Effect of preoperative inspiratory muscle training on postoperative outcomes in patients undergoing cardiac surgery: A systematic review and meta-analysis.

BACKGROUND: Cardiovascular disease is the most prevalent disease worldwide and places a great burden on the health and economic welfare of patients. Cardiac surgery is an important way to treat cardiovascular disease, but it can prolong mechanical ventilation time, intensive care unit (ICU) stay, and postoperative hospitalization for patients. Previous studies have demonstrated that preoperative inspiratory muscle training could decrease the incidence of postoperative pulmonary complications. AIM: To explore the effect of preoperative inspiratory muscle training on mechanical ventilation time, length of ICU stay, and duration of postoperative hospitalization after cardiac surgery. METHODS: A literature search of PubMed, Web of Science, Cochrane Library, EMBASE, China National Knowledge Infrastructure, WanFang, and the China Science and Technology journal VIP database was performed on April 13, 2022. The data was independently extracted by two authors. The inclusion criteria were: (1) Randomized controlled trial; (2) Accessible as a full paper; (3) Patients who received cardiac surgery; (4) Preoperative inspiratory muscle training was implemented in these patients; (5) The study reported at least one of the following: Mechanical ventilation time, length of ICU stay, and/or duration of postoperative hospitalization; and (6) In English language. RESULTS: We analyzed six randomized controlled trials with a total of 925 participants. The pooled mean difference of mechanical ventilation time was -0.45 h [95% confidence interval (CI): -1.59-0.69], which was not statistically significant between the intervention group and the control group. The pooled mean difference of length of ICU stay was 0.44 h (95%CI: -0.58-1.45). The pooled mean difference of postoperative hospitalization was -1.77 d in the intervention group vs the control group [95%CI: -2.41-(-1.12)]. CONCLUSION: Preoperative inspiratory muscle training may decrease the duration of postoperative hospitalization for patients undergoing cardiac surgery. More high-quality studies are needed to confirm our conclusion.

ARNI or ARB Treats Residual Left Ventricular Remodelling after Surgery for Valvular Regurgitation: ReReRe study protocol.

AIMS: Patients with persistent or de novo left ventricular (LV) dilation and/or reduced ejection fraction (EF) after correction for primary aortic (AR) or mitral (MR) regurgitation (i.e. residual LV remodelling) have not been well studied with regard to guideline-directed medical therapy after successful aetiology-reversing surgery. We aim to (i) compare the effectiveness of sacubitril/valsartan vs. valsartan in promoting LV reverse remodelling and (ii) explore the safety of medication withdrawal after LV recovery. METHODS AND RESULTS: The ReReRe study is a multicentre, randomized, open-label, parallel trial that consists of two consecutive parts. A total of 371 patients with an LV end-diastolic diameter (LVEDD) > 60 mm or LVEF < 50%, assessed by transthoracic echocardiography (TTE) 7-14 days after valve surgery for significant AR or primary MR will be enrolled. The 1st randomization into the sacubitril/valsartan or valsartan groups and structured follow-up (1, 3, 6, 9, and 12 months after randomization) will be conducted to observe the primary objective as the rate of complete recovery of LV remodelling (i.e. LVEDD < 55 mm and LVEF ≥ 60% by TTE at two consecutive visits). Those who have complete recovery of LV remodelling will be enrolled in Study Part 2; consequently, they will receive the 2nd randomization into the medication withdrawal or maintenance group and 6-monthly visits for the observation of the primary objective as the rate of LV remodelling relapse (LVEDD > 60 mm or LVEF < 50%). The secondary objectives include the rate of composite clinical outcomes and the degree of change in 6-min walk distance and Kansas City Cardiomyopathy Questionnaire scores. CONCLUSIONS: The ReReRe study will provide new evidence for the treatment of patients with residual LV remodelling after curable unloaded surgery, as well as the duration of treatment. The study results will fill the gap in identifying an appropriate medical therapy regimen for this group of patients and perhaps for those with reversible aetiologies of heart failure.

Postoperative Pulmonary Complications in Patients With Transcatheter Tricuspid Valve Implantation-Implications for Physiotherapists.

