received intraoperative predonated blood (group A: n = 31) and those who did not receive (group N: n = 22). In group A, autologous blood was retransfused immediately after cessation of cardiopulmonary bypass (c-CPB). RESULTS: The mean intraoperative allogenic blood or blood product transfusion requirements were significantly lesser in group A than in group N (packed red blood cells [RBCs]: 6.3 ± 5.1 vs. 9.1 ± 4.3 units, p = 0.04; fresh frozen plasma [FFP]: 3.0 ± 4.1 vs. 6.1 ± 5.7 units, p = 0.03). After c-CPB, hemoglobin (Hb) level, platelet count, and coagulopathy became significantly worse than those at the start of surgery in both the groups. However, the values significantly improved 30 min after c-CPB only in group A. Renal function was significantly worse in group N. CONCLUSIONS: Intraoperative predonated autotransfusion significantly improved coagulopathy, with reduced allogeneic blood transfusion volume during thoracic aortic surgery. Furthermore, reduction of allogeneic blood transfusion may reduce the adverse effects on renal function.

Minimally Invasive Endovascular Repair of Ascending Thoracic Aortic Aneurysm with Use of Local Anesthesia and Conscious Sedation.

Ascending thoracic aortic aneurysm (ATAA) is typically treated surgically. No commercially available device has been specifically designed for endovascular ATAA repair, and currently, multiple anatomic and technical challenges affect its feasibility. Previously, such repairs have been performed with the patients under general anesthesia. We describe a novel, minimally invasive approach to endovascular repair of ATAA, involving local anesthesia, conscious sedation, and 24-hour hospitalization. Two consecutive male patients (ages, 79 and 54 yr) who had comorbidities underwent percutaneous transfemoral endovascular ATAA repair with use of commercially available endografts. Patient 1 had a saccular aneurysm, and Patient 2 had a pseudoaneurysm consequent to recent surgical ATAA repair. The patients were discharged from the hospital 24 hours after technically successful, uncomplicated procedures. At 2 months, computed tomograms showed no endoleak or stent-graft migration. Our experience shows that minimally invasive endovascular ATAA repair is feasible for selected high-risk patients. We describe the procedure, access and closure devices, and challenges associated with this approach.

Hyperbaric oxygen therapy for spinal cord ischaemia after complex aortic repair - a retrospective review.

BACKGROUND: Complex aortic repair (CAR) carries high rates of debilitating postoperative complications, including spinal cord injury. The rate of spinal cord deficits post-CAR is approximately 10%, with permanent paraplegia in 2.9% and paraparesis in 2.4% of patients. Treatment options are limited. Rescue therapies include optimization of spinal cord perfusion and oxygen delivery by mean arterial pressure augmentation (> 90 mm Hg), cerebrospinal fluid drainage, and preservation of adequate haemoglobin concentration (> 100 g L⁻¹). Hyperbaric oxygen therapy (HBOT) has been described in several case reports as part of the multimodal treatment for spinal cord ischemia. HBOT has been used in our centre as adjunct rescue treatment for patients with spinal cord injury post-CAR that were refractory to traditional medical management, and we aimed to retrospectively review these cases. METHODS: After Research Ethics Board approval, we performed a retrospective review of all post-CAR patients who developed spinal cord injury with severe motor deficit and were treated with HBOT at our institution since 2013. RESULTS: Seven patients with spinal cord injury after CAR were treated with HBOT in addition to traditional rescue therapies. Five patients showed varying degrees of recovery, with two displaying full recovery. One developed oxygen-induced seizure, medically treated. No other HBOT-related complications were noted. CONCLUSIONS: Our retrospective study shows a potential benefit of hyperbaric oxygen therapy on neurological outcome in patients who developed spinal cord injury after CAR. Prospective research is needed to understand the role, efficacy, benefits and risks of HBOT in this setting.

One-year experience of a regional service model of teleconsultation for planning and treatment of complex thoracoabdominal aortic disease.

