RPL9 acts as an oncogene by shuttling miRNAs through exosomes in human hepatocellular carcinoma cells.

The exosomal pathway is an essential mechanism that regulates the abnormal content of microRNAs (miRNAs) in hepatocellular carcinoma (HCC). The directional transport of miRNAs requires the assistance of RNA­binding proteins (RBPs). The present study found that RBPs participate in the regulation of miRNA content through the exosomal pathway in HCC cells. First, differential protein expression profiles in the serum exosomes of patients with HCC and benign liver disease were detected using mass spectrometry. The results revealed that ribosomal protein L9 (RPL9) was highly expressed in serum exosomes of patients with HCC. In addition, the downregulation of RPL9 markedly suppressed the proliferation, migration and invasion of HCC cells and reduced the biological activity of HCC­derived exosomes. In addition, using miRNA microarrays, the changes in exosomal miRNA profiles in HCC cells caused by RPL9 knockdown were examined. miR­24­3p and miR­185­5p were most differentially expressed, as verified by reverse transcription­quantitative PCR. Additionally, using RNA immunoprecipitation, it was found that RPL9 was directly bound to the two miRNAs and immunofluorescence assays confirmed that RPL9 was able to carry miRNAs into recipient cells via exosomes. Overexpression of miR­24­3p in cells increased the accumulation of miR­24­3p in exosomes and simultaneously upregulated RPL9. Excessive expression of miR­24­3p in exosomes also increased their bioactivity. Exosome­mediated miRNA regulation and transfer require the involvement of RBPs. RPL9 functions as an oncogene, can directly bind to specific miRNAs and can be co­transported to receptor cells through exosomes, thereby exerting its biological functions. These findings provide a novel approach for modulating miRNA profiles in HCC.

Predicting lymph node metastasis in colorectal cancer: An analysis of influencing factors to develop a risk model.

BACKGROUND: Colorectal cancer (CRC) is a significant global health issue, and lymph node metastasis (LNM) is a crucial prognostic factor. Accurate prediction of LNM is essential for developing individualized treatment strategies for patients with CRC. However, the prediction of LNM is challenging and depends on various factors such as tumor histology, clinicopathological features, and molecular characteristics. The most reliable method to detect LNM is the histopathological examination of surgically resected specimens; however, this method is invasive, time-consuming, and subject to sampling errors and interobserver variability. AIM: To analyze influencing factors and develop and validate a risk prediction model for LNM in CRC based on a large patient queue. METHODS: This study retrospectively analyzed 300 patients who underwent CRC surgery at two Peking University Shenzhen hospitals between January and December 2021. A deep learning approach was used to extract features potentially associated with LNM from primary tumor histological images while a logistic regression model was employed to predict LNM in CRC using machine-learning-derived features and clinicopathological variables as predictors. RESULTS: The prediction model constructed for LNM in CRC was based on a logistic regression framework that incorporated machine learning-extracted features and clinicopathological variables. The model achieved high accuracy (0.86), sensitivity (0.81), specificity (0.87), positive predictive value (0.66), negative predictive value (0.94), area under the curve for the receiver operating characteristic (0.91), and a low Brier score (0.10). The model showed good agreement between the observed and predicted probabilities of LNM across a range of risk thresholds, indicating good calibration and clinical utility. CONCLUSION: The present study successfully developed and validated a potent and effective risk-prediction model for LNM in patients with CRC. This model utilizes machine-learning-derived features extracted from primary tumor histology and clinicopathological variables, demonstrating superior performance and clinical applicability compared to existing models. The study provides new insights into the potential of deep learning to extract valuable information from tumor histology, in turn, improving the prediction of LNM in CRC and facilitate risk stratification and decision-making in clinical practice.

Fluorescent Laparoscopic Central Hepatectomy for Liver Cancer Using Indocyanine Green Negative Staining.