Objectives: To investigate the incidence of postoperative pulmonary complications (PPCs) and short-term recovery after transcatheter tricuspid valve implantation (TTVI). Methods: A total of 17 patients diagnosed with severe tricuspid regurgitation who received a LuX-valve TTVI were included in this study. Spirometry lung function, maximal inspiratory pressure (MIP), and 6-min walk test distance (6MWD) were recorded. Prior to surgery, patients were stratified into high or low pulmonary risk groups based on published predefined criteria. A physiotherapist provided all patients with education on thoracic expansion exercises, effective cough and an inspiratory muscle training protocol at 50% of MIP for 3 days preoperatively. All patients received standard post-operative physiotherapy intervention including positioning, thoracic expansion exercises, secretion removal techniques and mobilization. Patients were assessed for PPCs as defined by the Melbourne-Group Score-version 2. Clinical characteristics and hospital stay, cost, functional capacity, and Kansas City Cardiomyopathy Questionnaire (KCCQ) heart failure score were recorded at admission, 1-week, and 30-days post-op. Results: The mean (SD) age of the 17 patients was 68.4 (8.0) years and 15 (88%) were female. Pre-surgical assessment identified 8 patients (47%) at high risk of PPCs. A total of 9 patients (53%) developed PPCs between the 1st and 3rd day post-surgery, and 7 of these 9 patients were amongst the 8 predicted as "high risk" prior to surgery. One patient died before the 30 day follow up. Pre-operative pulmonary risk assessment score, diabetes mellitus, a low baseline MIP and 6MWD were associated with a high incidence of PPCs. Compared to those without PPCs, patients with PPCs had longer ICU and hospital stay, and higher hospitalization cost. At 30 days post-surgery, patients without PPCs maintained higher MIP and 6MWD compared to those with PPCs, but there were no significant between-group differences in other lung function parameters nor KCCQ. Conclusion: This is the first study to report the incidence of PPCs post TTVI. Despite a 3-day prehabilitation protocol and standard post-operative physiotherapy, PPCs were common among patients after TTVI and significantly impacted on hospital and short-term recovery and outcomes. In the majority of patients, PPCs could be accurately predicted before surgery. A comprehensive prehabilitation program should be considered for patients prior to TTVI. Clinical Trial Registration: [www.ClinicalTrials.gov], identifier [ChiCTR2000039671].

Prediction of the severity of acute kidney injury after on-pump cardiac surgery.

STUDY OBJECTIVE: On-pump cardiac surgery is associated with a high risk of acute kidney injury (AKI), which can substantially affect risk of mortality and morbidity depending on its severity. Current methods are limited in predicting AKI severity. This study aimed to develop and validate a model to predict AKI severity after on-pump cardiac surgery. DESIGN: Observational retrospective cohort study. SETTING: Two tertiary general hospitals in China. PATIENTS: The sample in this study came from two hospitals: 6919 patients who underwent on-pump cardiac surgery between January 1, 2011 and June 30, 2017 at West China Hospital of Sichuan University, and 1575 patients who underwent on-pump cardiac surgery between September 1, 2013 and June 30, 2017 at the Second Affiliated Hospital of Zhejiang University. MEASUREMENTS: Data from West China Hospital was used to develop an individualized prediction for AKI severity. The model was internally validated, and a cohort from the Second Affiliated Hospital of Zhejiang University was used for external validation. MAIN RESULTS: AKI incidence was 14.7% in the development cohort and 42.3% in the external validation cohort. Ten predictors of AKI severity were identified: age; sex; preoperative levels of serum creatinine, serum cystatin C, and blood urea nitrogen; preoperative red blood cell count; hypertension; cardiopulmonary bypass time; operation time; and red blood cell transfusion. The model incorporating these variables showed a concordance index of 0.730 (95% CI 0.713, 0.747) for predicting stage I AKI, 0.772 (95% CI 0.738, 0.806) for predicting stage II, and 0.770 (95% CI 0.712, 0.828) for predicting stage III in the development cohort. The corresponding indices for the external validation cohort were 0.676 (95% CI 0.650, 0.703), 0.730 (95% CI 0.691, 0.769), and 0.795 (95% CI 0.737, 0.852). CONCLUSIONS: The prediction model incorporating 10 predictors may be useful for predicting severity of AKI after on-pump cardiac surgery.

