Combined low-dose aspirin and warfarin anticoagulant therapy of postoperative atrial fibrillation following mechanical heart valve replacement.

The safety and efficacy of combined low dose aspirin and warfarin therapy in patients with atrial fibrillation after mechanical heart valve replacement were evaluated. A total of 1016 patients (620 females, mean age of 36.8±7.7 years) admitted for cardiac valve replacement and complicated with atrial fibrillation after surgery were randomly divided into study (warfarin plus 75-100 mg aspirin) or control (warfarin only) groups. International normalized ratio (INR) and prothrombin time were maintained at 1.8-2.5 and 1.5-2.0 times the normal values, respectively. Thromboembolic events and major bleedings were registered during the follow-up period. Patients were followed up for 24±9 months. The average dose of warfarin in the study and control groups was 2.91±0.83 mg and 2.88±0.76 mg, respectively (P>0.05). The incidence of overall thromboembolic events in study group was lower than that in control group (2.16% vs. 4.35%, P=0.049). No statistically significant differences were found in hemorrhage events (3.53% vs. 3.95%, P=0.722) or mortality (0.20% vs. 0.40%, P=0.559) between the two groups. Combined low dose aspirin and warfarin therapy in the patients with atrial fibrillation following mechanical heart valve replacement significantly decreased thromboembolic events as compared with warfarin therapy alone. This combined treatment was not associated with an increase in the risk of major bleeding or mortality.

Totally thoracoscopic closure of ventricular septal defect without a robotically assisted surgical system: a summary of 119 cases.

OBJECTIVES: To summarize the clinical outcomes of totally thoracoscopic closure of a ventricular septal defect (VSD). METHODS: Totally thoracoscopic VSD closure was performed in 119 patients (66 boys; mean age, 7.1 ± 3.6 years). An additional 35 patients undergoing open-chest VSD closure were selected as a control group. Using 3 port incisions in the right chest, pericardiotomy, bicaval occlusion, atriotomy, and VSD closure were performed by thoracoscopy without the aid of a robotically assisted surgical system. RESULTS: Cardiopulmonary bypass and aortic crossclamp times were 42.2 ± 9.8 and 32.5 ± 7.3 minutes, respectively. There were no deaths but 1 patient required insertion of a permanent pacemaker as a result of postoperative atrioventricular conduction block. The length of stay in the intensive care unit (11.0 ± 2.6 vs 22.9 ± 4.9 hours, P < .01) or postoperative hospital stay (4.2 ± 1.1 vs 6.6 ± 2.1 days, P < .03) in the thoracoscopic group were shorter than in the control group. The percentage of patients who required postoperative opioid analgesics in the thoracoscopic group was lower than in the control group (31.9% vs 74.2%, P < .001). Rate of blood transfusion during the operation (17.6% vs 65.7%, P = .001) and the postoperative use of opioid analgesics (31.9% vs 74.3%, P = .003) in the thoracoscopic group was lower than in the control group. Transesophageal echocardiographic analysis 4.6 ± 2.3 months after the operation showed complete closure of the defect. CONCLUSIONS: Totally thoracoscopic closure of VSD through a 3-port entry was safe and effective.

Effect of prostaglandin E1 inhalation on pulmonary hypertension following corrective surgery for congenital heart disease.

BACKGROUND: Intravenous infusion of prostaglandin E1 (PGE1) has been used to treat pulmonary arterial hypertension (PAH); however, the efficacy and safety of inhaled PGE1 is unclear. OBJECTIVES: To investigate the effect of inhaled PGE1 on PAH following corrective surgery for congenital heart disease. METHODS: Sixty patients with postoperative residual PAH following corrective surgery for congenital heart disease were randomly assigned to a control group, a PGE1 infusion group (intravenous PGE1 infusion; 30 ng/kg/min daily for 10 days) or a PGE1 inhalation group (100 µg nebulized PGE1 every 8 h for 10 days). Systolic blood pressure, mean pulmonary arterial pressure, arterial oxygen pressure, oxygen saturation and serum endothelin-1 level were measured before and after the treatment. RESULTS: At the end of the study, the mean pulmonary arterial pressure in the two PGE1 groups were lower than in the control group (P<0.01), whereas the mean arterial oxygen pressure was higher (P<0.01). Compared with the PGE1 infusion group, the mean pulmonary arterial pressure in the PGE1 inhalation group was lower (P<0.01) whereas the arterial oxygen pressure was higher (P<0.01). The mean endothelin-1 levels in the two PGE1 groups were lower than in the control group (P<0.01), but there was no statistically significant difference in endothelin-1 levels between the PGE1 inhalation and infusion groups (P>0.05). CONCLUSIONS: In pediatric patients with PAH, PGE1 inhalation was associated with a reduction in pulmonary arterial pressure and improvement in arterial blood oxygen levels.