Laparoscopic hepatectomy is an important treatment method for liver cancer. In the past, the resection boundary was usually determined by intraoperative ultrasound, important vascular structures, and surgeon experience. With the development of anatomical hepatectomy, visual surgery technology has gradually been applied to this type of surgery, particularly indocyanine green (ICG)-guided anatomical hepatectomy. As ICG can be specifically ingested by hepatocytes and used for fluorescence tracing, negative staining techniques have been applied according to different tumor positions. Under ICG fluorescent guidance, the surface boundary and deep resection plane can be more accurately displayed during liver resection. Thus, the tumor-bearing liver segment can be anatomically removed, which helps to avoid damage to important vessels and reduce ischemia or congestion of the remaining liver tissue. Finally, the incidence of postoperative biliary fistula and liver dysfunction is reduced; therefore, a better prognosis is obtained after the resection of liver cancer. Centrally located liver cancer is usually defined as a tumor located at segments 4, 5, or 8 that requires resection of the middle section of the liver. These are among the most difficult hepatectomies to perform because of the large surgical wounds and multiple vessel transections. Based on the specific tumor location, we formulated the required resection ranges by designing personalized fluorescent staining strategies. By completing anatomical resection based on the portal territory, this work aims to achieve the best therapeutic effect.

p62 Promotes Malignancy of Hepatocellular Carcinoma by Regulating the Secretion of Exosomes and the Localization of ß-Catenin.

BACKGROUND: p62 is a multi-domain protein and participates in a variety of cellular biological activities. p62 is also related to tumor malignancy. However, the underlying molecular mechanism of p62 regulating the progression of hepatocellular carcinoma (HCC) remains unclear. METHODS: The expression levels of p62 in HCC tissues and adjacent non-tumor tissues were confirmed using the TCGA dataset and immunohistochemistry. Stable p62-overexpressing HepG2 cells and p62-knockdown MHCC97H cells were established with lentiviral vectors. Cell proliferation, migration, and invasion assays were carried out to investigate the role of p62 in HCC cells and HCC-derived exosomes. The relationship between p62 and ß-catenin was investigated by immunofluorescence and co-immunoprecipitation assays. Male nude mice (BALB/c-nu/nu) were used to establish the xenograft tumors. RESULTS: We found that p62 was significantly upregulated in HCC, and a high level of p62 indicated the promotion of malignancy including cell proliferation, migration, and invasion. Exosomes derived from p62-overexpressing HepG2 also demonstrated the ability to promote tumor malignancy. Immunofluorescence and co-immunoprecipitation assays indicated that p62 interacts with ß-catenin and regulates the localization of ß-catenin to affect the intercellular junction. p62 also promotes tumor growth of HCC and down-regulates the expression of ß-catenin in vivo. CONCLUSIONS: The results of this study concluded that p62 promotes the malignancy of HCC by regulating the secretion of exosomes and the localization of ß-catenin. These findings may provide new ideas for the diagnosis and treatment of HCC.

Angiopoietin-2 induces angiogenesis via exosomes in human hepatocellular carcinoma.

BACKGROUND: Hepatocellular carcinoma (HCC) is the most common primary liver cancer and is a highly vascularized solid tumor. Angiopoietin-2 (ANGPT2) has been described as an attractive target for antiangiogenic therapy. Exosomes are small extracellular vesicles secreted by most cell types and contribute to cell-to-cell communication by delivering functional cargo to recipient cells. The expression of ANGPT2 in tumor-derived exosomes remains unknown. METHODS: We detected the ANGPT2 expression in HCC-derived exosomes by immunoblotting, enzyme-linked immunosorbent assay and immunogold labeling, then observed exosomal ANGPT2 internalization and recycling by confocal laser scanning microscopy, co-immunoprecipitation and immunoblotting. We used two HCC cell lines (Hep3B and MHCC97H) to overexpress ANGPT2 by lentivirus infection or knockdown ANGPT2 by the CRISPR/Cas system, then isolated exosomes to coculture with human umbilical vein endothelial cells (HUVECs) and observed the angiogenesis by Matrigel microtubule formation assay, transwell migration assay, wound healing assay, cell counting kit-8 assay, immunoblotting and in vivo tumorigenesis assay. RESULTS: We found that HCC-derived exosomes carried ANGPT2 and delivered it into HUVECs by exosome endocytosis, this delivery led to a notable increase in angiogenesis by a Tie2-independent pathway. Concomitantly, we observed that HCC cell-secreted exosomal ANGPT2 was recycled by recipient HUVECs and might be reused. In addition, the CRISPR-Cas systems to knock down ANGPT2 significantly inhibited the angiogenesis induced by HCC cell-secreted exosomal ANGPT2, and obviously suppressed the epithelial-mesenchymal transition activation in HCC. CONCLUSIONS: Taken together, these results reveal a novel pathway of tumor angiogenesis induced by HCC cell-secreted exosomal ANGPT2 that is different from the classic ANGPT2/Tie2 pathway. This way may be a potential therapeutic target for antiangiogenic therapy. Video Abstract.