Extubation in the Operating Room After Transapical Transcatheter Aortic Valve Implantation Safely Improves Time-Related Outcomes and Lowers Costs: A Propensity Score-Matched Analysis.

OBJECTIVE: The experience of safe extubation in the operating room (OR) after transcatheter aortic valve implantation (TAVI) procedure remains not well established. The authors conducted this study to assess the effect of OR extubation in comparison with extubation in the intensive care unit (ICU) on the outcomes and cost in patients undergoing transapical-TAVI. DESIGN: A propensity score-matched analysis. SETTING: A single major urban teaching and university hospital. PARTICIPANTS: A total of 266 patients undergoing transapical TAVI under general anesthesia between June 2015 and March 2020. INTERVENTIONS: Propensity matching on pre- and intraoperative variables was used to identify 99 patients undergoing extubation in the OR versus 72 undergoing extubation in the ICU for outcome analysis. MEASUREMENTS AND MAIN RESULTS: After matching, extubation in the OR showed significant reductions of length of stay (LOS) in ICU (38.8 ± 17.4 v 58.0 ± 70.0 h, difference -19.2, 95% confidence interval [CI] -35.7 to -2.7, p = 0.009) and postoperative LOS in hospital (7.1 ± 3.9 v 10.1 ± 4.6 d, difference -3.0, 95% CI -4.3 to -1.7, p < 0.0001) compared with ICU extubation, but did not significantly affect the composite incidence of any postoperative complications (46.5% [46 of 99] v 52.8% [38 of 72], difference -6.3%, 95% CI -21.5 to 8.9, p = 0.415). Also, extubation in the OR led to significant reduction of total hospital cost compared with extubation in the ICU (¥303.5 ± 17.3 v ¥329.9 ± 52.3 thousand, difference -26.2, 95% CI -38.8 to -13.7, p < 0.0001). CONCLUSIONS: The current study provided evidence that extubation in the OR could be performed safely without increases in morbidity, mortality, or reintubation rate and could provide cost-effective outcome benefits in patients undergoing transapical-TAVI.

[Endoplasmic Reticulum Stress and Mitochondrial Damage in Rat Cardiomyocytes after Acute Myocardial Infarction].

OBJECTIVE: To study the alterations of endoplasmic reticulum (ER) stress and mitochondrial damage after acute myocardial infarction (AMI). METHODS: A total of 40 SD rats were used in this study and 32 of them were subjected to AMI by ligation of left anterior descending artery. The rats were sacrificed and the heart tissues were collected after 1 h, 2 h, 4 h and 6 h of AMI ( n=8 per group). The mRNA levels of activating transcription factor 6 alpha ( ATF6) and immunoglobulin heavy chain binding potein ( BiP), as well as the expression of mitochondrial DNA (mtDNA) in cytoplasm were detected by RT-PCR. The ATP levels in the cardiomyocytes were detected by a commercial ATP assay kit. RESULTS: The mRNA levels of ATF6 and BiP were significantly increased after 1 h of AMI, which were maintained at high level from 2 h of AMI to the end of the experiment ( P<0.05). The ATP concentrations in the cardiomyocytes were significantly elevated after 1 h of AMI but remarkably decreased after 4 h and 6 h of AMI ( P<0.05). The release of mtDNA in cytoplasm was significantly increased after 2 h of AMI, followed by further elevations at 4 h and 6 h after AMI ( P<0.05). CONCLUSION: Mitochondrial damage is secondary to ER stress in AMI.

Neuroprotective effects of a Smoothened receptor agonist against postoperative cognitive dysfunction by promoting autophagy in the dentate gyrus of aged rats.