Determinants of immediate extubation in the operating room after total thoracoscopic closure of congenital heart defects.

OBJECTIVE: This study was designed to assess the factors that influence immediate extubation following totally thoracoscopic closure of congenital heart defects. SUBJECTS AND METHODS: Clinical and operational data of 216 patients (87 males, average age 13.6 ± 10.9 years) were retrospectively analyzed. Atrial (ASD, n = 90) or ventricular septal defects (VSD, n = 126) were closed via a totally thoracoscopic approach. Ultra-fast-track anesthesia (UFTA) was used in all patients. RESULTS: Immediate extubation in the operating room was successfully performed in 156 (72.2%) patients. A delayed extubation was completed in the intensive care unit in the remaining 60 (27.8%) patients. There was no significant difference in the age, sex, body weight, or type of congenital heart defect between the immediate and delayed extubation groups (p > 0.05). However, more patients in the delayed extubation group had severe preoperational pulmonary hypertension [8 (13.3%) vs. 4 (2.3%), p < 0.05]. The cardiopulmonary bypass time, aortic clamp time, and total duration of the surgery in the immediate extubation group were shorter than in the delayed extubation group (p < 0.05). Multivariate logistic regression analysis showed that preoperational pulmonary hypertension, duration of the surgery or cardiopulmonary bypass, and dosage of fentanyl used during the surgery were independent predictors for immediate extubation. CONCLUSIONS: UFTA and immediate extubation in the operating room was feasible and safe in the majority of patients undergoing totally thoracoscopic closure of ASD or VSD. Preoperational pulmonary hypertension, duration of the surgery, and the dosage of fentanyl used for UFTA were the determining factors for immediate extubation.

Totally endoscopic atrial septal repair with or without robotic assistance: a systematic review and meta-analysis of case series.

OBJECTIVE: To evaluate the safety and efficacy of totally endoscopic repair of atrial septal defect (ASD). METHODS: A review of the literature was conducted. Studies were obtained from the following sources: MEDLINE, EMBASE, Web of Science and CENTRAL Library. Inclusion criteria were: (1) randomised controlled trials, non-randomised trials, observational studies, case series, and full text conference proceedings; (2) use of totally endoscopy closure of ASD; and (3) outcomes reported as clinical efficacy. When available, we also quantified the complication rates from each included study. Meta-analysis was performed on outcomes with a random-effects model. RESULTS: Six studies met all inclusion criteria. The pooled average success rate of totally endoscopic ASD repair was 94.8% from a total of 114 cases (95% CI, 88.0% to 97.8%), with a minimal heterogeneity in the group of studies (Q value x(2)=1.807, I(2)=0.000). In the studies with no robotic assistance, an average success rate of totally endoscopic ASD repair was 96.9% (95% CI, 85.9-99.4%), with a minimal heterogeneity in the two studies (Q value x(2)=0.683, I(2)=0.000). There were few complications for totally endoscopic ASD repair in the studies with and without robotic assistance. There were no statistically significant differences in success rates between robotically and non-robotically assisted totally endoscopic repairs (p>0.05). CONCLUSIONS: Totally endoscopic ASD repair was associated with a high success rate and a low complication rate. There is a need for prospective controlled clinical trials comparing totally endoscopic and conventional surgical repair of ASD.

Effect of preoperational mechanical ventilation on short-term postoperative outcomes in patients with severe tetralogy of Fallot.