SESN2 protects against doxorubicin-induced cardiomyopathy via rescuing mitophagy and improving mitochondrial function.

The clinical application of doxorubicin (Dox) in cancer therapy is limited by its serious cardiotoxicity. Our previous studies and others have recognized that mitochondrial dysfunction is the common feature of Dox-induced cardiotoxicity. However, mechanisms underlying mitochondrial disorders remained largely unknown. SESN2, a highly conserved and stress-inducible protein, is involved in mitochondrial function and autophagy in cardiovascular diseases. This study aimed to investigate whether SESN2 affects Dox-induced cardiotoxicity and the underlying mechanisms. Sprague-Dawley rats and neonatal rat cardiomyocytes were treated with Dox. SESN2 expression was assessed. The effects of SESN2 on Dox-induced cardiotoxicity were assessed by functional gain and loss experiments. Echocardiographic parameters, morphological and histological analyses, transmission electron microscope and immunofluorescence assays were used to assess cardiac and mitochondrial function. The protein expression of SESN2 was significantly reduced following Dox stimulation. Both knockout of SESN2 by sgRNA and Dox treatment resulted in the inhibition of Parkin-mediated mitophagy, marked cardiomyocytes apoptosis and mitochondria dysfunction. Ectopic expression of SESN2 effectively protected against Dox-induced cardiomyocyte apoptosis, mitochondrial injury and cardiac dysfunction. Mechanistically, SESN2 interacted with Parkin and p62, promoted accumulation of Parkin to mitochondria and then alleviated Dox-caused inhibition of Parkin mediated mitophagy. Ultimately, the clearance of damaged mitochondria and mitochondrial function were improved following SESN2 overexpression. SESN2 protected against Dox-induced cardiotoxicity through improving mitochondria function and mitophagy. These results established SESN2 as a key player in mitochondrial function and provided a potential therapeutic approach to Dox-induced cardiomyopathy.

Vps4A mediates the localization and exosome release of ß-catenin to inhibit epithelial-mesenchymal transition in hepatocellular carcinoma.

We previously reported that Vps4A acted as a tumor suppressor by influencing the microRNA profiles of exosomes and their parental cells in hepatocellular carcinoma (HCC). However, the underlying mechanism and if Vps4A contributes to sorting proteins into exosomes are not well known. Here, we performed mass spectrometry analysis of the immunoprecipitated Vps4A complex and confirmed that Vps4A was associated with ß-catenin and CHMP4B. Through this interaction, Vps4A promoted the plasma membrane (PM) localization and exosome release of ß-catenin. Silencing Vps4A or CHMP4B decreased the PM localization and exosome sorting of ß-catenin. Vps4A overexpression decreased ß-catenin signaling pathway and inhibited epithelial-mesenchymal transition (EMT) and motility of HCC cells. And, silencing Vps4A or CHMP4B promoted EMT in HCC. Furthermore, the expression of Vps4A was significantly related to that of several EMT markers in HCC tissues and the level of exosomal ß-catenin in patients with metastatic HCC was significantly lower compared to that of control patients. In conclusion, through the interaction with CHMP4B and ß-catenin, Vps4A regulates the PM localization and exosome sorting of ß-catenin, consequently decreases ß-catenin signaling, and thereby inhibits EMT and metastasis in HCC.

[Role of EuroSCORE and SinoSCORE in prediction of early postoperative quality of life in patients after coronary artery bypass surgery].

OBJECTIVE: To investigate the predicting value of European system for cardiac operative risk evaluation (EuroSCORE) and sino system for coronary operative risk evaluation (SinoSCORE) in early quality of life of patients after coronary artery bypass surgery (CABG). METHODS: A total of 218 consecutive patients who underwent CABG from March 2010 to January 2013 were evaluated with both systems before operation. Health related quality of life (QoL) was estimated by using 36-item short form health survey (SF-36) preoperatively and postoperatively in order to evaluate the predicting value of the two systems in early post-operative QoL. Calibration was evaluated by Hosmer-l,emeshow goodness-of-fit test.Discrimination was tested by determining the area under the receiver operating characteristic (ROC) curve. RESULTS: There was no significant difference between the accumulation of the EuroSCORE and SinoSCORE in the all patients (t=-0.904, P=0.368), When using Wilcoxon test on life quality in the preoperative and postoperative patients respectively,the data showed that the quality of life improved significantly in various dimensions of the postoperative patients (Z=-2.886, P<0.001).Except for bodily pain (BP) and mental health (MH), statistically significant correlation was found between the preoperative risk evaluation scores and the postoperative QoL scores (r:-0.203 to -0.493, P<0.05). Logistic regression analyses indicated that both the scores emerged as the independent predictor for a relatively worse QoL (OR>1, P<0.05). Furthermore, the EuroSCORE predicted the outcome with a higher OR. For SinoSCORE the Hosmer-Lemeshow test was significant (P=0.628) and the area under ROC curve was 0.754.For the EuroSCORE the Hosmer-Lemeshow test was significant (P=0.538) and the area under ROC curve was 0.854. CONCLUSION: Both EuroSCORE and SinoSCORE could be viewed as a predictor for several aspects of postoperative QoL, while EuroSCORE might have a greater predicting value.