Objectives: To investigate the effect of purmorphamine (PUR), a Shh co-receptor Smoothened (Smo) agonist, on postoperative cognitive dysfunction (POCD) rat models. Methods: Eighteen-month-old male Sprague-Dawley rats were subjected to intramedullary fixation of a tibial fracture with 7% chloral hydrate anesthesia to mimic human clinical surgery. PUR was administered via an intraperitoneal injection at a dose of 15mg/kg/day for 3 consecutive days at 6 h after surgery. The aged rats were sacrificed after performing a Morris water maze test 1, 3, and 7 days postoperatively to evaluate the expression of related proteins at the appointed time. Results: Compared to the POCD + vehicle group and sham + PUR group, the POCD + PUR group restored neurological deficit (P = 0.01). PUR administration induced upregulation of Shh expression on postoperative day 1 (P = 0.02), which continued on the third day (P = 0.008) but dropped by the 7th day (P = 0.03). Immunofluorescent analysis, similar to western blot analysis, showed a significant increase in the autophagy-marker LC3 (P = 0.006) as well as p62 degradation (P = 0.000) in the dentate gyrus of the aged rats (P = 0.000) after PUR treatment. Importantly, LC3 was mainly found in the presynaptic and postsynaptic membranes of the hippocampus. Conclusions: These results indicate a link between Shh and autophagy in the rat model of POCD, providing new insights into Shh signaling pathway-mediated mechanisms of neuroprotection and cognitive repair after POCD. It also provides a potential entry point for the development of clinical drugs.

Inhalation versus intravenous anesthesia for adults undergoing heart valve surgery: a systematic review and meta-analysis.

INTRODUCTION: Many studies have found that volatile anesthetics are associated with improved clinical outcomes for adults undergoing coronary artery bypass grafting. However, the effect of volatile anesthetics for adults after heart valve surgery has been unclear. So we conducted a meta-analysis of randomized controlled trials (RCTs) to explore whether the choice of an anesthetic regimen might influence patients' outcomes after valve surgery. EVIDENCE ACQUISITION: PubMed, Embase, and Cochrane Library were searched from inception to June 2018. We included eligible research comparing inhalation anesthesia with total intravenous anesthesia (TIVA) in adult patients undergoing valve surgery. The major endpoints involved mortality, postoperative arrhythmia, acute kidney injury, pulmonary complications, neurological events, myocardial infarction, reoperation for bleeding. The postoperative peak troponin release, hospital stay, Intensive Care Unit (ICU) stay and ventilation time were also analyzed. EVIDENCE SYNTHESIS: After screening through 243 potentially relevant articles, we included 13 RCTs with 962 patients. The inhalation anesthesia group revealed comparable mortality (inhalation group 12/249 [4.8%] vs. TIVA group 13/247 [5.3%], RR=0.97; 95% CI: 0.45 to 2.09; P=0.93; P for heterogeneity=0.66, I2=0%) and other postoperative complications with no heterogeneity. The postoperative peak troponin release, hospital/ICU stay and ventilation time were comparable between two groups with considerable heterogeneity. CONCLUSIONS: Among patients undergoing heart valve surgery, the use of inhalation anesthesia compared with TIVA failed to demonstrate superiority for survival and major postoperative complications, and the evidence was insufficient to draw firm conclusions due to the limited sample size. A determination of equivalence or superiority between these two anesthetic regimens requires further researches.

Changes in left ventricular function in patients with aortic regurgitation 12 months after transapical transcatheter aortic valve implantation.

