Sufentanil: a risk factor for lactic acidosis in patients after heart valve surgery.

BACKGROUNDS: Hyperlactatemia is a common metabolic disorder after cardiac surgery with cardiopulmonary bypass. Epinephrine use has been identified as a potential cause of increased lactate levels after cardiac surgery. Stress can lead to an increase in catecholamines, mainly epinephrine, in the body. Exogenous epinephrine causes hyperlactatemia, whereas endogenous epinephrine released by stress may have the same effect. Opioids are the most effective anesthetics to suppress the stress response in the body. The authors sought to provide evidence through a retrospective data analysis that helps investigate the relationship between intraoperative opioid dosage and postoperative lactic acidosis after cardiac surgery. METHODS: The clinical data of 215 patients who underwent valvular heart surgery with cardiopulmonary bypass from July 2016 to July 2019 were analyzed retrospectively. Blood lactate levels were measured at 0.1 h, 2 h, 4 h, and 8 h after surgery. Patients with continuous increases in lactate levels and lactate levels exceeding 5 mmol/L at two or more time points were included in the lactic acidosis group, whereas the other patients were included in the control group. First, univariate correlation analysis was used to identify parameters that were significantly different between the two groups, and then multivariate regression analysis was conducted to elucidate the independent risk factors for lactic acidosis. Fifty-one pairs of patients were screened by propensity score matching analysis (PSM). Then, lactic acid levels at four time points in both groups were analyzed by repeated measures ANOVA. RESULTS: he EF (heart ejection fraction) (OR = 0.94, P = 0.003), aortic occlusion time (OR = 10.17, P < 0.001) and relative infusion rate (OR = 2.23, P = 0.01) of sufentanil was an independent risk factor for lactic acidosis after valvular heart surgery. The patients were further divided into two groups with the mean sufentanil infusion rate as the reference point. The data were filtered with PSM (Propensity Score Matching). Lactic acid values in both groups peaked at 4 h after surgery and then declined. The rate of lactic acid decline was significantly faster in the group with a higher sufentanil dosage than in the lower group. The difference was statistically significant (P < 0.05). There was also a significant difference in lactic acid levels at the four time points (0.1 h, 2 h, 4 h and 8 h after surgery) in both groups (P < 0.001). CONCLUSION: The inadequate intraoperative infusion rate of sufentanil is an independent risk factor for lactic acidosis after heart valve surgery. The possibility of lactic acidosis caused by this factor after cardiac surgery should be considered, which is helpful for postoperative patient management.

Intraoperative method based on tricuspid annular circumference in patients with mild or no tricuspid regurgitation during left-sided cardiac valve surgery for the prophylactic tricuspid annuloplasty.

BACKGROUND: During left-sided cardiac valve surgery in patients with mild or no tricuspid regurgitation (TR), the tricuspid valve exploration plays a vital role in the decision-making of concomitant tricuspid annuloplasty. Currently lack of an appropriate standard to define tricuspid annular dilatation is a challenge. The aim of this study is to introduce and evaluate an alternative intraoperative method for Tricuspid Valve annuloplasty based on annular circumference that could trace the extent of annular dilatation and predict TR-progression, which can also guide the surgeons to intraoperative decision. METHODS: From January 2011 to December 2011, 131 patients (73 females, 58 males, and mean age 54±10.8) were selected for the study underwent left-sided cardiac valve surgery at Anzhen Hospital, all the subjects preoperatively diagnosed with non-significant TR. The enrolled subjects were followed-up over 5years for TR-progression. Tricuspid annular circumference (TAC) measurement was performed via special sizer for each patient, and the obtained values divided on the subject's body surface area (BSA) to achieve the tricuspid annular circumference index (TACI). The endpoint was set as the TR-progression by more than two grades, or a final TR grade ≥3+. RESULTS: The mean follow up period was 68±3.8 months (range, 60-77 months). In univariate, multivariate and logistic regression analysis three variables were noticed to be associated with TR progression, female gender (P<0.002), body mass index (BMI) (P<0.021), and intraoperatively measured TACI (P<0.001). But in multiple regression the TACI (OR 0.812; 95% CI: 0.748-0.883; P<0.001) was the single parameter which significantly related to TR-progression. Based on the receiver-operator curve (ROC), it was likely to derive an optimal cut-off 80.2 mm/m2 which could predict the postoperative development of TR with acceptable sensitivity and specificity 69%, 89%. CONCLUSIONS: Patients with mild or no TR undergoing left-sided valve surgery, intraoperative measurement of the TAC proved to be an ideal method to judge the tricuspid-annulus, it is capable to predict TR-progression. For prophylactic tricuspid repair a presumed TACI of 80.2 mm/m2 is recommended as an indicative threshold.

Ablation in selective patients with long-standing persistent atrial fibrillation: medium-term results of the Dallas lesion set.

OBJECTIVES: The aim of the study was to investigate the efficacy and safety of the Dallas lesion set, which mimics the Cox-maze III left atrial (LA) lesions, for long-standing persistent atrial fibrillation (LSPAF). METHODS: Over a 4-year period, 103 LSPAF patients were treated with the Dallas lesion set. Linear lesions were created at the roofline, at the anterior line and between the roofline and left atrial appendage (LAA). All patients underwent ganglionated plexi ablation and LAA excision as well as pulmonary vein isolation. Follow-up at 6, 12 and 24 months was performed by 48-h Holter recordings and real-time 3-dimensional echocardiography. RESULTS: At the 24-month follow-up, 83 of 103 (80.6%) patients were free of any atrial arrhythmia lasting >30 s, with 77 patients (74.8%) off of antiarrhythmic drugs (AADs). At 3.1 ± 0.7 years, 74 of 103 patients (71.8%) were in sinus rhythm, with 71 patients (68.9%) off AADs. The optimal cut-off value of LA dimension to discriminate atrial arrhythmia recurrence was 55 mm (receiver operating characteristic curve analysis), and the Kaplan-Meier analysis showed that patients with an LA dimension of <55 mm had less recurrence during the follow-up (log-rank test, P = 0.015). After 6 months, a significant reduction in LA volume and improvement in LA function was noted in patients without recurrence (P < 0.05). In contrast, patients with recurrence showed no improvement in LA volume or function. CONCLUSIONS: The Dallas lesion set is an effective treatment in patients with LSPAF. It resulted in significant improvement in LA volume and function after restoration of sinus rhythm.