BACKGROUND: This study is designed to investigate the effect of preoperational mechanical ventilation on the short-term postoperative outcomes following corrective surgery for severe tetralogy of Fallot (TOF). METHODS: Ninety-two patients (58 males, mean age 20.5±8.5 months) with severe TOF were randomised into study and control groups. In the study group, mechanical ventilation was performed in PEEP/PRVC mode in the intensive care unit to correct blood gas imbalances for the corrective surgery. In the control group, preoperative oxygen supply was provided via face mask or nasal tubes. RESULTS: The postoperative mechanical ventilation time (14.3±1.9 vs 22.5±2.2h, p=0.02), intensive care stay (2.3±1.2 vs 4.7±1.1d, p=0.03) and duration for positive inotropic drug administration (2.5±1.1 vs 4.8±1.2d, p=0.04) in the study group were shorter than those in the control group. The postoperative capillary leak syndrome in the study group was lower than that in the control group (4.3% vs 23.9%, p=0.006). There was no statistically significant difference in the postoperative mortality between the study and control groups (2.1% vs 6.5%, p=0.606). CONCLUSIONS: Preoperational mechanical ventilation in patients with severe forms of TOF was associated with improved short-term outcomes following the corrective surgery. The effect of the preoperational ventilation on postoperative mortality requires further investigation.

Thoracoscopic closure of ventricular septal defect in young children: technical challenges and solutions.

OBJECTIVES: To investigate the feasibility and safety of totally thoracoscopic repair of ventricular septal defects (VSDs) in young children. METHODS: VSD repair was conducted in 36 children (21 boys, mean age 2.5 ± 1.7 years, range 2-5, mean body weight 17.4 ± 2.1 kg) by a totally thoracoscopic approach. Cardiopulmonary bypass (CPB) was achieved peripherally. Through three port incisions in the right chest wall, pericardiotomy, atriotomy and VSD repair were performed under the direct view of a thoracoscopy. Forty patients who were treated with a traditional VSD closure through a sternotomy were selected as a control group. RESULTS: There was no statistically significant difference in age, sex or types of VSD between the study and control group (P > 0.05). In the study group, CPB was established through femoral vessels in 28 (77.8%) patients, and through both the right internal jugular vein and the femoral vessels in eight (22.2%). The aortic cross-clamp time (32 ± 6 vs 29 ± 3 min, P = 0.06) and CPB time (46 ± 11 vs 48 ± 4 min, P = 0.107) were similar between the study and control groups. However, the total operation time, mechanical ventilation time, intensive care stay and overall hospital stay in the study group were shorter than in the control group (P < 0.05). Transthoracic echocardiography 3 months after the operation showed no residual shunt in the ventricular septum. CONCLUSIONS: Thoracoscopic closure of VSDs in young children appears feasible and safe.

Totally thoracoscopic closure for atrial septal defect on perfused beating hearts.

OBJECTIVES: To investigate the feasibility and safety of non-robotically assisted totally thoracoscopic closure for atrial septal defect (ASD) on perfused beating hearts. METHODS: Twenty-four patients (8-45 years, mean 14.4 ± 18.7) underwent ASD closure on beating hearts by a totally thoracoscopic approach without the aid of a robotic surgical system. Additional 72 patients undergoing totally thoracoscopic ASD closure on cardioplegic arrested hearts were selected as a control. Cardiopulmonary bypass (CPB) was achieved peripherally. The aorta was not cross-clamped in the study group but it was cross-clamped in the control group. RESULTS: ASD closure was successful in all study and control group patients without in-hospital mortality or major complications. The total duration of operation (76 ± 9 vs. 98 ± 6 min, P = 0.012), CPB time (32 ± 5 vs. 48 ± 4 min, P = 0.001), duration of intensive care stay (10.0 ± 5.1 vs. 19.2 ± 4.2 h, P = 0.003) and post-operative hospital stay (4.5 ± 0.8 vs. 5.0 ± 1.1 days, P = 0.045) in the study group were shorter than in the control group. There was no statistically significant difference in the proportion of patients requiring in-operation blood transfusion between study group and control group (25.0 vs. 36.1%, P = 0.226). Follow-up transthoracic echocardiography on Day 5 and Day 30 showed no residual shunts in study or control group patients. CONCLUSIONS: Non-robotically assisted totally thoracoscopic closures of ASD on perfused beating hearts are feasible and safe. These procedures are associated with a shorter operation time and a shorter hospital stay than in surgeries on cardioplegic arrested hearts.