Transcatheter aortic valve implantation (TAVI) is an established treatment for high surgical risk aortic stenosis patients; in recent years, it has also been used in patients with pure/dominant aortic regurgitation (AR). This study aimed to determine the impact of transapical TAVI on left ventricle myocardial mechanics in AR patients. Thirty AR patients (70% men; mean age, 72.8 ± 4.3 years) were enrolled. Conventional echocardiography was performed on all patients before and 12 months after TAVI. Three-dimensional speckle tracking was accomplished in 20 AR patients for the evaluation of global longitudinal strain, global circumferential strain, twist, torsion, apical rotation and basal rotation. Preoperative left ventricular ejection fraction (LVEF), global longitudinal strain (GLS), global circumferential strain (GCS), twist, torsion and apical rotation were impaired in AR patients compared with controls. Mean left ventricular (LV) end-diastolic diameter (from 62.9 ± 7.3 to 52.0 ± 6.8 mm, p < 0.001), LV end-diastolic volume (from 199.4 ± 55.0 to 130.1 ± 48.9 mL, p < 0.001), and LV mass index (179.8 ± 52.2-134.4 ± 42.5 g/m2, p = 0.001) decreased 12 months after TAVI. Interestingly, GLS (from - 17.2 ± 3.2 to - 18.9 ± 3.7, p = 0.007) and GCS (from - 23.9 ± 4.9 to - 25.7 ± 5.0, p = 0.008) improved significantly, but LVEF did not significantly improve. In terms of the rotational mechanics, twist, rotation and basal rotation remained almost unchanged, whereas apical rotation (from 7.4 ± 4.0 to 5.5 ± 3.9, p = 0.009) was significantly impaired after transapical TAVI. Our results indicate that LV function was improved in terms of myocardial deformation but worsened in terms of apical rotation 12 months after TAVI in AR patients. Three-dimensional speckle tracking echocardiography appears to be a sensitive method for detecting subtle cardiac remodeling after TAVI.

Can multiphase dynamic CT angiography provide a better assessment of aortic dissection compared with the standard triphasic protocol?

Background Acute aortic dissection (AD) is a life-threatening medical emergency. It has been debated whether the multiphase dynamic computed tomography angiography (CTA) protocol is superior to the standard triphasic protocol for revealing the characteristics of AD. Purpose To examine two multiphase dynamic protocols, Dynamic four-dimensional (4D) CTA using the shuttle mode and Flash 4D CTA using the high-pitch mode for the assessment of AD and to compare them with the standard triphasic protocol. Material and Methods A total of 54 consecutive patients were randomly and equally assigned to three groups and scanned with a second-generation DSCT scanner. Groups A, B, and C were assessed with the Dynamic 4D CTA in the shuttle mode, the Flash 4D CTA in the high-pitch mode, and the standard triphasic acquisition protocol, respectively. Image quality of all patients was evaluated. The effective radiation dose (ED) was recorded. Results In 54 patients, CTA images could display the true and false lumens, the intimal flap, the entry tear, and branch vessel involvement in the AD. Compared with group C, additional diagnostic information was obtained in groups A and B, including the dynamic enhancement delay between the true and false lumens (A = 18, B = 18); the presence of membrane oscillation (A = 8, B = 14); dynamic ejection of the contrast material from the true lumen into the false lumen (A = 6, B = 7); and the dynamic obstruction of the left renal artery (B = 2). The ED in these three groups was significantly different ( P < 0.05). Conclusion Compared to the standard triphasic protocol, the multiphase dynamic CTA protocol is feasible and is able to reveal additional diagnostic information. Therefore, we recommend using the high-pitch, dual-source multiphase dynamic CTA to assess ADs.

[Application of Echocardiography to Support Transapical Transcatheter Aortic Valve Implantation in Patients with Aortic Regurgitation].

OBJECTIVE: To explore the role of echocardiography in pre-procedural,peri-procedural and post-procedural stages of transapical transcatheter aortic valve implantation (TAVI) in patients with aortic regurgitation (AR). METHODS: 31 patients with pure/dominant AR at a high risk on surgery were enrolled in this study. The degree of their aortic regurgitation was evaluated before TAVI,as well as the related diameters of aortic root and the left ventricular systolic function measured by transthoracic echocardiography (TTE). TEE was used to reevaluate the valve pathology after general anesthesia. TEE in combination with fluoroscopy provided accurate position of the prosthetic valve for implantation. TEE was also used to monitor complications and to evaluate immediate post-procedure paravalvular regurgitation. The post TAVI follow-up included valve heamodynamic status,complications,left ventricular systolic function and left ventricular mass index (LVMI) measured by TEE. RESULTS: Transapical TAVI was successful in 29 of the 31 patients: 23 experienced no or little paravalvular regurgitation; 6 had mild paravalvular regurgitation. The left ventricular end-diastolic diameter (LVDd) and left ventricular mass index (LVMI) of the patients decreased significantly one week after TAVI,which progressed until one month later ( P<0.05) . The left ventricular ejection (EF) of the patients also decreased one week after TAVI ( P<0.05) ,but it resumed to the pre-procedural level one month later. CONCLUSION: Transapical TAVI is a potentially safe and effective therapy for patients with pure/dominant AR at a high risk on open-heart surgery. Echocardiography plays an important role in pre-procedural evaluation,peri-procedural monitoring and post-procedural follow-up in TAVI.

