No-Touch Versus Conventional Vein Harvesting Techniques at 12 Months After Coronary Artery Bypass Grafting Surgery: Multicenter Randomized, Controlled Trial.

BACKGROUND: Vein graft occlusion is deemed a major challenge in coronary artery bypass grafting. Previous studies implied that the no-touch technique for vein graft harvesting could reduce occlusion rate compared with the conventional approach; however, evidence on the clinical benefit and generalizability of the no-touch technique is scare. METHODS: From April 2017 to June 2019, we randomly assigned 2655 patients undergoing coronary artery bypass grafting at 7 hospitals in a 1:1 ratio to receive no-touch technique or conventional approach for vein harvesting. The primary outcome was vein graft occlusion on computed tomography angiography at 3 months and the secondary outcomes included 12-month vein graft occlusion, recurrence of angina, and major adverse cardiac and cerebrovascular events. The generalized estimate equation model was used to account for the cluster effect of grafts from the same patient. RESULTS: During the follow-up, 2533 (96.0%) participants received computed tomography angiography at 3 months after coronary artery bypass grafting and 2434 (92.2%) received it at 12 months. The no-touch group had significantly lower rates of vein graft occlusion than the conventional group both at 3 months (2.8% versus 4.8%; odds ratio, 0.57 [95% CI, 0.41-0.80]; P<0.001) and 12 months (3.7% versus 6.5%; odds ratio, 0.56 [95% CI, 0.41-0.76]; P<0.001). Recurrence of angina was also less common in the no-touch group at 12 months (2.3% versus 4.1%; odds ratio, 0.55 [95% CI, 0.35-0.85]; P<0.01). Rates of major adverse cardiac and cerebrovascular events were of no significant difference between the 2 groups. The no-touch technique was associated with higher rates of leg wound surgical interventions at 3-month follow-up (10.3% versus 4.3%; odds ratio, 2.55 [95% CI, 1.85-3.52]; P<0.001). CONCLUSIONS: Compared with the conventional vein harvesting approach in coronary artery bypass grafting, the no-touch technique significantly reduced the risk of vein graft occlusion and improved patient prognosis. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03126409.

Bioprosthetic mitral valve stenosis secondary to hypereosinophilic syndrome.

Herein we present a case of hypereosinophilic syndrome (HES) with recurrent involvement of mitral valve. The patient developed mitral regurgitation secondary to HES. Surgical mitral valve replacement was performed successfully. The prosthetic valve dysfunction occurred 3 years later and echocardiography showed severe mitral valve stenosis. Extensive mural thrombi were discovered on both sides of the stenotic valve with eosinophilic infiltration. The patient underwent a repeated mechanical prosthesis replacement and recovered uneventfully.

Different treatment options for Takayasu arteritis patients with moderate-to-severe aortic regurgitation: long-term outcomes.

OBJECTIVES: To determine the prognosis of Takayasu arteritis (TA) patients with moderate-to-severe aortic regurgitation treated with surgical vs conservative treatment and to identify independent prognostic factors of long-term outcomes. METHODS: Between January 2002 and January 2017, 101 consecutive TA patients with moderate-to-severe aortic regurgitation treated with either surgical (n = 38) or conservative (n = 63) treatments were investigated in this retrospective observational case-control study. The primary end point was all-cause mortality, and the secondary end point comprised the combined end points of death, non-fatal stroke and cardiac events (non-fatal myocardial infarction and congestive heart failure). Propensity score matching was used to reduce the bias of baseline risk factors. RESULTS: The unadjusted all-cause 10-year mortality in the conservative group was increased compared with the surgical group (28.2% vs 7.4%; log-rank P = 0.036), and the combined end points showed the same trend (52.1% vs 25.3%; log-rank P = 0.005). After an adjustment of baseline risk factors, the conservative treatment was associated with reduced survival rates of both all-cause mortality [hazard ratio (HR): 8.243; 95% CI: 1.069, 63.552; P = 0.007] and combined end points (HR: 6.341; 95% CI: 1.469, 27.375; P = 0.002). Conservative treatment (HR: 3.838, 95% CI: 1.333, 11.053; P = 0.013) and left ventricular end-diastolic diameter (HR: 1.036, 95% CI: 1.001, 1.071; P = 0.042) were risk factors for increased combined end points. CONCLUSION: Surgical treatment improves the outcomes of patients with moderate-to-severe aortic regurgitation due to TA. The dilated left ventricle indicated a worse prognosis.