OBJECTIVE: The objective of this study was to report the methodology and 1-year experience of a regional service model of teleconsultation for planning and treatment of complex thoracoabdominal aortic disease (TAAD). METHODS: Complex TAADs without a feasible conventional surgical repair were prospectively evaluated by vascular surgeons of the same public health service (National Health System) located in a huge area of 22,994 km2 with 3.7 million inhabitants and 11 tertiary hospitals. Surgeons evaluated computed tomography scans and clinical details that were placed on a web platform (Google Drive; Google, Mountain View, Calif) and shared by all surgeons. Patients gave informed consent for the teleconsultation. The surgeon who submits a case discusses in detail his or her case and proposes a possible therapeutic strategy. The other surgeons suggest other solutions and options in terms of grafts, techniques, or access to be used. Computed tomography angiography, angiography, and clinical outcomes of cases are then presented at the following telemeetings, and a final agreement of the operative strategy is evaluated. Teleconsultation is performed using a web conference service (WebConference.com; Avaya Inc, Basking Ridge, NJ) every month. An inter-rater agreement statistic was calculated, and the κ value was interpreted according to Altman's criteria for computed tomography angiography measurements. RESULTS: The rate of participation was constant (mean number of surgeons, 11; range, 9-15). Twenty-four complex TAAD cases were discussed for planning and operation during the study period. The interobserver reliability recorded was moderate (κ = 0.41-0.60) to good (κ = 0.61-0.80) for measurements of proximal and distal sealing and very good (κ = 0.81-1) for detection of any target vessel angulation >60 degrees, significant calcification (circumferential), and thrombus presence (>50%). The concordance for planning and therapeutic strategy among all participants was complete in 16 cases. In one case, the consultation was decisive for creating an innovative therapeutic strategy; in the remaining seven cases, the strategy proposed by the patient's surgeon was changed completely after the discussion. Technical success was the same (100%) if concordance in planning was present initially or not. Overall 6-month mortality was 4%, 0% for those patients with initial concordance in planning vs 12% for those without initial concordance (P = .33). Surgery was always performed in a tertiary hospital by local surgeons, and in two cases (8%) external surgeons joined the local surgical team. CONCLUSIONS: Such a regional service of teleconsultation may be of value in standardizing the treatment and derived costs of complex TAADs in a huge region under the same health provider. The shared decision-making strategy may be of medical-legal value as well.

Salvianolic Acid B Alleviates Heart Failure by Inactivating ERK1/2/GATA4 Signaling Pathway after Pressure Overload in Mice.

BACKGROUND: Heart failure(HF) is a dangerous disease that affects millions of patients. Radix Salvia is widely used in Chinese clinics to treat heart diseases. Salvianolic acid B(SalB) is the major active component of Radix Salvia. This study investigated the mechanisms of action and effects of SalB on HF in an experimental mouse model of HF. METHODS: We created a mouse model of HF by inducing pressure overload with transverse aortic constriction(TAC) surgery for 2 weeks and compared among 4 study groups: SHAM group (n = 10), TAC group (n = 9), TAC+MET group (metprolol, positive drug treatment, n = 9) and TAC+SalB group (SalB, 240 mg•kg-1•day-1, n = 9). Echocardiography was used to evaluate the dynamic changes in cardiac structure and function in vivo. Plasma brain natriuretic peptide (BNP) concentration was detected by Elisa method. In addition, H9C2 rat cardiomyocytes were cultured and Western blot were implemented to evaluate the phosphorylation of ERK1/2, AKT, and protein expression of GATA4. RESULTS: SalB significantly inhibited the phosphorylation of Thr202/Tyr204 sites of ERK1/2, but not Ser473 site of AKT, subsequently inhibited protein expression of GATA4 and plasma BNP(P < 0.001), and then inhibited HF at 2 weeks after TAC surgery. CONCLUSIONS: Our data provide a mechanism of inactivating the ERK1/2/GATA4 signaling pathway for SalB inhibition of the TAC-induced HF.

The management of newborns with esophageal atresia and right aortic arch: A systematic review or still unsolved problem.