A modified Cox maze IV procedure: a simpler technique for the surgical treatment of atrial fibrillation.

OBJECTIVES: To determine the effectiveness of a simplified surgical treatment method for atrial fibrillation (AF). METHODS: Between September 2012 and October 2013, 120 patients (mean age, 52.3 ± 8.8 years) underwent valve surgery and concomitant bipolar radiofrequency ablation for the treatment of AF. Patients were randomized to a Cox maze IV procedure (CMP-IV) group (n = 60) or a modified CMP-IV (MCMP-IV) group (n = 60). Freedom from AF was defined as freedom from any left atrial arrhythmia lasting <30 s and no requirement of antiarrhythmic drugs after 6 months. Data were recorded at postoperative follow-up examinations, which were scheduled at 1, 3, 6 and 12 months, and annually thereafter. RESULTS: No ablation-related complications occurred in either group. The mean ablation time was longer in the CMP-IV group than in the MCMP-IV group (18.5 ± 1.7 vs 16.6 ± 1.6 min, P < 0.001). The mean follow-up time was 32.4 ± 3.6 months (range, 26-39 months). Freedom from AF tended to be higher, but not significantly so, among the MCMP-IV group than among the CMP-IV group over the entire follow-up period. CONCLUSIONS: The MCMP-IV is an effective surgical procedure for the treatment of AF. In certain patients, such as those with anatomic variations of the pulmonary veins, the MCMP-IV is simpler than the CMP-IV. CLINICAL TRIALS REGISTRATION ID: ChiCTR-TRC-12002742.

Papillary fibroelastoma of the aortic valve in association with rheumatic heart disease: a case report.

BACKGROUND: Papillary fibroelastoma (PFE) is a rare primary cardiac neoplasm that is usually discovered incidentally at autopsy or during cardiac surgery. PFE combined with rheumatic heart disease (RHD) is extremely rare, and only a few cases have been reported. Additionally, the growth rate of the tumor is unknown. CASE PRESENTATION: Here, we present a very rare case of PFE of the aortic valve combined with RHD, which were identified in a female patient who survived for 5 years without surgical intervention, and who subsequently underwent successful surgical treatment. CONCLUSIONS: PFEs may be generally slow-growing tumors, however, the better treatment of choice may be surgery because it produces good curative effects with very low risk of complications, while preventing serious disease consequences.

[The Association Between Bone Morphogenic Protein-4 and in-situ Saphenous Vein Graft Pathology in Diabetic Patients Undergoing Coronary Revascularization].

OBJECTIVES: This study was designed to assess the expression levels of bone morphogenic protein-4 (BMP4) in saphenous veins harvested from diabetic patients undergoing coronary artery bypass grafting (CABG), and to investigate its association with in-situ morphological and pathological changes within the venous wall. METHODS: From January 2013 to December 2014, forty patients with type 2 diabetes mellitus (DM) and risk factors matched non-DM controls (n =40) were enrolled prospectively. Of the 40 DM patients, 24 had noninsulin-dependent diabetes (NIDM) and the remaining 16 had insulin-dependent diabetes (IDM). Segments of saphenous vein without surgical dilatation from these 80 patients were obtained. Vessel wall characteristics were evaluated by hematoxylin-eosin (HE) staining, and the expression and distribution of BMP4 was assessed by Western blot assay and immunohistochemistry analysis. RESULTS: The intimal and medial thickness of the saphenous veins harvested from DM patients were higher than those from non-DM controls. Compared with non-DM patients, the expression level of BMP4 was significantly elevated in diabetic veins ( P<0.05), and BMP4 was highly expressed in smooth muscle cells located in the medial layer. Moreover, the expression levels of BMP4 in diabetic veins were significantly correlated with intimal thickness (r =0.655, P<0.01), intimal area (r =0.684, P<0.01), medial thickness (r =0.642, P<0.01) and medial area (r =0.692, P<0.01). CONCLUSIONS: The pre-existing intimal and medial hyperplasia were significantly correlated with the high expression levels of BMP4 in saphenous veins harvested from diabetic patients, implying a potential role of BMP4 in the progression of vein graft stenotic diseases in this cohort of post-CABG patients. Future studies were warranted in investigating novel therapeutic strategy targeting at BMP4 for improving long-term vein graft patency.