Comparisons of simulation results between passive and active fluid structure interaction models for left ventricle in hypertrophic obstructive cardiomyopathy.

BACKGROUND: Patient-specific active fluid-structure interactions (FSI) model is a useful approach to non-invasively investigate the hemodynamics in the heart. However, it takes a lot of effort to obtain the proper external force boundary conditions for active models, which heavily restrained the time-sensitive clinical applications of active computational models. METHODS: The simulation results of 12 passive FSI models based on 6 patients' pre-operative and post-operative CT images were compared with corresponding active models to investigate the differences in hemodynamics and cardiac mechanics between these models. RESULTS: In comparing the passive and active models, it was found that there was no significant difference in pressure difference and shear stress on mitral valve leaflet (MVL) at the pre-SAM time point, but a significant difference was found in wall stress on the inner boundary of left ventricle (endocardium). It was also found that pressure difference on the coapted MVL and the shear stress on MVL were significantly decreased after successful surgery in both active and passive models. CONCLUSION: Our results suggested that the passive models may provide good approximated hemodynamic results at 5% RR interval, which is crucial for analyzing the initiation of systolic anterior motion (SAM). Comparing to active models, the passive models decrease the complexity of the modeling construction and the difficulty of convergence significantly. These findings suggest that, with proper boundary conditions and sufficient clinical data, the passive computational model may be a good substitution model for the active model to perform hemodynamic analysis of the initiation of SAM.

Midterm results of different treatment methods for myocardial bridging in patients after septal myectomy.

BACKGROUND: Myocardial bridging (MB) is commonly treated in patients with hypertrophic cardiomyopathy. However, whether and how MB should be treated in patients with hypertrophic obstructive cardiomyopathy (HOCM) who underwent septal myectomy remain unclear. METHODS: A total of 823 adults with HOCM who underwent septal myectomy at the Fuwai Hospital from 2011 to 2017 were retrospectively studied. RESULTS: Overall, 31 events occurred: 24 patients died and 7 had nonfatal myocardial infarction (MI). The 3-year cumulative event-free survival of all-cause death (97.9% vs. 100% vs. 100% vs. 98.4%, p = .89) and cardiovascular death (98.3% vs. 100% vs. 100% vs. 98.4%, p = .63) were similar among the four groups (non-MB, coronary artery bypass grafting [CABG], unroofing, untreated, respectively). However, the 3-year cumulative event-free survival of nonfatal MI (100% vs. 97.5% vs. 98.0% vs. 89.9%, p < .001) and combined endpoints (97.9% vs. 97.5% vs. 98.0% vs. 88.4%, p = .02) were significantly lowest in untreated MB (non-MB, CABG, unroofing, untreated, respectively). Cox regression analysis indicated that untreated MB was a significant independent predictor of combined endpoints (hazard ratio: 4.06, 95% confidence interval: 1.60-10.32, p < .001). Moreover, 49 patients underwent coronary artery computed tomography 1 year after surgery. The patency rate of the saphenous vein graft was significantly higher than that of the left internal mammary artery (13.3% vs. 84.2%, p < .001). No MB was detected in the unroofing group. CONCLUSIONS: Surgical MB treatment could be beneficial and performed safely during septal myectomy. Myocardial unroofing is the recommended treatment for MB, and unroofing when technically possible may be preferable for long-term outcomes.

Proteomic Analyses of Endarterectomized Tissues from Patients with Chronic Thromboembolic Pulmonary Hypertension.

BACKGROUND: The pathogenesis of chronic thromboembolic pulmonary hypertension (CTEPH) is largely unknown. Proteomics offers an approach to overview the molecular activities and signal transduction pathways involved in specific disease processes. OBJECTIVES: In this study, the expression of proteins in endarterectomized tissues from patients with CTEPH was investigated in a novel strategy to explore the pathophysiology of this disease. METHODS: We used the iTRAQ (isobaric tag for relative and absolute quantitation) approach combined with a Thermo Scientific Q Exactive MS analysis to compare the protein profiles in endarterectomized tissues from CTEPH patients and that of the control samples (mixture of cultured human pulmonary artery endothelial cells, human pulmonary artery smooth muscle cells, and human pulmonary fibroblasts). GO and KEGG analyses were performed to understand the functional classification and molecular activities of all the tissue-specific proteins, and the involved signal transduction pathways. RESULTS: Six hundred and seventy-nine tissue-specific proteins were detected. Bioinformatic analysis showed that the major biological processes involving these proteins were: response to wounding, defense response, acute inflammatory response, immune response, complement activation, and blood coagulation. The main pathways involved were: complement and coagulation cascade, systemic lupus erythematosus, extracellular matrix-receptor interaction, cell adhesion molecules, FcεRI signaling, and leukocyte transendothelial migration. CONCLUSIONS: The present study revealed that immune and defense response might play an important role in CTEPH.

