Successful Surgical Treatment of Mitral Valve Endocarditis Caused by Brucella: A Case Report.

Brucellosis endocarditis is a rare but life-threatening complication of brucellosis, involving congenital, prosthetic and even native valves. Its diagnosis and treatment is a great challenge for doctors. The patient's prognosis requires prompt diagnosis and continuous evaluation of treatment plans to assess the need for either surgical intervention of the infected valves or continuation of antibiotic therapy alone. We present a patient with brucellosis endocarditis, predominantly involving the mitral valve, presenting with vegetations and prolapse of the anterior leaflet of the mitral valve with moderate to severe regurgitation. The patient was treated with triple antibiotic therapy before surgery. After the patient's blood culture results were negative, we removed the infected mitral valve vegetations and performed a mitral valve replacement. The patient was successfully extubated 4 hours after surgery and discharged 11 days after surgery. After discharge, the patient continued to receive triple antibiotic therapy for 2 months and was followed up at the cardiac surgery and infectious disease outpatient clinics.

PR-957 retards rheumatoid arthritis progression and inflammation by inhibiting LMP7-mediated CD4+ T cell imbalance.

OBJECTIVE: Low molecular mass polypeptide 7 (LMP7) is an immunoproteasome subunit that regulates T cell amplification, differentiation, and inflammation and is involved in rheumatoid arthritis (RA) progression. This study intended to apply PR-957 (an anti-LMP7 agent) for RA treatment in vitro and in vivo and evaluate its interaction with LMP7-mediated CD4+ T cell imbalance. METHODS: Peripheral blood mononuclear cells (PBMCs) were obtained from 30 RA patients and 30 healthy controls. RA fibroblast-like synoviocytes (RA-FLSs) and CD4+ T cells were isolated from RA patients and then cocultured with PR-957 and/or LMP7 overexpression adenovirus (Ad-LMP7). Collagen-induced arthritis (CIA) mice were constructed and then treated with PR-957 and/or Ad-LMP7. RESULTS: LMP7 was higher in RA patients (versus healthy controls) and positively correlated with T helper (Th)1 cells, the Th1/Th2 ratio, Th17 cells, and the Th17/Treg ratio but not with Th2 or T regulatory (Treg) cells. PR-957 reduced Th1 and Th17 cells but increased Th2 and Treg cells in RA-CD4+ T cells, and this effect was partially reversed by Ad-LMP7 transfection. Interestingly, when cocultured with RA-CD4+ T cells, PR-957 increased RA-FLS apoptosis and decreased its invasive ability, viability, and inflammation, as suggested by IL-6, CCL2, MMP1, and MMP3; however, these phenomena were weakened in RA-FLSs without RA-CD4+ T cell coculture. In addition, Ad-LMP7 transfection attenuated the above effects of PR-957. In CIA mice, PR-957 decreased the arthritis score, synovial hyperproliferation and articular injury, inflammation in the synovium and serum, and the imbalance of Th1/Th2 and Th17/Treg in the spleen, and these effects were attenuated by Ad-LMP7. CONCLUSION: PR-957 ameliorates RA progression and inflammation by repressing LMP7-mediated CD4+ T cell imbalance.

Transapical transcatheter mitral valve implantation with J-valve in patients with degenerated mitral bioprostheses.

BACKGROUND: Due to the widespread application of bioprosthetic valve in the treatment of mitral valve disease in recent years, the incidence of valve failure has increased significantly, which is facing the need of reoperation. For high-risk patients, transcatheter mitral valve-in-valve placement is increasingly being used as an alternative to surgical reoperation. CASE PRESENTATION: Here we report the successful transapical transcatheter mitral valve-in-valve implantations of J-Valves in 3 patients with high risk of mitral bioprostheses failure. All patients were discharged successfully, and the follow-up results were good 30 days after operation without major complication. CONCLUSIONS: For high-risk patients, transcatheter implantation of the J-valve is a feasible solution for the treatment of degenerated mitral bioprostheses.

Mitral degenerative valve leaflets suspected as primary valvular tumor: a case report.