Outcomes of tricuspid annuloplasty with and without prosthetic rings: a retrospective follow-up study.

BACKGROUND: The efficacies of tricuspid valve repair, risk factors for treatment failure and postoperative quality of life have not been thoroughly evaluated in patients with tricuspid insufficiency associated with rheumatic heart disease (RHD). We therefore reviewed our experience with ring and non-ring tricuspid annuloplasty for the treatment of functional tricuspid insufficiency (TI) in RHD. METHODS: This retrospective, follow-up study involved 74 RHD patients who underwent either non-ring annuloplasty (De Vega procedure; 34 patients, 45.95 %) or ring annuloplasty (40 patients, 54.05 %) along with concurrent mitral or/and aortic valve replacement. Operation time, cardiopulmonary bypass time, aortic clamping time, intensive care unit stay and extubation time were recorded. Echocardiographic findings and Short Form (SF)-36 scores were compared between the two groups. RESULTS: In hospital mortality and complications were similar in the two study groups (P = 0.6755). At 1 week, 1 month, 6 months, 1 year, 2 years and even longer after the operation, the Kaplan-Meier curve of freedom from mild and above recurrent TI showed significantly better efficacy in the ring annuloplasty group than the De Vega procedure group (log rank P = 0.0377). Risk factors for recurrent TI included high pulmonary artery systolic pressure (PASP) and non-ring annuloplasty (PASP: hazard ratio = 1.52; non-ring: hazard ratio = 1.42). The mental component summary score at 1 year after the operation did not significantly differ between the two groups (P = 0.6446), but the physical component summary score was significantly better in the ring annuloplasty group (P = 0.0037). CONCLUSION: Compared with non-ring annuloplasty, ring annuloplasty was associated with improved survival, decreased TI recurrence and higher quality of life in RHD patients undergoing tricuspid valve repair combined with mitral and/or aortic valve replacement.

A novel "box lesion" minimally invasive totally thoracoscopic surgical ablation for atrial fibrillation.

INTRODUCTION: Minimally invasive surgical ablation is an emerging alternative method to catheter ablation and the full surgical maze procedure for nonpharmacologic treatment of atrial fibrillation (AF). We present a totally thoracoscopic "box lesion" radiofrequency ablation procedure in patients with paroxysmal or persistent AF. MATERIALS AND METHODS: From June 2011 to October 2012, 14 patients with lone paroxysmal (n = 7) or persistent AF (n = 7) were enrolled in this study. Procedures were performed through 3 5-12 mm holes on each side of the chest wall. A bipolar ablation device was used to create a box lesion in the posterior wall of the left atrium that encircled the 4 pulmonary veins (achieving bilateral pulmonary vein/posterior left atrial wall isolation). Perioperative complications were recorded for all patients. Freedom from AF was assessed by 24-hour Holter monitoring every 3 months or during symptoms of arrhythmia. RESULTS: The ablation was successfully performed in all patients, with median operation time of 128 minutes (range, 45 to 180 minutes). No operative mortality or morbidity were noted during the study period. Freedom from AF was achieved in 12 patients (85.7%) during follow-up (median follow-up 9 months). One patient with persistent AF was shifted to paroxysmal AF. No atrial flutter or atrial tachycardia was noted during the follow-up. CONCLUSION: These early results show that totally thoracoscopic surgical ablation using a unique "box lesion" procedure for persistent or paroxysmal AF is a feasible and effective method with good short-term results. Further study is necessary to validate this result.