Postoperative anxiety and depression in patients undergoing thoracoscopic closure of congenital heart defects.

BACKGROUND: Thoracoscopic closure of atrial or ventricular septal defect is a new surgical method. The postoperative mental health status of patients treated with this novel approach is presently unknown. OBJECTIVE: The aims of this study were to compare psychological symptoms between patients treated with thoracoscopy and those treated with conventional open heart surgery and to evaluate the effect of perioperative counseling on postoperative psychological symptoms. METHODS: In this prospective study, 120 patients were divided into thoracoscopic and conventional open heart surgery groups. All patients received standard preoperative and postoperative nursing care. The thoracoscopic group was randomized into study (n = 30) and control (n = 30) groups. The thoracoscopic study group received daily counseling 2 days before and within the first 4 days after the surgery. Psychological symptoms were assessed by Symptom Checklist-90 on day 5 after the surgery. RESULTS: There was no statistically significant difference in baseline characteristics or Symptom Checklist-90 scores between the thoracoscopic and conventional surgery groups (P > .05) or between the thoracoscopic study and control groups (P > .05). After surgery, the mean scores of somatization, anxiety, depression, and phobic ideation in the thoracoscopic control group were lower than in the conventional surgery group (P < .05). The mean scores of anxiety, depression, and phobic ideation in the thoracoscopic study group were lower than in the thoracoscopic control group (P < .05). CONCLUSIONS: Thoracoscopic closure of congenital heart defects is associated with less postoperative anxiety or depression symptoms compared with conventional open heart surgery. Perioperative counseling in patients undergoing thoracoscopic closure reduces postoperative anxiety or depression symptoms and should be conducted in all patients before the surgery.

Effect of prostaglandin E1 on pulmonary arterial hypertension following corrective surgery for congenital heart disease.

OBJECTIVE: To evaluate the therapeutic effects of prostaglandin E(1) (PGE(1)) on residual pulmonary arterial hypertension (PAH) after corrective surgery for congenital heart disease. METHODS: Thirty-one patients with postoperational PAH were randomly divided into control group (n = 15) and PGE(1) group (n = 16, 6 courses of intravenous PGE(1) plus conventional therapy). Mean pulmonary arterial pressure (MPAP), right ventricular ejection fraction (RVEF), and left ventricular ejection fraction (LVEF) were measured by echocardiography before and 3, 6, and 12 months after the treatment. Arterial oxygen pressure (Pao (2)) was monitored. RESULTS: In both groups, MPAP decreased and RVEF, LVEF, and Pao (2) increased at 6 and 12 months following surgery. In the PGE(1) group, the MPAP (32.2 ± 5.2 vs 40.2 ± 5.1 mm Hg; P = .008) was lower and RVEF (66.6% ± 6.5% vs 54.9% ± 2.1%; P = .019), LVEF (65.9% ± 3.9% vs 53.5% ± 5.1%; P = .031), and Pao (2) (94.3% ± 11.2% vs 93.1% ± 11.3%; P = .009) was higher than in the control group 12 months after the surgery. Four patients (26.7%) in the control group died of pulmonary hypertension crisis, but there was no death in the PGE(1) group (P = .029). Cumulative survival rate in the control group were 86.7%, 80%, 73.3%, and 73.3% at 1, 2, 3, and 5 years, respectively. CONCLUSIONS: Intravenous PGE(1) therapy after corrective surgery for congenital heart disease was associated with a reduction in mean pulmonary arterial pressure and a lower risk of death.

Impact of peripherally established cardiopulmonary bypass on regional and systemic blood lactate levels.