Quantitative fragmented QRS has a good diagnostic value on myocardial fibrosis in hypertrophic obstructive cardiomyopathy based on clinical-pathological study.

BACKGROUND: To investigate the relationship between fragmented QRS (fQRS) quantified by a new method and myocardial fibrosis (MF) and the diagnostic value of quantitative fQRS (Q-fQRS) to detect MF in hypertrophic obstructive cardiomyopathy (HOCM) patients based on histological validation. METHODS: We performed a retrospective study that included 69 patients with HOCM who underwent ventricular septal surgery. Nine individuals who died from accidents were studied as a control reference for the histological parameters. Septal myocardium samples were subjected to Masson's trichrome staining to quantify the collagen volume fraction (CVF). An fQRS pattern was defined as the presence of additional R waves or RSR', evidenced by notched R or S wave on electrocardiography (ECG). The Q-fQRS was quantified as the total amount of deflections in the QRS complex in all 12 routine ECG leads together. Cardiac magnetic resonance imaging was conducted, and late gadolinium enhancement (LGE) was measured at 2, 4, 6 and 8 standard deviations (SDs). RESULTS: Of the 69 patients, fQRS was documented in 38 (55.1%) patients, the mean number of leads with fQRS was 3.7 ± 1.6, and the mean Q-fQRS was 17 ± 7.2. Compared with HOCM patients without fQRS, HOCM patients with fQRS had a higher CVF and more LGE at 6 SD (P < 0.001; P = 0.040). Q-fQRS was correlated with CVF (r = 0.640, P < 0.001), and Q-fQRS showed the best correlation with LGE measured at 8 SD (r = 0.379, P = 0.002). Multivariate regression analyses revealed that Q-fQRS was independently associated with the extent of CVF in HOCM patients after adjusting for age, sex, body surface area and the extent of LGE at 6 SD (P < 0.001). When the patients were divided into subgroups with normal CVF or high CVF according to the CVF in controls, Q-fQRS and LGE at 6SD showed similar diagnostic value in detecting patients with high CVF, with sensitivities of 66.7% vs 68.6%, specificities of 76.7% vs 72.4%, and accuracies of 71% vs 70.3%. CONCLUSIONS: HOCM patients with fQRS showed more extensive MF. Q-fQRS was an independent predictor for MF and had a good diagnostic value, with a sensitivity of 66.7% and specificity of 76.7%, in identifying patients with higher fibrotic burden.

Elevated lymphatic vessel density measured by Lyve-1 expression in areas of replacement fibrosis in the ventricular septum of patients with hypertrophic obstructive cardiomyopathy (HOCM).

Lymphatic microvessel density (LMVD) contributes to fibrosis in patients with myocardial infarction. However, the role of LMVD in the process of myocardial fibrosis in hypertrophic obstructive cardiomyopathy (HOCM) patients is unclear. We studied LMVD in ventricular septal (VS) samples from 52 individuals (42 was HOCM patients who underwent a transaortic extended septal myectomy, and 10 traffic accident victims), and examined the relationships between the LMVD stained immunohistochemically with lymphatic vessel endothelial hyaluronan receptor (LYVE-1) antibodies, collagen volume fraction (CVF), and clinical characteristics. Compared with traffic accident victims, LMVD was significantly increased in VS of HOCM patients (132.0 ± 49.0 VS 57.8 ± 48.8/mm2, p = 0.000). HOCM patients with syncope had higher level of LMVD than without syncope [166.7 (131.0-201.1) VS 116.4 (80.7-152.1)/mm2, p = 0.017], and LMVD were positively correlated with Log (CVF) (r = 0.431, p = 0.004). On multiple variables regression analysis, LMVD was independently associated with Log (CVF) (r = 0.379, p = 0.009) and syncope (r = 0.335, p = 0.020). In conclusions, the LYVE-1-positive lymphatics have close associations with VS fibrosis in HOCM patients.

Surgical results and pathological analysis of cardiac fibroma in the adolescent and the adult.