BACKGROUND: Echocardiography plays an important role in the diagnosis of heart disease. Sometimes, however, it may also provide misdiagnosis information. CASE PRESENTATION: We report a rare case of a misdiagnosis of primary mitral valvular tumor with severe regurgitation by preoperative echocardiography. During the surgery, the true lesion was found to be mitral valve leaflet prolapse due to degenerative mitral valve disease. CONCLUSION: For individual patient, the best clinical decision not only needs the extensive application of echocardiography, but also needs the combination of clinical symptoms and more auxiliary examination.

Surgical treatment of left atrial dissection caused by percutaneous coronary intervention.

Left atrial dissection (LatD), also known as left atrial intramural haematoma, is a rare condition that requires rapid diagnosis and frequently calls for timely surgical intervention. Diagnosis can be challenging because of a lack of definitive clinical criteria, and a patient's situation can be complicated by co-morbidities, including unstable haemodynamics. We surgically repaired a case of LatD related to percutaneous coronary intervention (PCI). The operation went smoothly, and the patient was discharged one week after the operation. For LatD patients with co-morbidities, especially haemodynamic disorders, active surgical intervention is recommended.

Outcomes of preoperative antiplatelet therapy in patients with acute type A aortic dissection.

BACKGROUND: Acute type A aortic dissection (ATAAD) is life-threatening and requires immediate surgery. Sudden chest pain may lead to a risk of misdiagnosis as an acute coronary syndrome and may lead to subsequent antiplatelet therapy (APT). We used the Chinese Acute Aortic Syndrome (AAS) Collaboration Database to study the effects of APT on clinical outcomes. METHODS: The AAS database is a retrospective multicentre database where 31 of 3092 patients had APT with aspirin or clopidogrel or both before surgery. Before and after propensity score matching (PSM), the incidence of complications and mortality was compared between APT and non-APT patients by using a logistic regression model. The sample remaining after PSM was 30 in the APT group and 80 in the non-APT group. RESULTS: The sample remaining after matching was 30 in the APT group and 80 in the non-APT group. We found 10 cases with percutaneous coronary intervention in the APT group (33.3%). The APT group received more volume of packed red blood cells, 8.4 ± 6.05 units; plasma, 401.67 ± 727 ml, and platelet transfusion (14.07 ± 8.92 units). The drainage volume was much more in the APT group (5009.37 ± 2131.44 ml, p = .004). Mortality was higher in APT group (26% vs. 10%, p = .027). The preoperative APT was an independent predictor of mortality (odds ratio: 6.808, 95% confidence interval: 1.554-29.828, p = .011). CONCLUSION: APT before ATAAD repair was associated with more transfusions and higher early mortality. The timing of surgery should be carefully considered based on the patient's status and the surgeon's experience.

Parvovirus B19-induced severe anemia in heart transplant recipient: A case report.

RATIONALE: Human parvovirus B19 (B19V) is a non-enveloped single-stranded DNA virus associated with a variety of human diseases. Reports of B19V infection after cardiac transplantation are relatively rare. PATIENT CONCERNS: We report a case of a 48-year-old women who underwent orthotopic heart transplant for dilated cardiomyopathy. She developed an anemia after cardiac transplantation. Anemia was most severe 2 months after surgery, with a decrease in reticulocyte count. Serological DNA test for parvovirus B19V was performed and the result was positive. DIAGNOSES: B19V infection. INTERVENTIONS AND OUTCOMES: Intravenous immunoglobulin administration resulted in a resolution of the anemia. The patient's blood test results showed a normal hemoglobin and reticulocyte count 1 year after surgery. LESSONS: Patients with parvovirus B19V infection may develop severe anemia after heart transplantation. The diagnosis mainly relies on viral DNA detection. Intravenous immunoglobulin is an effective treatment for viral infection.

Aortic valve bypass for high-risk patients with symptomatic aortic stenosis: A case report.