AIM OF THE STUDY: The management of newborns with esophageal atresia (EA) and right aortic arch (RAA) is still an unsolved problem. This study provides a systematic review of epidemiology, diagnosis, management and short-term results of children with EA and RAA. MATERIALS AND METHODS: The PubMed database was searched for original studies on children with EA and RAA. In each study, data were extracted for the following outcomes: number of patients, associated anomalies, type of surgical repair, morbidity and mortality rate. RESULTS: Eight studies were selected, including 54 patients with EA and RAA. RAA was encountered in 3.6% of infants. Preoperative detection of RAA was reported in 7 of them. In these patients, primary anastomosis was achieved through the right approach in 3 (thoracotomy in 2 and thoracoscopy in 1) while the left approach was the primary choice in 4 (thoracotomy in 2 and thoracoscopy in 2). No significant differences were found between the right and left approaches with regard to leaks (P=0.89), strictures (P=1) or mortality (P=1). In 47/54 patients (87%) RAA was noted during right thoracotomy, and primary anastomosis was achieved through the same approach in 29 (61.7%); conversion to other approaches (left thoracotomy or esophageal substitution) was performed in 15 children (38.3%). No significant differences were found between primary left thoracotomy (LT) and LT after RT with regard to leaks (P=0.89), strictures (P=1) or mortality (P=1). CONCLUSIONS: Skills and preferences of the surgeon still guide the choice of surgical approach even when preoperatively faced with RAA. A multicenter, prospective randomized study is strongly required.

Hybrid therapy for hypoplastic left heart syndrome: Myth, alternative, or standard?

OBJECTIVE: This retrospective study presents our operative results, mortality, and morbidity with regard to pulmonary artery growth and reinterventions on the pulmonary artery and aortic arch, including key features of our institutional standards for the 3-stage hybrid palliation of patients with hypoplastic left heart syndrome. METHODS: Between June 1998 and February 2015, 182 patients with hypoplastic left heart structures underwent the Giessen hybrid stage I procedure. Among these, 126 patients with hypoplastic left heart syndrome who received a univentricular palliation or heart transplantation were included in the main analysis. Median age and body weight of patients at hybrid stage I were 6 days (0-237) and 3.2 kg (1.2-7), respectively. Comprehensive stage II operation was performed at 4.5 months (2.9-39.5), and Fontan completion was established at 33.7 months (21.1-108.2). Operative and interstage mortality, morbidity, growth and reinterventions on the pulmonary arteries, and long-term operative results of the aortic arch reconstruction were assessed. RESULTS: Median follow-up time after Giessen hybrid stage I palliation was 4.6 years (0-16.8). Operative mortality at hybrid stage I, comprehensive stage II, and Fontan completion was 2.5%, 4.9%, and 0%, respectively. Cumulative interstage mortality was 14.2%. At 10 years, the probability of survival is 77.8%. Body weight (<2.5 kg) and aortic atresia had no significant impact on survival. McGoon ratio did not differ at comprehensive stage II and Fontan completion (P = .991). Freedom from pulmonary artery intervention was estimated to be 32.2% at 10 years. Aortic arch reinterventions were needed in 16.7% of patients; 2 reoperations on the aortic arch were necessary. CONCLUSIONS: In view of the early results and long-term outcome, the hybrid approach has become an alternative to the conventional strategy to treat neonates with hypoplastic left heart syndrome and variants. Further refinements are warranted to decrease patient morbidity.

Autologous platelet-rich plasma reduces transfusions during ascending aortic arch repair: a prospective, randomized, controlled trial.