BACKGROUNDS: Disparities may exist between the adolescent and the adult patients with cardiac fibromas in the symptoms, surgical outcomes, and pathological characteristics. The aim of this study was to compare short and midterm surgical outcomes of cardiac fibromas and to compare the biomarker expressions of tumor tissue samples between the adult and the adolescent. METHODS: Consecutive patients with the diagnosis of cardiac fibroma were admitted and received surgeries. Primary outcomes included in-hospital mortality, low cardiac output, and readmission due to heart failure. The expression of PCNA and Ki67, two widely adopted indicators of cell proliferation, were evaluated in tissue samples. RESULTS: A total of five adolescent patients and five adult patients diagnosed as cardiac fibroma were admitted and given surgeries. When compare with the adults, the adolescent patients were more likely to present symptoms on admission (P = .048). Postoperative low cardiac output syndrome was significantly higher in the adolescents than in the adults (80.0% vs 0.0, P = .048). The tumor volume relative to ventricular end diastolic diameter had good discriminative ability for low cardiac output (c statistics: 0.96). Pathologically, the percentage of PCNA-positive cell nuclei was significantly higher in the adolescents than in the adults (36.04% ± 10.54% vs 4.15% ± 3.93%, P = .001). However, there were no Ki67-positive nuclei in the 10 cases. CONCLUSIONS: In the current study, we found that postoperative low cardiac output was more likely to occur in the adolescent patients than in the adult patients. When compared with the adult patients, significantly more PCNA-positive nuclei were observed in the adolescents.

Mid-Term Outcome for Anomalous Origin of the Left Coronary Artery From the Pulmonary Artery.

BACKGROUND: This study is a single-centre experience with surgical intervention of anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA). METHODS: A retrospective review was performed of patients who underwent ALCAPA repair between November 1991 and October 2017. RESULTS: A total of 138 patients with a median age of 36 months underwent ALCAPA repair. The median follow-up period was 3.5 years. Overall, 114 (82.6%) patients received coronary reimplantation, 21 (15.2%) underwent Takeuchi repair, and three (2.1%) were treated by closure of the ALCAPA plus coronary artery bypass graft. Concomitant mitral repair was performed in 50 patients with moderate-to-severe mitral regurgitation (MR). Three (2.1%) patients died in hospital. Three (2.1%) patients needed extracorporeal membrane oxygenation (ECMO) support. Seven (5.0%) patients needed delayed sternal closure. In patients with decreased preoperative left ventricular ejection fraction (LVEF) (<50%), the LVEF significantly improved from 25% to 33% at discharge (p = 0.001). The percentage of more than moderately significant MR decreased from 36.2% to 5.2% (p = 0.02). There was no late mortality. Two patients needed reoperation because of baffle leaks after Takeuchi repair. Three patients had severe MR. All patients had normal LVEF at last follow-up. The median normalisation time of left ventricular function was 6 months. CONCLUSIONS: Short-term and mid-term outcomes of surgical treatment for ALCAPA patients were excellent. The concomitant mitral valve repair did not increase the perioperative risk but had satisfactory mid-term outcomes. Normalisation of left ventricular function is expected within the first 6 months.

Predictors of long-term outcome after septal myectomy in symptomatic hypertrophic obstructive cardiomyopathy patients with previous alcohol septal ablation and residual obstruction.

BACKGROUND AND AIM: Recently alcohol septal ablation (ASA) has emerged as an alternative treatment for drug-refractory hypertrophic obstructive cardiomyopathy (HOCM) and a subgroup of HOCM patients with previous ASA may need myectomy. However, subsequent outcome and mechanism of residual obstruction has not been determined. This study aims to determine outcome after myectomy and mechanism of residual obstruction in HOCM patients with previous ASA. METHODS: From February 2009 to June 2017, 38 HOCM patients with previous ASA underwent surgical septal myectomy at our institution. Seventy-six patients who underwent surgical septal myectomy initially were included as the comparison group through one-to-two propensity score matching method. RESULTS: Fourteen available cardiac magnetic resonance images revealed inferior location and small area of infarcted myocardium induced by ASA in 12 patients and outside targeted location in two patients. During follow-up (median, 2.4; maximum, 7.8 years), event-free survival at 7 years was 83.2% in the previous ASA group and 94.6% in the comparison group, respectively (P = 0.0378). Multivariable analysis indicated previous ASA (hazard ratio, 4.28; 95% confidence intervals [CI], 1.20-15.26; P = 0.025) and postoperative left ventricular end-diastolic diameter (hazard ratio, 1.14; 95% CI, 1.05-1.23; P = 0.002) were independent predictors of adverse events. CONCLUSIONS: This study demonstrated that uncontrollable extent and location of infarcted myocardium induced by ASA may attribute to residual obstruction after previous ASA, and the long-term event-free survival after myectomy was inferior. It may provide special precaution to patient selection and the increased number of ASA practiced worldwide.