Redo coronary artery bypass grafting: on-pump and off-pump coronary artery bypass grafting revascularization techniques.

OBJECTIVE: To analyze the short-term outcomes of redo coronary artery bypass grafting (CABG) using on-pump and off-pump CABG techniques. METHODS: From January 2003 to August 2013, non-randomized 80 patients were treated with redo CABG in the Department of Cardiac Surgery, Peking University Third Hospital. Among these patients, 40 underwent on-pump CABG technique (redo-ONCAB group) and 40 underwent off-pump CABG technique (redo-OPCAB group). Furthermore, transmyocardial laser revascularization was performed in high-risk patients who were not suitable to conventional grafting. Clinical data of the two groups were recorded and analyzed including operation time, coronary grafts, incomplete revascularization, postoperative ventilation, perioperative stroke, and low output syndrome, etc. RESULTS: There were no significantly differences in age, gender distribution, incidences of hypertension, stroke, and other clinical characteristics between redo-OPCAB group and redo-ONCAB group (all P>0.05), except for incidences of renal dysfunction and pulmonary disease (all P<0.05). The number of grafting vessels in the redo-ONCAB and redo-OPCAB groups was 2.1 ± 0.74 and 1.4 ±0.52 respectively. There was significant difference between the two groups (P=0.0243). Compared with the redo-ONCAB group, there was shorter operation time (P=0.0045), postoperative ventilation (P=0.0211) and intensive care unit stay (P=0.0400), as well as fewer use of platelet (P=0.0338) and blood transfusion (P=0.0034) in the redo-OPCAB group. The incidence of incomplete revascularization (P=0.0253) and the use of transmyocardial laser revascularization (P=0.0052) were higher in the redo-OPCAB group than those in the redo-ONCAB group (all P<0.05). However, no significant differences were showed for the incidence of the use of intra aortic balloon pump and continuous renal replacement therapy, perioperative stroke, low output syndrome, and in-hospital mortality between the two groups (all P>0.05). CONCLUSION: Redo CABG is the safety and efficacy surgical procedure, and redo-OPCAB technique with better outcomes is commended especially in high-risk patients.

Sternal reconstruction of deep sternal wound infections following median sternotomy by single-stage muscle flaps transposition.

OBJECTIVE: To assess clinical effectiveness of using bilateral pectoralis major or plus rectus abdominis muscle flaps in treating deep sternal wound infection (DSWI) following median sternotomy. METHODS: Between January 2009 and December 2013, 19 patients with DSWI after median sternotomy for cardiac surgery were admitted to our hospital, including 14 males (73.7%) and 5 females (26.3%), aged 55±13 (18-78) years. According to the Pairolero classification of infected median sternotomies, 3 (15.8%) patients were type II, and the other 16 (84.2%) were type III. Surgical procedure consisted of adequate debridement of infected sternum, costal cartilage, granulation, steel wires, suture residues and other foreign substances. Sternal reconstruction used the bilateral pectoralis major or plus rectus abdominis muscle flaps to obliterate dead space. The drainage tubes were placed and connected to a negative pressure generator for adequate drainage. RESULTS: There were no intraoperative deaths. In 15 patients (78.9%), bilateral pectoral muscle flaps were mobilized sufficiently to cover and stabilize the defect created by wound debridement. 4 patients (21.0%) needed bilateral pectoral muscle flaps plus rectus abdominis muscle flaps because their pectoralis major muscle flaps could not reach the lowest portion of the wound. 2 patients (10.5%) presented with subcutaneous infection, and 3 patients (15.8%) had hematoma. They recovered following local debridement and medication. 17 patients (89.5%) were examined at follow-up 12 months later, all healed and having stable sternum. No patients showed infection recurrence during the follow-up period over 12 months. CONCLUSION: DSWI following median sternotomy may be effectively managed with adequate debridement of infected tissues and reconstruction with bilateral pectoralis major muscle or plus rectus abdominis muscle flap transposition.