BACKGROUND: Blood conservation using autologous platelet-rich plasma (aPRP), a technique of whole blood harvest that separates red blood cells from plasma and platelets before cardiopulmonary bypass with retransfusion of the preserved platelets after completion of cardiopulmonary bypass, has not been studied extensively. We sought to prospectively determine whether aPRP reduces blood transfusions during ascending and transverse aortic arch repair. METHODS: We randomly assigned 80 patients undergoing elective ascending and transverse aortic arch repair using deep hypothermic circulatory arrest to receive either aPRP (n = 38) or no aPRP (n = 42). Volume of aPRP retransfused was 726 ± 124 mL. The primary end point was transfusion amount. Secondary end points were death, stroke, renal failure, pulmonary failure, and transfusion costs. Perioperative transfusion rate was defined as blood transfusions given during surgery and up to 72 hours afterward. The surgeon and intensivist were blinded to the treatment arm. Because an anesthesiologist initiated the protocol, the surgeon was not aware of aPRP collection, as this occurred only after the sterile drape was in place. In addition, because cell salvage was performed on all cases, differentiation in perfusionist activities (during spinning of aPRP) was not evident. Platelet, fresh frozen plasma, and cryoprecipitate intraoperative transfusions were performed only after heparin was reversed and the patient was judged as coagulopathic on the basis of associated criteria: cryoprecipitate transfusion for fibrinogen level less than 150 µg/dL, platelet transfusion for platelet count less than 80,000, and fresh frozen plasma when thromboelastogram test was suggestive or a partial thromboplastin time was greater than 55 seconds, and prothrombin time was greater than 1.6 seconds. RESULTS: Early mortality, stroke, and respiratory complications were similar between groups. Only acute renal failure was reduced in the aPRP group, 7% versus 0% (p < 0.014). Mean transfusion rate of packed red blood cells was reduced by 34%, fresh frozen plasma by 52.8%, cryoprecipitate by 70%, and platelets by 56.7% in the aPRP group (p < 0.02). Hospital length of stay (9.4 ± 5.3 days versus 12.7 ± 6.3 days; p < 0.014) and transfusion costs ($1,396 ± $1,755 versus $2,762 ± $2,267; p < 0.004) were reduced in the aPRP group. CONCLUSIONS: The use of aPRP reduced allogeneic transfusions during ascending and transverse aortic arch repair with deep hypothermic circulatory arrest. This translated to less acute renal failure, decreased length of stay, and lower transfusion costs. Further studies examining the coagulation factors of aPRP are required.

[MODERN TECHNOLOGIES OF THE SAVING OF PATIENT'S BLOOD AND REDUCTION OF THE USE OF DONOR BLOOD DURING OPERATIONS ON THE ASCENDING AORTA AND AORTIC ARCH].

Questions of saving of the patient's blood and limitation of the use of donated blood in the aortic surgery remain relevant in contrast with interventions on the valves of the heart and coronary arteries. In this regard, the aim of the study was to develop and introduce ofcomplex of technologies for saving the patient's blood in order to minimize transfusion of donor blood components during operations on the ascending aorta and aortic arch under hypothermic arrest. The study included 37 patients operated on the ascending aorta and aortic arch under cardiopulmonary bypass (CPB) and hypothermic cardiac arrest (CA) in 2013-2014 (Group 1). 2nd group consisted of 65 patients who at the same time performed reconstructive surgery on the ascending aorta with CBP without stopping the blood circulation. The comparative aspect studied the following parameters: duration of the CBP, CA, temperature, volume of intraoperative and postoperative blood loss, frequency of use of donor blood components autoplasma, washed red blood cells, autologous blood, hemostatic agents, the frequency resternotomy, hematocrit dynamics, glucose, and blood lactate. Comparative studies have shown that the amount of intraoperative blood loss during operations on the aortic arch under the CA was 1294 ± 303 mL, 20% higher than the blood loss during operations on the ascending aorta without CA. Program of saving of the blood of patients with aortic disease included preoperative preparation of autoplasma in 60% of patients, intraoperative collection and laundering of autoerythrocytes in 40-70% of patients and autotransfusion modified method, the improvement of surgical and pharmacological hemostasis and monitoring. Design and implementation of these methods reduced the patients need for donor red blood cells (from 76 to 47%), fresh frozen plasma (from 65 to 35%) during the operation at the aortic arch and the ascending aorta and to completely avoid the use of donor blood in 25% of patients. Proof of the adequacy of the developed strategy of conservation and limitation of the patient's blood was allogeneic blood conservation targets hemoglobin, hematocrit levels and metabolism at the end of the operation.

Long-term outcomes after aortic arch surgery: results of a study involving 623 patients.