Perfusion strategy and mid-term results of 58 consecutive pulmonary endarterectomy.

OBJECTIVE: The aim of this retrospective study was to review and report short-term and mid-term outcomes of pulmonary endarterectomy for chronic thromboembolic pulmonary hypertension at our institute in the recent 2 years and to describe perfusion strategy. METHODS: A total of 58 consecutive patients with chronic thromboembolic pulmonary hypertension underwent pulmonary endarterectomy under deep hypothermia circulatory arrest with an established perfusion practice between November 2015 and December 2017. Peri-operative data and patients' outcome were retrospectively analyzed. RESULTS: Mean pulmonary artery pressure was decreased (49 (40-56) mmHg vs 27 (20-31) mmHg, p < 0.001), and pulmonary vascular resistance (724 (538-1108) vs 206 (141-284) dyn second cm-5, p < 0.001) improved significantly after surgery. In-hospital mortality was 1.7% and postoperative complication rate was 27.6%. Antipsychotic medication of olanzapine was prescribed for 36 patients (62.1%), which was independently related to total deep hypothermic circulatory arrest time, postoperative blood potassium concentration, and hematocrit. The majority of patients recovered uneventfully with good mid-term cardiac function (New York Heart Association I-II: 98.1%) and neurological outcome (Glasgow Outcome Scale-Extended Upper Good Recovery: 74.1% and Lower Good Recovery: 20.3%). Mid-term neurological outcome was associated with post-pulmonary endarterectomy antipsychotic medication. CONCLUSION: Short-term and mid-term outcome after pulmonary endarterectomy was comparable to high-volume centers. Incidence of post-pulmonary endarterectomy delirium was relatively high and associated with mid-term neurological outcome. Total deep hypothermic circulatory arrest time, postoperative blood potassium concentration, and hematocrit were independent risk factors of postoperative olanzapine medication. More efforts and further research are required to optimize the neuroprotection of perfusion practice.

Microvascular Rarefaction and Myocardial Fibrosis in Hypertrophic Obstructive Cardiomyopathy.

BACKGROUND: Hypertrophic obstructive cardiomyopathy (HOCM) is a myocardial disease characterized by fibrosis and microvascular ischemia. Microvessels play a critical role in myocardial fibrosis in HOCM. However, it remains unclear whether or not myocardial fibrosis is associated with microvascular density (MVD) changes. OBJECTIVE: The aim of the present study was to investigate whether a reduction in MVD is related to myocardial fibrosis in HOCM cardiac samples. METHODS: We analyzed MVD and fibrosis in myectomy left ventricular (LV) septal wall specimens from 53 HOCM patients. Control myocardium from the LV septal wall was collected at autopsy of 9 individuals who died of noncardiac causes. RESULTS: The fibrosis ratio (% area) in HOCM was higher and the MVD was lower than that in control subjects (i.e., 12.7 ± 10.0 vs. 4.0 ± 1.4%, p = 0.012, and 480.9 ± 206.7 vs. 1,425 ± 221/mm2, p < 0.001). Patients with mild fibrosis had a higher MVD than patients with moderate fibrosis (i.e., 568.2 ± 214.8 vs. 403.2 ± 167.8/mm2, p = 0.006) and patients with severe fibrosis (i.e., 568.2 ± 214.8 vs. 378.6 ± 154.0/mm2, p = 0.024). Furthermore, a significant negative correlation was found between myocardial fibrosis and MVD in HOCM patients (r = -0.40, p = 0.003), which was also found in mild fibrosis (r = -0.40, p = 0.043), moderate fibrosis (r = -0.50, p = 0.024), and severe fibrosis (r = -0.24, p = 0.61), although no significant differences were observed in severe fibrosis. Additionally, we demonstrated that late gadolinium enhancement was negatively correlated with MVD (r = -0.37, p = 0.03) and positively correlated with fibrosis (r = 0.44, p = 0.01). CONCLUSION: HOCM patients had a higher myocardial fibrosis ratio and a lower MVD. The severity of myocardial fibrosis was negatively correlated with MVD in HOCM. These findings showed that a reduced MVD may contribute to myocardial fibrosis in HOCM.