There are a significant number of symptomatic aortic stenosis (AS) patients not referred to the traditional methods for some complex conditions. We described a case of a 61-year-old female with severe symptomatic AS, calcific small aortic annulus (16.6 mm), narrow porcelain ascending aorta (aortic root: 14.6 mm, internal diameter: 14.0 mm), chronic renal insufficiency, and a history of the previous sternotomy for mechanical mitral valve replacement and coronary artery bypass grafting who underwent aortic valve bypass (AVB) with favorable results. AVB has been proposed as a complementary to surgery operation of aortic valve replacement and transcatheter aortic valve implantation in high-risk AS patients.

Application of extracorporeal cardiopulmonary resuscitation in adult patients with refractory cardiac arrest.

BACKGROUND: The aim of this study was to summarize the clinical experience of extracorporeal cardiopulmonary resuscitation (ECPR) in the treatment of adult patients with refractory cardiac arrest. METHODS: The clinical data of 12 cases of adult patients with cardiac arrest hospitalized between June 2015 and September 2019 who were unable to achieve return of spontaneous circulation effectively with conventional cardiopulmonary resuscitation (CCPR) and were treated with ECPR technology were retrospectively analyzed. The group included six males and six females aged between 18 and 69 years. All the patients underwent veno-arterial extracorporeal membrane oxygenation (V-A ECMO) support with the adoption of femoral artery and vein catheterization. RESULTS: The duration of cardiopulmonary resuscitation (CPR) for the 12 patients was 32-125 min, and the ECMO duration was 2-190 h. Four patients were successfully weaned from ECMO and survived until hospital discharge. The other eight patients died in hospital; hemodynamic collapse (four patients) in the early stage of ECMO and severe neurological complications (three patients) were the main causes of death. CONCLUSIONS: Single-center data showed that ECPR provided a new rescue alternative for some patients with reversible refractory cardiac arrest. We have demonstrated that the success rate of treatment could be improved by selecting suitable patients and reducing the CPR duration as much as possible.

Analysis of ascending aortic diameter and long-term prognosis in patients with ascending aortic dissection.

OBJECTIVES: This study was designed to review the ascending aortic diameter of patients undergoing surgery for AAD in China and its influence on prognosis. METHODS: In the period between January 2018 and January 2020, 265 patients eligible for analysis of ascending aorta were included in this study. The maximum diameter of the ascending aorta was assessed using preoperative computed tomography (CT) scan for patients. RESULTS: The mean diameter of the ascending aorta of the reference population was 48.16 ± 9.37 mm, and the percentage of subjects with an aorta <55 mm was 80.38%. In this study, we found that BMI, hypertension, and bicuspid aortic valve are the main factors affecting the widening of the ascending aorta, and the diameter of the ascending aorta in patients with AAD is negatively correlated with the patient's long-term prognosis. However, there is no significant difference in survival rates among patients with different ascending aortic diameter. CONCLUSIONS: Ascending aortas with smaller diameter are also prone to dissection, most of which occur at a lower surgical threshold than recommended by current guidelines. Therefore, the diameter of ascending aorta cannot be used as an independent risk factor for high-risk patients with aortic dissection, but it can be used as an important indicator to evaluate the long-term prognosis of patients.

Machine Learning Prediction Model for Acute Renal Failure After Acute Aortic Syndrome Surgery.

BACKGROUND: Acute renal failure (ARF) is the most common major complication following cardiac surgery for acute aortic syndrome (AAS) and worsens the postoperative prognosis. Our aim was to establish a machine learning prediction model for ARF occurrence in AAS patients. METHODS: We included AAS patient data from nine medical centers (n = 1,637) and analyzed the incidence of ARF and the risk factors for postoperative ARF. We used data from six medical centers to compare the performance of four machine learning models and performed internal validation to identify AAS patients who developed postoperative ARF. The area under the curve (AUC) of the receiver operating characteristic (ROC) curve was used to compare the performance of the predictive models. We compared the performance of the optimal machine learning prediction model with that of traditional prediction models. Data from three medical centers were used for external validation. RESULTS: The eXtreme Gradient Boosting (XGBoost) algorithm performed best in the internal validation process (AUC = 0.82), which was better than both the logistic regression (LR) prediction model (AUC = 0.77, p < 0.001) and the traditional scoring systems. Upon external validation, the XGBoost prediction model (AUC =0.81) also performed better than both the LR prediction model (AUC = 0.75, p = 0.03) and the traditional scoring systems. We created an online application based on the XGBoost prediction model. CONCLUSIONS: We have developed a machine learning model that has better predictive performance than traditional LR prediction models as well as other existing risk scoring systems for postoperative ARF. This model can be utilized to provide early warnings when high-risk patients are found, enabling clinicians to take prompt measures.