OBJECTIVES: To assess early and long-term outcomes in a large cohort of patients undergoing open aortic arch surgery. METHODS: From 1996 to 2012, 623 consecutive patients (mean age: 62.8 years) underwent aortic arch interventions in our institution. Of these, 208 (33.4%) presented with an acute aortic syndrome (AAS) and 415 (66.6%) with a chronic aortic pathology (CAP). During the study period, our surgical strategy involved extensive resections of the diseased aortic tissue at elective interventions, and a tear-oriented aortic replacement in patients with acute dissection. More extensive interventions were often performed in younger patients, and in those with connective tissue diseases and bicuspid aortic valves. A total arch replacement was frequently performed (53.3%). Antegrade selective cerebral perfusion was used in all cases. RESULTS: Overall in-hospital mortality was 23.1% in patients with AAS and 11.1% in patients with a CAP; in the same groups, postoperative permanent neurological dysfunction (PND) occurred in 9.6 and 5.6%, respectively. The follow-up was 94.4% complete. For in-hospital survivors, 5- and 10-year survival (%) were 79.4 ± 2.1 and 60.9 ± 3.2, respectively, not influenced by the underlying aortic disease. Cox regression identified age (hazard ratio [HR]: 1.048; P < 0.001), preoperative renal failure (HR: 2.3; P = 0.003), diabetes (HR: 1.805; P = 0.005) and PND (HR: 2.4; P = 0.03) to be independent predictors for the follow-up mortality. Overall, 109 (59% endovascular) aortic reinterventions were performed: 18.3% were proximal and 81.7% distal to the aortic arch. Five- and 10-year freedom from aortic redo (%) were 82.8 ± 1.9 and 77.7 ± 2.6, respectively. Aortic dissection (HR: 1.7; P = 0.03) was the only independent predictor of reoperative surgery at the follow-up. CONCLUSIONS: Aortic arch surgery was associated with satisfactory early and long-term outcomes. Survival was largely determined by patient comorbidities and postoperative PND. While the underlying aortic disease did not affect long-term mortality, chronic dissection was associated with increased need for aortic reinterventions.

[Successful endovascular treatment under cardiopulmonary resuscitation for spontaneous rupture of the thoracic aorta].

The patient was a 67-year-old man. He was admitted to a local hospital with severe back pain, and left hydrothorax was noted by a chest X-ray. Then, he went into shock and was transferred to our hospital. Enhanced computed tomography (CT) showed massive liquid retention of the left thorax, but no aortic dissection or aneurysms. He was diagnosed with spontaneous aortic rupture, and endovascular treatment was chosen because of his unstable hemodynamics. He fell into cardiac arrest 10 minutes after the operation started, and we implanted 2 stent-grafts while giving cardiac massage. After 23 minutes cardiac massage, he was resuscitated. He was discharged without any complication. Even if no signs of aortic aneurysms or aortic dissection were detected, the possibility of spontaneous aortic rupture should be suspected. Endovascular treatment is a reliable option in the case of unstable hemodynamics.

Analysis of autologous platelet-rich plasma during ascending and transverse aortic arch surgery.

BACKGROUND: Coagulopathy is a common complication after ascending and transverse arch aortic surgery with profound hypothermic circuit arrest (PHCA). Blood conservation strategies to reduce transfusion have been ongoing and involve multiple treatment modalities in modern cardiac surgery. The purpose of this study is to evaluate the effectiveness of autologous platelet-rich plasma (aPRP) as a blood conservation technique to reduce blood transfusion in ascending and arch aortic surgery. METHODS: Between 2003 and 2009, we retrospectively reviewed 685 cases of ascending aorta and transverse arch repair using PHCA. A total of 287 patients in which aPRP was used (aPRP group) were compared with 398 patients who did have aPRP (non-aPRP group). Perioperative transfusion requirements and clinical outcomes that included early mortality, postoperative stroke, renal dysfunction, prolonged ventilation, coagulopathy, and length of postoperative intensive care unit stay were analyzed. The data were analyzed by mean and frequency for continuous variables and qualitative variables. To account for potential selection bias, 2 types of propensity analysis were performed. RESULTS: In both unadjusted and adjusted analysis, perioperative transfusions were fewer in the aPRP group compared with the non-aPRP group: (3.9 units fewer packed red blood cells, 4.5 units fewer fresh frozen plasma, 7.9 units fewer platelets, and 6.8 units fewer cryoprecipitate). In all analyses, postoperative morbidity (stroke, duration of mechanical ventilation, and intensive care unit stay) were significantly improved. Hospital mortality rate was not significantly decreased. CONCLUSIONS: The utilization of aPRP was associated with a reduction in allogeneic blood transfusions as well as a decrease in early postoperative morbidity during repairs of the ascending and transverse arch aorta using PHCA.