[Association between nuclear factor of activated T cells 1 gene mutation and simple congenital heart disease in children].

OBJECTIVE: To elucidate association between the mutation of nuclear factor of activated T cells 1 (NFATC1) gene in IPT-NFAT region and simple congenital heart disease (CHD) in children. METHOD: We used polymerase chain reaction (PCR) and the sequencing reaction to detect the mutations on the patients and their parents and (or) siblings. RESULTS: PCR amplification of the exon 7 region showed that 2 bands are obtained in 58% of patients with CHD and in 74% of their healthy parents and (or) siblings. Sequencing of the 2 bands revealed that both are amplicons of the exon 7 region, and that the additional band harbors an additional 44 nucleotides segment in the intronic region. The homozygous form of this allele was only present in patients with ventricular septal defect (2/24), atrial septal defect (3/18) and bicuspid aortic valve (1/4) in which G to A transition at nucleotide 17 of the third 44 bps was found. Neither the unrelated non-CHD individuals nor the ones with other CHD showed positive presence for the homozygous form of this allele. CONCLUSIONS: There is a differential amplification of a tandem repeat region in intron 7 of NFATC1 and homozygous form of this allele in patients with ventricular septal defect, atrial septal defect and bicuspid aortic valve. NFATC1 gene may be an a susceptibility marker for ventricular septal defect, atrial septal defect and bicuspid aortic valve.

[The role of European system for cardiac operative risk evaluation in the prediction of quality of life in patients after coronary artery bypass graft surgery].

OBJECTIVE: To assess the value of European system for cardiac operative risk evaluation (EuroSCORE) in predicting quality of life in patients post coronary artery bypass graft surgery (CABG). METHODS: A total of 387 patients underwent CABG in our institute from December of 2002 to December of 2007 were assessed by EuroSCORE before operation. Health-related quality of life (QoL) was estimated postoperatively with Seattle angina questionnaire (SAQ), Nottingham healthy profile (NHP) and Duke activity status index (DASI) in order to evaluate the value of EuroSCORE for predicting quality of life in patients post CABG. RESULTS: There were statistically significant but weak correlations between postoperative QoL score and preoperative EuroSCORE score (r: 0.010 - 0.276). Emotional and psychological experience subgroup analysis showed better predictive value of EuroSCORE score on postoperative QoL score in improved physical functioning subgroups (r > 0.2). Linear regression analysis showed that EuroSCORE score was significant but weakly (r(2) < 0.1) correlated with postoperative QoL score (P < 0.05). CONCLUSION: Preoperative EuroSCORE score is weakly correlated with postoperative QoL score in patients post CABG.

A novel mutation in GATA4 gene associated with dominant inherited familial atrial septal defect.

OBJECTIVE: Atrial septal defect (ASD) is a common congenital heart disease (CHD). Although most cases are sporadic, familial cases have been reported. The transcription factors NKX2.5 and GATA4 play important roles in the pathogenesis of ASD. Mutations in either gene have been identified in familial cases of ASD. Here, we examine a Chinese family with isolated ASD to find out whether there is any mutation in NKX2.5 or GATA4 accounting for the etiology. METHODS: We identified kindred spanning 3 generations in which 8 of 31 (38%) individuals had ASD. One hundred seventy unrelated individuals were included as controls. Peripheral blood samples were collected and genomic DNA was extracted from the leukocytes. NKX2.5 and GATA4 were amplified by polymerase chain reaction (PCR) with specific primers. The sequences of PCR products were compared between affected members and unaffected members, as well as controls. RESULTS: Direct sequencing of NKX2.5 from the genomic DNA of family members failed to identify mutations, whereas sequencing of GATA4 identified an A-to-G transition at nucleotide 928 in exon 5 that predicted a methionine to valine substitution at codon 310 (M310V) in the NLS region. All affected members and a patriarch of the family who was recognized as a carrier exhibited this mutation, whereas the other unaffected family members or control individuals did not. This mutation has not been reported previously in either familial or sporadic cases of CHD. CONCLUSIONS: We identified a novel M310V mutation in GATA4 gene that is located in the NLS region and leads to hereditary ASD in a Chinese family. In this family, we identified a carrier with incomplete penetrance and 8 patients with variable expressivity. However, the mechanism by which this mutation contributes to the development of a congenital heart defect remains to be ascertained.