Effectiveness of Alcohol Septal Ablation Versus Transaortic Extended Myectomy in Hypertrophic Cardiomyopathy with Midventricular Obstruction.

OBJECTIVES: Investigate the effectiveness of alcohol septal ablation (ASA) and transaortic extended myectomy (TEM) in hypertrophic cardiomyopathy (HCM) with midventricular obstruction (MVO). BACKGROUND: MVO is less common than subaortic obstruction. Data on the effectiveness of ASA and TEM in MVO are lacking. METHODS: The clinical profiles of 22 patients undergoing ASA and 37 patients undergoing TEM were compared. No patient had apical aneurysm, abnormal chordae, mitral valve replacement or repair. RESULTS: Baseline midventricular pressure gradient and symptoms were comparable between the ASA and TEM groups. During follow-up, both groups demonstrated substantial reduction in pressure gradient (the ASA group: 79.7 ± 21.2 mm Hg to 43.7 ± 28.9 mm Hg, P < 0.001; the TEM group: 69.0 ± 23.9 mm Hg to 15.0 ± 16.9 mm Hg, P < 0.001). The reduction in pressure gradient was greater (78.9 ± 18.6% vs. 46.4 ± 33.4%, P < 0.001) and the residual pressure gradient was lower after TEM versus ASA (P < 0.001). Patients with New York Heart Association class III/IV dyspnea decreased from 59.1 to 18.2% (P = 0.022) in the ASA group and from 56.8 to 5.6% (P < 0.001) in the TEM group. Patients with Canadian Cardiovascular Society class III/IV angina decreased from 40.9 to 9.1% (P = 0.016) in the ASA group and from 32.4 to 0% (P < 0.001) in the TEM group. CONCLUSIONS: While ASA and TEM both improve gradients and symptoms, TEM may provide a more reliable reduction in gradients compared to ASA.

[Correlation between VE/VCO2slope and echocardiographic derived systolic pulmonary artery pressure in patients with chronic heart failure].

OBJECTIVE: To explore the relationship between ventilator efficiency of cardiopulmonary exercising test (the slope of the relation between ventilation and carbon dioxide production, VE/VCO(2)slope) and systolic pulmonary artery pressure (sPAP) measured by echocardiography in patients with chronic heart failure (HF). METHODS: Data from 86 HF patients who were treated in Fuwai Hospital between December 2012 and July 2014 and performed the symptom limited maximal cardiopulmonary exercise test (CPET) and echocardiography were retrospectively analyzed.H F patients were divided into 3 groups (mild, moderate and severe) according to the maximum oxygenconsumption (peakVO(2)). RESULTS: There is a significant linear correlation between VE/VCO(2)slope and sPAP (r=0.260, P=0.016). Using VE/VCO(2)slope>34.2 as a cutoff value to predict patients with sPAP>50 mmHg (1 mmHg=0.133 kPa) yielded a sensitivity of 70.0% and a specificity of 64.3%. The degree of the linear correlation between VE/VCO(2)slope and sPAP is stronger in mild HF patients (peakVO(2)>14 ml·kg(-1)·min(-1), r=0.686, P<0.001). Using VE/VCO(2) slope>34.2 as a cutoff value to predict sPAP>50 mmHg in mild HF patients, the sensitivity is 71.4% and the specificity is 93.8%. CONCLUSION: There is a significant linear correlation between VE/VCO(2)slope and sPAP in HF patients. VE/VCO(2)slope>34.2 is linked with a high possibility of sPAP>50 mmHg in HF patients, especially for patients with mild HF. Invasive hemodynamic examination and impact of special therapy are warranted in future studies to veryfy present results.

The role of matrix metalloproteinase-2 in the treatment of atrial fibrillation recurrence after a radiofrequency modified maze procedure.