Time-dependent changes of plasma inflammatory biomarkers in type A aortic dissection patients without optimal medical management.

OBJECTIVES: To investigate the time-dependent changes in plasma levels of interleukin-6, C-reactive protein, and tumor necrosis factor-α in patients with type A aortic dissection (TAAD) who received unoptimal medical management since the onset of dissections. DESIGN AND METHODS: Plasma levels of interleukin-6, C-reactive protein, and tumor necrosis factor-α were detected by ELISA and immuno-turbidimetric assay in 92 TAAD patients at hospital admission. Blood samples from 78 patients with uncontrolled hypertension and 82 healthy volunteers were also analyzed as controls. The occurrence of TAAD-related complication and its relationship with the plasma levels of these inflammatory biomarkers was also investigated. RESULTS: The concentrations of inflammatory mediators were significant higher in TAAD than those in the uncontrolled hypertension and the healthy group. The time to peak plasma level of IL-6.and TNF-α was shorter than that of CRP in TAAD group. In the TAAD group, 51 patients suffered TAAD-related complications, and their plasma level of CRP was significantly higher than that in patients without TAAD-related complications (94.5 ± 58.8 mg/L versus 47.4 ± 47.8 mg/L, p < 0.001). Also, CRP levels strongly correlated with the value of PaO2/FiO2 ratio (r = -0.69, p < 0.001) and creatinine (r = 0.60, p < 0.001). The time to the peak level of CRP was shorter and the duration of persistently high CRP level was longer in the complication group than those in the complication-free group. CONCLUSIONS: Elevated and persistently high levels of plasma CRP, IL-6 and TNF-α were associated with progressively development of the TAAD. The changing pattern of CRP might be a marker for diagnosis and prophylactic treatment of complications. Our findings suggested a critical role of the inflammation in the progression of dissection and TAAD-related complications.

Rare early prosthesis obstruction after mitral valve replacement: a case report and literature review.

As a dreadful complication after the mechanical heart valve replacement, prosthetic valve obstruction caused by pannus formation occurs increasingly with time. The authors here present a case of 42-year-old woman who was urgently admitted to hospital with acute heart failure symptoms due to the mechanical mitral valve failure only 3 months after surgery. Transthoracic and transesophageal echocardiography demonstrated that the bileaflet of the mitral prosthesis were completely immobilized with only a small transvalvular jet remained. During the reoperation, the reason of the prosthetic valve obstruction was attributed to the noncircular pannus ingrowth extending from the atrioventricular side. For a better understanding of the prosthetic valve dysfunction caused by pannus formation, the authors then compile a literature review to briefly discuss the status quo of the clinical characteristics of this uncommon complication.

Chest injuries associated with earthquakes: an analysis of injuries sustained during the 2008 Wen-Chuan earthquake in China.

PURPOSE: The goal of this study was to analyze the patterns, therapeutic modalities, and short-term outcomes of patients with chest injuries in the aftermath of the Wen-Chuan earthquake, which occurred on May 12, 2008 and registered 8.0 on the Richter scale. METHODS: Of the 1522 patients who were referred to the West China Hospital of Sichuan University from May 12 to May 27, 169 patients (11.1%) had suffered major chest injuries. The type of injury, the presence of infection, Abbreviated Injury Score (AIS 2005), New Injury Severity Score (NISS), treatment, and short-term outcome were all documented for each case. RESULTS: Isolated chest injuries were diagnosed in 129 patients (76.3%), while multiple injuries with a major chest trauma were diagnosed in 40 patients (23.7%). The mean AIS and the median NISS of the hospitalized patients with chest injuries were 2.5 and 13, respectively. The mortality rate was 3.0% (5 patients). CONCLUSIONS: Most of the chest injuries were classified as minor to moderate trauma; however, coexistent multiple injuries and subsequent infection should be carefully considered in medical response strategies. Coordinated efforts among emergency medical support groups and prior training in earthquake preparedness and rescue in earthquake-prone areas are therefore necessary for efficient evacuation and treatment of catastrophic casualties.