[Differential expressions of miRNAs in patients with nonvalvular atrial fibrillation].

OBJECTIVE: To detect the differential expressions of miRNAs in left atrial appendage (LAA) in patients with atrial fibrillation (AF). METHODS: Left atrial samples were collected from nonvalvular AF patients and healthy controls. The miRNA transcriptome was analyzed by microarray and verified by real-time reverse transcription-polymerase chain reaction. Computational prediction identified the AF-related miRNAs and its target gene. In the meantime, construction of reporter plasmids and reporter assays were performed to test whether miRNA could represses the Luciferase activity of 3' untranslated regions of its target gene. RESULTS: MiR-155, miR-142-3p, miR-19b, miR-223, miR-146b-5p, miR-486-5p, miR-301b, miR-193b, miR-519b were found to be up-regulated by > 2 folds whereas miR-193a-5p was down-regulated. In particular, the level of miR-155 increased by 5.78 folds in AF patients versus healthy controls (9.42 ± 4.74 vs 1.63 ± 0.65). Furthermore, computational prediction identified CACNA1C encoding Cav1.2 as a direct target of miR-155. In the meantime, the construction of reporter plasmids and reporter assays showed that miR-155 repressed the Luciferase activity of 3' untranslated regions of CACNA1C. CONCLUSION: In LAA sample of nonvalvular AF, there is an expression of AF-related miRNAs including miR-155. And it reveals a potential link between the regulation of Cav1.2 and miR-155 in electric remodeling of AF.

Treatment of long-lasting persistent atrial fibrillation using minimally invasive surgery combined with irbesartan.

BACKGROUND: Recent studies have provided evidence that the renin-angiotensin system plays a key role in the onset and progression of atrial fibrillation (AF). The current study was designed to assess the efficacy and safety of video-assisted minimally invasive radiofrequency ablation for long-lasting persistent AF, as well as to evaluate the efficacy of the angiotensin-receptor blocker irbesartan for maintaining sinus rhythm. METHODS: Over a period of 4 years, 83 patients with long-lasting persistent AF underwent minimally invasive ablation at our center. The patients were randomly assigned to two groups, one group treated with ablation plus irbesartan, and the other with ablation alone. Follow-up ranged from 1 to 3.6 years. RESULTS: No patient died postoperatively. At the end of the procedure, 38 patients (45.7%) were in sinus rhythm, and 36 (43.4%) had AF. At the last follow-up, 65 patients (80.2%) were in sinus rhythm, 38 (92.7%) in group 1 and 27 (67.5%) in group 2 (p = 0.002). Patients in group 2 had a significantly higher rate of recurrent arrhythmia (Kaplan-Meier analysis, p = 0.004; hazard ratio, 0.24; 95% confidence interval: 0.087 to 0.637). Kaplan-Meier analysis also showed that patients treated with irbesartan had a significantly lower rate of use of antiarrhythmic drugs (p = 0.02). CONCLUSIONS: The video-assisted minimally invasive ablation procedure was safe and effective for patients with long-lasting persistent AF. Patients who were additionally treated with irbesartan had a significantly lower rate of AF recurrence than patients who were treated with ablation alone.

[Video-assisted minimally invasive radiofrequency ablation in the treatment of persistent atrial fibrillation].

OBJECTIVE: To evaluate the effectiveness of the video-assisted minimally invasive radiofrequency ablation combined irbesartan use for the treatment of the persistent atrial fibrillation (AF). METHODS: From January 2006 to December 2009, 83 patients with persistent AF having a video-assisted minimally invasive radiofrequency ablation. There were 58 males, 25 females with a mean age of (57 ± 11) years. Mean duration of preoperative AF was (61 ± 65) months. Follow-up for the whole patients ranged from 1.0 to 3.6 years [mean (2.2 ± 0.8) years]. Patients were randomly divided into irbesartan group (n = 42) and without irbesartan group (n = 41) postoperatively. RESULTS: No patient died postoperatively. During follow-up, there was 1 patient died of unknown reason. At the end of the procedure, 38 patients (45.7%) were sinus rhythm, 4 patients (4.9%) were pacing rhythm, 5 patients (6.0%) were atrial flutter or atrial tachycardia, and 36 patients (43.4%) were AF. Before discharge, 53 patients (63.9%) were sinus rhythm, 24 patients (28.9%) were AF. At late follow-up, 65 patients (80.2%) were sinus rhythm; 14 patients (17.3%) were AF or atrial flutter. After follow-up, the Kaplan-Meier analysis showed the irbesartan group had fewer patients with AF (P = 0.020). The hazard ratio for AF recurrence in patients treated with irbesartan was 0.24 (95% CI: 0.087 to 0.637, P = 0.004). CONCLUSIONS: The video-assisted minimally invasive radiofrequency ablation is safe and effective. The patients treated with irbesartan have a lower rate of recurrence of AF.