BACKGROUND: To investigate blood lactate levels during and after peripherally established cardiopulmonary bypass (CPB). METHODS: In 86 patients (41 males, mean age 13.8 ± 7.2), CPB was established via femoral vein and artery cannulation for thoracoscopic closure of atrial (n=54) or ventricular septal defect (n=32). Arterial and venous blood lactate levels were measured from the cannulated limb during CPB, and from systemic circulation after CPB. RESULTS: The mean duration of CPB and cannulation of a lower extremity were 50.0 ± 10.5 min and 76.0 ± 18.5 min, respectively. The mean arterial lactate level measured from the systemic circulation remained unchanged during CPB (P>0.05). In patients with CPB for 3h or more, mean arterial lactate in the cannulated limb were higher than the baseline values (3.3 ± 0.5 vs 0.8 ± 0.2 mmol/L, P<0.05). In patients with more than 2h of CPB, mean venous lactate levels in the cannulated limb were also higher than the baseline values (3.4 ± 0.2 vs 1.1 ± 0.3 mmol/L, P<0.05). Within 6h after CPB, systemic arterial (3.0 ± 0.2 vs 0.8 ± 0.1 mmol/L, P<0.01) and venous lactate levels (6.5 ± 0.2 vs 1.0 ± 0.1 mmol/L, P<0.01) were higher than the pre-CPB values. CONCLUSIONS: Peripherally established CPB was associated with an arterial and venous lactate elevation in local and systemic circulation. The duration of CPB and lower limb cannulation appears to be related to the lactate elevation.

Quality of life in patients undergoing totally thoracoscopic closure for atrial septal defect.

BACKGROUND: Quality of life in patients undergoing totally thoracoscopic closure of atrial septal defect is unclear. METHODS: Thoracoscopic atrial septal defect repair was performed in 96 patients (37 males, aged 19.4 ± 8.7 years) without the aid of a computerized robotic surgical system. An additional 56 patients (23 males, aged 21.0 ± 16.1 years) undergoing conventional atrial septal defect closure through sternotomy were enrolled as a control group. Quality of life was assessed with the Medical Outcomes Study Short Form Survey on day 60 after surgery. RESULTS: Atrial septal defect closure was successful in all patients. There was no perioperative mortality or reoperation for bleeding. Total duration of operations (98 ± 11 versus 128 ± 21 minutes, p < 0.01) and hospital stays (5.3 ± 1.7 versus 6.9 ± 2.1 days, p = 0.024) were shorter in the study group than in the control group, respectively. At discharge, patients with moderate to severe incisional pain in the study and control groups was 11.6% and 62.5%, respectively (p = 0.008). The time interval between discharge and returning to school or work in the study group was shorter than in the control group (28 ± 4 versus 42 ± 7 days, p = 0.003). The mean scores of eight variables in the Short Form Survey, such as physical function, bodily pain, social function, and general or mental health in the study group were higher than in the control group (p < 0.05 or p < 0.01). CONCLUSIONS: Compared with conventional sternotomy, totally thoracoscopic atrial septal defect closure was associated with a faster recovery of physical function and a better quality of life.

Anticoagulation therapy with combined low dose aspirin and warfarin following mechanical heart valve replacement.

INTRODUCTION: This study was designed to evaluate safety and efficacy of combined low dose aspirin and warfarin therapy following mechanical heart valve replacement. METHODS: A total of 1496 patients (686 males, mean age 35±8.5 years) undergoing mechanical heart valvular replacement were randomly divided into study (warfarin plus 75-100 mg aspirin) or control (warfarin only) group. International normalized ratio (INR) and prothrombin time was maintained at 1.8-2.5 and 1.5-2.0 times of the normal value, respectively. Thromboembolic events and major bleedings were registered during follow up. RESULTS: Patients were followed up for 24±9 months. The average dose of warfarin in the study and control group was 2.92±0.87 mg and 2.89±0.79 mg, respectively (p>0.05). The overall thromboembolic events in study group were lower than in control group (2.1% vs. 3.6%, p=0.044). No statistically significant differences were found in hemorrhage events (3.5% vs. 3.7%, p>0.05) or mortality (0.3% vs 0.4%, p>0.05) between the two groups. CONCLUSIONS: Following mechanical valve replacement, combined low dose aspirin and warfarin therapy was associated with a greater reduction in thromboembolism events than warfarin therapy alone. This combined treatment was not associated with an increase in the rate of major bleeding or mortality.

Totally thoracoscopic repair of ventricular septal defect: a short-term clinical observation on safety and feasibility.