BACKGROUND AND OBJECTIVE: Our study aimed to elucidate the potential clinical and molecular issues in recurrent atrial fibrillation (AF) following a radiofrequency modified maze procedure in patients with rheumatic valvular disease and persistent AF. METHODS AND RESULTS: Eighty patients with rheumatic valvular disease and persistent AF (lasting more than 6 months) who had undergone a radiofrequency modified maze procedure and mitral valve replacement were enrolled into this single-center pilot study and were followed up for another 6 months. Their clinical characteristics were analyzed and the expression of matrix metalloproteinase (MMP)-2 including its specific inhibitor and collagen volume fraction (CVF) was also assessed. During the 6-month follow-up, 24 subjects had recurrent AF. Among them, the left atrial diameter was larger compared to that achieved in sinus rhythm (SR). The mRNA and protein expression of MMP-2 was significantly increased in recurrent AF patients, while its specific inhibitor did not show a significant difference (p > 0.05). The CVF of type I collagen increased significantly in the recurrent AF patients compared to SR patients (18.16 ± 3.22 vs. 11.66 ± 3.38, p < 0.001), whereas the CVF of type III collagen showed no significant difference (8.33 ± 3.44 vs. 9.55 ± 3.67, p > 0.05). CONCLUSION: This study suggests that the overexpression of MMP-2 is associated with CVF-I in the left atrial appendage which potentially leads to the recurrence of AF following a radiofrequency modified maze procedure in patients with rheumatic valve disease.

Mortality risk model for heart valve surgery in China.

BACKGROUND AND AIM OF THE STUDY: The study aim was to construct a scoring system for the prediction of early mortality in heart valve surgery patients in China, on the basis of objective risk factors. METHODS: Data from 43 Chinese medical centers recorded between January 2007 and December 2008 were analyzed for 13,353 heart valve surgery patients aged > or = 18 years. There were 2,505 cases of aortic valve surgery, 6,996 cases of mitral valve surgery, and 3,852 cases of double-valve surgery (concomitant aortic valve surgery with mitral valve surgery). The EuroSCORE performance was first studied for valve procedures, and a logistic regression then used to examine the relationship between risk factors and in-hospital mortality. RESULTS: The overall mortality was 1.95%. The EuroSCORE has a low discrimination ability for valve surgery, and sensibly overpredicts risk. The risk index contains a total of 10 risk factors, including age, body mass index (BMI), prior valve operation, serum creatinine level, and NYHA functional class. The mathematical models were highly significant predictors of the outcome and in-hospital mortality, and the results were in general agreement with those reported by others. The risk model exhibited a good predictive ability (Hosmer-Lemeshow test, p = 0.97) and discriminated between high- and low-risk patients reasonably well (area under the receiver operating characteristic curve = 0.76). CONCLUSION: Results and methods are presented for use in clinical practice to calculate patient-specific in-hospital mortality after valve surgery, either by applying the logistic equation for each model or by using a simple scoring system with a look-up table for mortality rate.

[Surgical treatment for hypertrophic obstructive cardiomyopathy: a report of 118 cases].

OBJECTIVE: To assess the clinical outcomes of transaortic extended septal myectomy on early and midterm survival of patients with hypertrophic obstructive cardiomyopathy (HOCM). METHODS: From October 2009 to April 2012, 118 consecutive patients underwent extended Morrow's procedure for HOCM. There were 69 males and 49 females with an average age of (46 ± 13) years. Their clinical data were analyzed retrospectively. Preoperative transthoracic, intraoperative transoesophageal and postoperative transthoracic echocardiography was performed to assess septal thickness, left ventricular outflow tract (LVOT) gradient, mitral valve function and systolic anterior motion (SAM) of anterior mitral valve leaflet, etc. Concomitant surgical procedures were performed if other cardiac diseases required surgical interventions. Follow-up study was carried out during subsequent clinic visits at outpatient department and through telephone interviews with patients and their relatives. RESULTS: The septal thickness was (25 ± 7) mm. SAM was detected in all. The in-hospital mortality was 0.8% (1/118) since one patient died of multiple organs failure one week later. Postoperative echocardiography demonstrated marked reduction in LVOT gradient (92 ± 22 vs 13 ± 10 mm Hg (1 mm Hg = 0.133 kPa), P = 0.000), New York Heart Association (NYHA) class (2.9 ± 0.6 vs 1.2 ± 0.4, P = 0.000) and significant improvement in mitral regurgitation. Concomitant surgical procedures were performed in 45 cases (38.1%, all for preexisting conditions). Complications included complete atrioventricular block (n = 3), first degree atrioventricular block (n = 6), complete left bundle branch block (n = 51), intraventricular conduction delay or left anterior division block (n = 26), transient renal dysfunction (n = 2) and intra-aortic-balloon-pumping (n = 2). No other severe complication was observed. During a follow-up period of 1 - 27 (7 ± 6) months, there was no readmission or death. All patients reported significant increase in physical ability and obvious decrease in limiting symptoms. At the latest follow-up, the NYHA functional class maintained grade I-II in all. And mitral regurgitation remained absent or mild. CONCLUSION: Surgical procedure for HOCM patients is both safe and efficacious. It provides an excellent relief of LVOT obstruction.