Iatrogenic Dissection of The Right Coronary Artery and The Ascending Aorta Secondary to Percutaneous Coronary Intervention: A Case Report.

Iatrogenic dissections of coronary artery and aorta is a rare and potentially fatal event, often following percutaneous coronary intervention (PCI). The prognosis of patients often depends on early accurate diagnosis and timely and effective treatment. There are no definite guidelines for the treatment of acute coronary artery dissection caused by PCI. Here, we report a 50-year-old patient with iatrogenic dissection of the right coronary artery and type A aortic dissection who underwent PCI for chest pain. We performed emergency surgery of right coronary artery ostium repair, aortic valvoplasty, ascending aorta replacement, and aortic arch descending stent implantation for the patient. The operation went smoothly, and the patient successfully was discharged two weeks after the operation.

MiR-421 inhibition protects H9c2 cells against hypoxia/reoxygenation-induced oxidative stress and apoptosis by targeting Sirt3.

BACKGROUND: MicroRNAs (miRNAs) are involved in myocardial ischemia-reperfusion injury. miRNA-421 (miR-421) plays a significant role in the initiation of apoptosis and myocardial infarction. However, the molecular regulation of miR-421 in myocardial ischemia-reperfusion injury requires further elucidation. METHODS: An in vitro hypoxia/reoxygenation model was established, and the expression levels of miR-421 and Sirtuin-3 (Sirt3) in H9c2 cells were quantified using quantitative real-time polymerase chain reaction. Flow cytometry was employed to measure the effects of miR-421 on myocardial apoptosis induced by hypoxia/reoxygenation. The activity of lactate dehydrogenase and superoxide dismutase and levels of malondialdehyde were measured. The binding sites of miR-421 on Sirt3 were predicted using TargetScan software. A luciferase reporter assay was used to validate the direct targeting of Sirt3 with miR-421. Protein expression levels of Sirt3 and its downstream proteins were evaluated using Western blot analysis. RESULTS: Exposure of H9c2 cells to hypoxia/reoxygenation led to increased apoptosis, levels of malondialdehyde and lactate dehydrogenase, and decreased levels of superoxide dismutase. miR-421 knockdown resulted in decreased apoptosis, levels of lactate dehydrogenase and malondialdehyde, and increased superoxide dismutase levels in H9c2 cells. Hypoxia/reoxygenation significantly decreased the relative expression levels of Sirt3. Down-regulation of Sirt3 resulted from overexpression of miR-421, which directly targeted Sirt3. Knockdown of miR-421 up-regulated Sirt3 expression, inhibited activation of the Jun N-terminal kinase/activator protein 1 pathway and caspase 9/3-dependent cell death. CONCLUSION: The miR-421-Sirt3-Jun N-terminal kinase/activator protein 1 axis is a novel molecular mechanism that accommodates hypoxia/reoxygenation-induced oxidative stress and apoptosis and provides a new direction for the study and treatment of hypoxia/reoxygenation.

Treatment experience of thoracic aortic aneurysm recurrence after multiple surgeries for Marfan syndrome: A case report.