OBJECTIVES: We sought to investigate the feasibility and safety of totally thoracoscopic repair of a ventricular septal defect. METHODS: Totally thoracoscopic repair of a perimembranous ventricular septal defect was performed in 36 patients (16 male patients; age, 5-19 years; average age, 10.2 ± 4.5 years). Patients with a pulmonary arterial systolic pressure of 60 mm Hg or greater or with supracristal or muscular ventricular septal defects were excluded. An additional 16 patients undergoing open-chest ventricular septal defect repair were selected as a control group. Through 3 port incisions in the right chest, pericardiotomy, bicaval occlusion, atriotomy, and ventricular septal defect repair were performed by a surgeon by means of thoracoscopy. RESULTS: The cardiopulmonary bypass and aortic crossclamp times were 66.2 ± 21.3 and 36.4 ± 8.2 minutes, respectively. The length of stay in the intensive care unit was 20.0 ± 4.1 hours. There were no mortalities and no major complications. Transesophageal echocardiographic analysis 5.2 ± 3.6 months after the operation showed complete closure of the defect without residual shunt. The intensive care unit (17 ± 2 vs 25 ± 5 hours, P = .01) or postoperative hospital (4.2 ± 1.1 vs 6.7 ± 2.1 days, P = .03) stays in the thoracoscopic group were shorter than in the control group. The percentage of patients who required postoperative opioid analgesics in the thoracoscopic group was lower than in the control group (37.5% vs 87.5%, P = .001). CONCLUSIONS: Totally thoracoscopic repair of a perimembranous ventricular septal defect is feasible and safe for older children. This technique is associated with a reduced intensive care and hospital stay in comparison with conventional ventricular septal defect repair.

Totally thoracoscopic repair of atrial septal defect without robotic assistance: a single-center experience.

OBJECTIVE: The recent advent of robotically assisted surgery has enabled totally endoscopic repair of atrial septal defects and patent foramen ovale. This study investigates the feasibility and safety of totally endoscopic repair of an atrial septal defect through small incisions on the chest without robotic assistance. METHODS: Forty patients (23 female patients; average age, 15.4 ± 8.7 years; age range, 6-47 years) with secundum-type ASDs were selected for this study. Cardiopulmonary bypass was achieved peripherally. Through 3-port incisions in the right chest, pericardiotomy, bicaval occlusion, atriotomy, and ASD repair were performed by a surgeon through a thoracoscopy. RESULTS: The cardiopulmonary bypass and aortic crossclamp times were 56.2 ± 21.1 and 38.3 ± 8.6 minutes, respectively. The length of stay in the intensive care unit was 23.0 ± 4.1 hours. There were no mortalities and no major complications in this cohort. Patients were discharged from the hospital 4 to 6 days after the operation. Transesophageal echocardiographic analysis immediately after the operation and at 30 days showed complete closure of the defect without residual shunt. CONCLUSIONS: Totally endoscopic atrial septal defect repair can be achieved without a robotically assisted surgical system. This technique is safe and effective and can be used as a therapeutic option for ASD.

Effect of captopril on pulmonary artery pressure following corrective surgery for tetralogy of fallot.

BACKGROUND: This study was designed to investigate the effect of captopril on systolic pulmonary arterial pressure (PAP) and circulating endothelin-1 (ET-1) following surgical repair of tetralogy of Fallot (TOF). METHODS AND RESULTS: Seventy-six consecutive patients were divided into captopril and control groups following successful repair of TOF. The captopril group was treated with oral captopril (0.2 mg/kg/day) for 12 months. Venous blood was taken before and after the surgery for the analysis of ET-1. Systolic PAP and ventricular function were assessed by Doppler echocardiography. In the control group, there was an increase in ET-1 and systolic PAP following the surgery (p < 0.05). In the captopril group, there was no significant increase in the systolic PAP and ET-1 during the 12-month follow-up. The PAP and ET-1 values in the captopril group were lower than those in the control group following the surgery (p < 0.05). CONCLUSIONS: Systolic PAP is elevated following the complete surgical repair of TOF. Increased circulating ET-1 may be responsible for the elevation of PAP. Captopril treatment prevents postsurgical increases in systolic PAP and circulating ET-1.