[Risk factors for hypertension and impact of postoperative hypertension on medium survival after heart transplantation].

OBJECTIVE: To access the prevalence and risk factors for hypertension after heart transplantation (HT), and the impact of post-transplant hypertension on medium-term survival among HT patients. METHODS: Data from 265 consecutive patients underwent HT between June 2004 and May 2012 in Fuwai hospital and survived for at least 6 months were retrospectively analyzed. Hypertension was defined as systolic pressure ≥ 140 mm Hg (1 mm Hg = 0.133 kPa) and/or diastolic pressure ≥ 90 mm Hg or current treatment with antihypertensive drugs. Patients were divided into post-HT hypertension group and non-hypertension group. Logistic regression analysis was used to determine preoperative and postoperative risk factors for hypertension after HT. Kaplan-Meier method and log rank test were used for survival analysis. RESULTS: Hypertension was present in 17.4% (46/265) patients before HT and in 57.4% (152/265) patients post HT. The median follow-up time was 37 months (20 - 57 months). Logistic regression analysis showed that male gender (OR: 2.27, 95%CI: 1.16 - 4.42, P < 0.05), history of pre-HT hypertension (OR: 2.22, 95%CI: 1.05 - 4.71, P < 0.05), and cyclosporine A based immunosuppressive therapy (OR: 2.54, 95%CI: 1.51 - 4.29, P < 0.01) were independent risk factors for the development of post-HT hypertension. At the end of 1, 3, 5 years, the survival rate of heart transplant patients by Kaplan-Meier method estimation were 100%, 97.2%, 86.7% in post-HT hypertension group; 98.1%, 93.8%, 93.8% in non-hypertension group. Log rank test displayed that there was no significant difference between the two survival curves (P > 0.05). CONCLUSIONS: Hypertension is a frequent comorbidity after HT. Male gender, pre-HT hypertension together with cyclosporine A based immunosuppressive therapy are independent predictors for the development of post-HT hypertension. By adjusting the controllable risk factors and active control of blood pressure, the medium-term survival is similar between patients with or without postoperative hypertension in this cohort.

[Clinical features and management of complete heart block after transaortic extended septal myectomy in patients with hypertrophic obstructive cardiomyopathy].

OBJECTIVE: To analyze the clinical features, precaution and management of complete heart block (CHB) after transaortic extended septal myectomy operation (extended Morrow procedure) in patients with hypertrophic obstructive cardiomyopathy (HOCM). METHODS: From October 1996 to December 2011, 10[6 men; mean age (45.4 ± 15.8) years, range 13-60 years] out of 160 consecutive HOCM patients underwent extended Morrow procedure developed CHB postoperatively. Their clinical data were retrospectively analyzed. Baseline transthoracic echocardiography showed that the left ventricular outflow tract (LVOT) gradients was from 68 to 149 (105.1 ± 25.9) mm Hg (1 mm Hg = 0.133 kPa), ECG showed right bundle branch block in 5 patients and atrial fibrillation, atrial premature beats or ST-T segment changes in other 5 patients. Besides extended Morrow procedure, concomitant surgical procedures included mitral valve replacement (MVR) in 2 (2/10) and MVR plus coronary artery bypass grafting in another 2 (2/10) patients. Follow-up data were obtained by subsequent clinic visits in outpatient department and telephone interviews. RESULTS: The in-hospital mortality was 20% (these two patients died of low cardiac output syndrome and multiple organs failure). Four patients underwent MVR simultaneously survived the operation. Postoperative echocardiography demonstrated a reduced LVOT gradient[(13.6 ± 9.7) mm Hg, P < 0.001]. Permanent pacemakers were implanted in all 8 survived patients at 6 days to 7 months after operation. No other severe complications were observed. During follow-up [from 4 to 72 (19.4 ± 22.1) months], there was no death, 1 patient readmitted to our center at 71 months post operation to change the pacemaker because of low voltage of previously implanted pacemaker. Physical capacity and quality of life improved significantly post operation in these 8 patients. The NYHA functional class remained at I-II post operation and during follow up. CONCLUSIONS: CHB is a severe complication after extended Morrow procedure for patients with HOCM and timely permanent pacemaker implantation is mandatory for patients with post procedure CHB.