RATIONALE: Marfan syndrome (MFS), an autosomal dominant hereditary disease, often results in structural and functional abnormalities of the aortic wall. Because of residual aortic aneurysm or aortic dissection, patients with MFS usually need repeat operations after the first operation. PATIENT CONCERNS: A patient diagnosed with MFS who had undergone 2 surgeries because of abdominal aortic dissection aneurysm and Stanford A type aortic dissection at different times. DIAGNOSES: MFS. INTERVENTIONS: Due to aneurysmal dilatation of the residual descending aorta, we performed the third surgery for him through using 2 artificial stent grafts to fix and package the area of the remaining vessel in our hospital. OUTCOMES: The result was good, and the patient was discharged successfully. LESSONS: Using artificial material to repair and wrap the area of the residual vessel during the first surgery can provide an anchor area for future endovascular stent implantation and also offer a possibility for stent implantation in patients with MFS.

A Rare Giant Pulmonary Aneurysm with Left Lung Compression: A Case Report with Insights from the Literature.

Pulmonary artery aneurysm (PAA) is a rare condition that results from several pathologies. Here, we report a case of a rare giant PAA accompanied by left lung compression due to recurrent chest tightness for >13 years. Through this case and review of the literature, we explore the treatment options to improve the diagnosis and treatment of PAA. We found that patients with PAA may survive longer even if they also have pulmonary hypertension. In addition, it is recommended that if a PAA diameter is >5.5 cm or if the PAA diameter has increased by >0.5 cm in 6 months, the PAA should be operated on as soon as possible. Conservative treatment can be recommended in patients with congenital PAA if pulmonary arterial pressure is normal.

Nomogram for the prediction of postoperative hypoxemia in patients with acute aortic dissection.

BACKGROUND: Postoperative hypoxemia is quite common in patients with acute aortic dissection (AAD) and is associated with poor clinical outcomes. However, there is no method to predict this potentially life-threatening complication. The study aimed to develop a regression model in patients with AAD to predict postoperative hypoxemia, and to validate it in an independent dataset. METHODS: All patients diagnosed with AAD from December 2012 to December 2017 were retrospectively screened for potential eligibility. Preoperative and intraoperative variables were included for analysis. Logistic regression model was fit by using purposeful selection procedure. The original dataset was split into training and validating datasets by 4:1 ratio. Discrimination and calibration of the model was assessed in the validating dataset. A nomogram was drawn for clinical utility. RESULTS: A total of 211 patients, involving 168 in non-hypoxemia and 43 in hypoxemia group, were included during the study period (incidence: 20.4%). Duration of mechanical ventilation (MV) was significantly longer in the hypoxemia than non-hypoxemia group (41(10.5140) vs. 12(3.75,70.25) hours; p = 0.002). There was no difference in the hospital mortality rate between the two groups. The purposeful selection procedure identified 8 variables including hematocrit (odds ratio [OR]: 0.89, 95% confidence interval [CI]: 0.80 to 0.98, p = 0.011), PaO2/FiO2 ratio (OR: 0.99, 95% CI: 0.99 to 1.00, p = 0.011), white blood cell count (OR: 1.21, 95% CI: 1.06 to 1.40, p = 0.008), body mass index (OR: 1.32, 95% CI: 1.15 to 1.54; p = 0.000), Stanford type (OR: 0.22, 95% CI: 0.06 to 0.66; p = 0.011), pH (OR: 0.0002, 95% CI: 2*10- 8 to 0.74; p = 0.048), cardiopulmonary bypass time (OR: 0.99, 95% CI: 0.98 to 1.00; p = 0.031) and age (OR: 1.03, 95% CI: 0.99 to 1.08; p = 0.128) to be included in the model. In an independent dataset, the area under curve (AUC) of the prediction model was 0.869 (95% CI: 0.802 to 0.936). The calibration was good by visual inspection. CONCLUSIONS: The study developed a model for the prediction of postoperative hypoxemia in patients undergoing operation for AAD. The model showed good discrimination and calibration in an independent dataset that was not used for model training.

Right axillary and femoral artery perfusion with mild hypothermia for aortic arch replacement.