[Quality of life five years after coronary artery bypass grafting].

OBJECTIVE: The quality of life (QOL) 5 years after coronary artery bypass grafting (CABG) was evaluated by NHP, SAQ and DASI questionnaires. METHODS: NHP, SAQ and DASI questionnaires were mailed to 287 patients who received CABG in our department between Jan 2001 and Jan 2002. The reliability and construct validity of the questionnaires and the influence factor of QOL were analyzed. RESULTS: Two hundred and seventy-three patients (95%) responded to the questionnaires. The reliability of three questionnaires about QOL was 0.81, 0.75 and 0.78, respectively. QOL at 5 years post CABG was significantly better in CCS I/II patients than CCS III/IV patients' according to SAQ. Exertional scale and disease perception scale according to SAQ, social isolation and physical abilities to NHP also significantly related to QOL 5 years post CABG. CONCLUSIONS: All 3 questionnaires had high reliability and statistical validity for evaluating QOL. CCS angina degree affect the quality of life in patients 5 years post CABG.

[A study on viral gastroenteritis attributed to noroviruses in hospitals].

OBJECTIVE: To better understand the clinical feature of viral gastroenteritis attributed to noroviruses and to summarize the experience on an outbreak of acute gastroenteritis through rapidly colleting and confirmation of related information regarding to noroviruses in hospitals. METHODS: Information on an outbreaks involving 18 patients with acute gastroenteritis in one hospital regarding its epidemiological and clinical features and to perform bacteria culture for stool specimens on every patient. On 7 patients, rotavirus antigen were RNA tested together with norovirus nucleic acid were examined by ELISA and PAGE and RT-PCR. RESULTS: (1) Most of the patients were elderly with several chronic diseases. (2) Watery diarrhea (12/18, 66.67%) and few with mucous (3/18, 16.67%) were seen. Most stool examination was normal (10/18, 55.56%) but few stool specimen could be found with some leucocytes (3/18, 16.67%) and little occult blood (4/18, 22.22%). (3) All bacteria culture in stools showed negative. There was no rotavirus RNA identified but 3 specimen showed norovirus nucleic acid positive as 42.86% (3/7). CONCLUSION: Norovirus was one of the important pathogens causing acute gastroenteritis outbreaks in hospitals attacking elderly with several chronic diseases in particular. Surveillance program targeting elderly inpatient with diarrhea should be enhanced, especially in autumn and winter.

[Chronic effects of transmyocardial laser revascularization combined with off-pump coronary artery by pass (OPCAB) compared with OPCAB alone in patients with ischemic heart disease: a prospective multicenter follow-up study].

OBJECTIVE: To approach the long term safety and efficacy of transmyocardial laser revascularization (TMLR, holmium: YAG) combined with off-pump coronary artery bypass (OPCAB) compared with OPCAB alone in patients with ischemic cardiac disease. METHODS: Between 1999 and 2005, 80 patients with diffusely diseased target vessels from two centers in Beijing were enrolled to the study and randomized to receive either TMLR/OPCAB (n = 40) or OPCAB (n = 40) operation. Baseline demographics and operative characteristics were similar between groups. Follow-up (mean 3.4 +/- 1.7 years) included CCS angina class and NYHA classification assessments, 6 minutes walking test (6MWT) and echocardiography. RESULTS: Perioperative mortality was 5% in both groups. No death occurred during follow up. At the end of follow-up, patients at both groups experienced significant improvement on angina score compared with baseline, and angina score was also significantly lower (1.21 +/- 0.42 vs. 1.57 +/- 0.87, P = 0.03) and 6MWT-distance significantly increased (518.0 +/- 65.5 m vs. 473.8 +/- 65.8m, P = 0.006) in OPCAB/TMLR group than that in the OPCAB group. Fewer patients developed recurrent severe angina and received re-CABG/PCI in OPCAB/TMLR group than that in the OPCAB (1 vs. 6 cases, P = 0.113). NYHA and LVEF were similar between the groups at the end of follow up. CONCLUSION: Our study showed that the addition of TMLR to OPCAB is superior in improving angina and exercise tolerance, but there is no further improvement in cardiac function compared to OPCAB alone.