OBJECTIVES: Aortic arch replacement is associated with increased mortality and morbidity especially in acute type-A aortic dissection. Although hypothermic circulatory arrest with selective antegrade cerebral perfusion has been widely used because of its excellent cerebral protection, its optimal perfusion characteristics are unknown. The present study investigates clinical results obtained after perfusion method modification and temperature management during cardiopulmonary bypass (CPB). METHODS: Between July 2010 and August 2012, 16 consecutive adult patients (mean age 50.0 yr ± 14.1 yr, range 25 yr to 73 yr, 12 males, 4 females) who presented with acute Stanford type-A aortic dissection underwent aortic arch replacement (total arch, n = 11; hemiarch, n = 5) under mild hypothermia (31.1 °C ± 1.5 °C) with right axillary and femoral artery perfusion. RESULTS: The mean CPB time was 201 min ± 53 min, and the mean myocardial ischemic time was 140 min ± 42 min. The mean selective cerebral perfusion time was 80 min ± 16 min, and the mean lower-body circulatory arrest time was 20 min ± 13 min. No patient death occurred within 30 post-operative days. The following details were observed: new post-operative permanent neurologic deficit in 1 patient (6.3%), temporary neurologic deficit in 2 patients (12.5%), acute renal dysfunction (creatinine level > 230 umol/L) in 3 patients (18.8%) and mechanical ventilation > 72 h in 5 patients (31.2%). CONCLUSIONS: Aortic arch replacement for acute type-A aortic dissection under mild hypothermia with right axillary and femoral artery perfusion could be safely performed in the patient cohort.

[Impact of prosthesis-patient mismatch on the quality of life of elderly patients after aortic valve replacement].

OBJECTIVE: To evaluate the long-term changes in the quality of life (QOL) scores in elderly patients after aortic valve replacement, and assess the impact of prosthesis-patient mismatch on the QQL of the patients. METHODS: A prospective cohort study was conducted involving 100 consecutive elderly patients above 70 years of age, who underwent isolated aortic valve or simultaneous aortic valve-coronary artery bypass graft (CABG) procedures between August 10, 1995 and August 19, 1998. Patient-prosthesis mismatch (PPM) was defined as a prosthetic aortic valve EOAI of 0.85 cm2/m2 or less. The clinical follow-up examinations were carried out at 4 weeks and 6 months after the operation, and then annually afterwards. Cumulative and comparative analyses of the long-term outcomes and gradient pressure of the prosthetic valve were performed. The QOL of the patients was evaluated using the Short Form 36-Item Health Survey (SF-36) questionnaire. RESULTS: The mean age of the patients at prosthesis implantation was 74.7-/+5.7 years (range 70-87 years). The patients were followed up for a mean of 7.3-/+4.5 years. The thirty-day mortality was 6.3% in the mismatch group, and 3.3% in the matching group. The freedom from death showed no significant difference between the two groups at the first, third and fifth years after the prosthetic implantation, but differed significantly at the seventh year. The echocardiographic data showed significant differences in the mean gradient pressure between the two groups at the first and fifth years postoperatively. At most of the time points for follow-up examination, the general health and energy/vitality of the patients all improved from the preoperative levels, but no significant improvement was found at the third, fifth, and seventh years in the role emotional, social role, or general mental health; at the first postoperative year, however, the role emotional, social role, and particularly mental health, presented with significant improvements in comparison with the preoperative levels. No obvious difference in the QOL was noted between the two groups at the time points of observation. CONCLUSIONS: Aortic vale replacement improves the QOL of the elderly patients, but the degree of improvements do not seem to be influenced by PPM. The interpretation of the impact of PPM on the clinic outcome of the patients still remains controversial.

[Experience with coronary artery bypass grafting and concomitant procedures in 21 cases].

OBJECTIVE: To review our experience with coronary artery bypass grafting (CABG) and its concomitant procedures. METHODS: From December, 1998 to December, 2002, 21 patients underwent CABG and their clinical data were analyzed. RESULTS: Nineteen patients were discharged uneventfully after the procedure. Early death occurred in 2 patients who received emergency operation after acute myocardial infarction. Among the 18 patients followed up, angina was eliminated in all but one patient. CONCLUSION: Although the concomitant procedures such as valve replacement may prolong the operation time for CABG, good clinical outcome of the patients can still be expected by implementation of intensive perioperative management and complete myocardial revascularization.