Mediating effect of kinesiophobia between self-efficacy and physical activity levels in post-CABG patients: protocol for a prospective, multicentre, cross-sectional study in China.

INTRODUCTION: Physical activity (PA) can improve cardiac function, exercise capacity, and quality of life, in addition to reducing mortality by 20%-30% and preventing the recurrence of adverse cardiovascular events in patients following coronary artery bypass graft (CABG). However, PA levels are low in patients after CABG. This study intends to explore the mediating effect of kinesiophobia between self-efficacy and PA levels in patients following CABG. METHODS AND ANALYSIS: The proposed study constitutes a prospective, multicentre and cross-sectional study comprising 413 patients. Four teaching hospitals with good reputations in CABG will be included in the study. All of them are located in Beijing, China, and provide medical service to the whole country. This study will assess the following patient-reported outcome measures: demographic information, International Physical Activity Questionnaire-Long, Social Support Rating Scale, Cardiac Exercise Self-Efficacy Instrument, Multidimensional Fatigue Inventory, Hospital Anxiety and Depression Scale, and Tampa Scale for Kinesiophobia Heart. ETHICS AND DISSEMINATION: This study conforms to the principles of the Declaration of Helsinki and relevant ethical guidelines. Ethical approval has been obtained from the Ethics Committee of The Sixth Medical Centre of PLA General Hospital (approval number: HZKY-PJ-2022-2). All study participants will provide written informed consent. Findings from this study will be published in Chinese or English for widespread dissemination of the results. TRIAL REGISTRATION NUMBER: Chinese Clinical Trial Register, ChiCTR2100054098.

A Partially Randomized Patient Preference Trial to Assess the Quality of Life and Patency Rate After Minimally Invasive Cardiac Surgery-Coronary Artery Bypass Grafting: Design and Rationale of the MICS-CABG PRPP Trial.

Background: Minimally invasive cardiac surgery-coronary artery bypass grafting (MICS-CABG) has emerged as a safe alternative to standard cardiac surgery. However, treatment preferences can decrease the generalizability of RCT results to the clinical population (i.e., reduce external validity) and influence adherence to the treatment protocol and study outcomes (i.e., reduce internal validity). However, this has not yet been properly investigated in randomized trials with consideration of treatment preferences. Study Design: In this study, patients with a preference will be allocated to treatment strategies accordingly, whereas only those patients without a distinct preference will be randomized. The randomized trial is a 248-patient controlled, randomized, investigator-blinded trial. It is designed to compare whether treatment with MICS-CABG is beneficial in comparison to CABG. This study is aimed to establish the superiority hypothesis for the physical component summary (PCS) accompanied by the non-inferiority hypothesis for overall graft patency. Patients with no treatment preference will be randomized in a 1:1 fashion to one of the two treatment arms. The primary efficacy endpoints are the PCS score at 30 days after surgery and the overall patency rate of the grafts within 14 days after surgery. Secondary outcome measures include the PCS score and patency rate at different time points. Safety endpoints include major adverse cardiac and cerebrovascular events, complications, bleeding, wound infection, death, etc. Conclusions: This trial will address essential questions of the efficacy and safety of MICS-CABG. The study will also address the impact of patients' preferences on external validity and internal validity.

Carotid Endarterectomy with Stent Graft Removal and End to End Bypass in the Treatment of In-Stent Occlusion after Endovascular Therapy of Carotid Gunshot Injury.

Carotid jugular fistula and pseudoaneurysm are easy to form after gunshot injury of carotid artery. Endovascular therapy, such as stent graft implantation, can successfully block the fistula and pseudoaneurysm cavity. However, the possibility of in-stent restenosis or occlusion will lead to treatment failure. The authors describe the case of a 30-year-old man with carotid jugular fistula and pseudoaneurysm after gunshot injury of left carotid artery who had received stent graft placement. However, two years after stent graft, the stenosis of proximal carotid artery near stent was found and gradually aggravated. During the follow-up, transient amaurosis of his left eye occurred intermittently and in-stent occlusion and severe stenosis of proximal carotid artery were found by computed tomography angiography (CTA) in our center. Carotid endarterectomy (CEA)with stent graft removal and end to end bypass using vascular graft was performed to reconstruct the blood flow of left carotid artery. To the extent of the authors' knowledge, this case illustrates a rare CEA and vascular graft bypass in the treatment of in-stent occlusion following the gunshot injury to the carotid artery. The successful treatment of this rare case provides an option to deal with this kind of tricky problem.

Cell sheet formation enhances the therapeutic effects of human umbilical cord mesenchymal stem cells on myocardial infarction as a bioactive material.

Stem cell-based therapy has been used to treat ischaemic heart diseases for two decades. However, optimal cell types and transplantation methods remain unclear. This study evaluated the therapeutic effects of human umbilical cord mesenchymal stem cell (hUCMSC) sheet on myocardial infarction (MI). METHODS: hUCMSCs expressing luciferase were generated by lentiviral transduction for in vivo bio-luminescent imaging tracking of cells. We applied a temperature-responsive cell culture surface-based method to form the hUCMSC sheet. Cell retention was evaluated using an in vivo bio-luminescent imaging tracking system. Unbiased transcriptional profiling of infarcted hearts and further immunohistochemical assessment of monocyte and macrophage subtypes were used to determine the mechanisms underlying the therapeutic effects of the hUCMSC sheet. Echocardiography and pathological analyses of heart sections were performed to evaluate cardiac function, angiogenesis and left ventricular remodelling. RESULTS: When transplanted to the infarcted mouse hearts, hUCMSC sheet significantly improved the retention and survival compared with cell suspension. At the early stage of MI, hUCMSC sheet modulated inflammation by decreasing Mcp1-positive monocytes and CD68-positive macrophages and increasing Cx3cr1-positive non-classical macrophages, preserving the cardiomyocytes from acute injury. Moreover, the extracellular matrix produced by hUCMSC sheet then served as bioactive scaffold for the host cells to graft and generate new epicardial tissue, providing mechanical support and routes for revascularsation. These effects of hUCMSC sheet treatment significantly improved the cardiac function at days 7 and 28 post-MI. CONCLUSIONS: hUCMSC sheet formation dramatically improved the biological functions of hUCMSCs, mitigating adverse post-MI remodelling by modulating the inflammatory response and providing bioactive scaffold upon transplantation into the heart. TRANSLATIONAL PERSPECTIVE: Due to its excellent availability as well as superior local cellular retention and survival, allogenic transplantation of hUCMSC sheets can more effectively acquire the biological functions of hUCMSCs, such as modulating inflammation and enhancing angiogenesis. Moreover, the hUCMSC sheet method allows the transfer of an intact extracellular matrix without introducing exogenous or synthetic biomaterial, further improving its clinical applicability.

Graft patency and completeness of revascularization in minimally invasive multivessel coronary artery bypass surgery.

OBJECTIVES: Graft patency and completeness of revascularization were analyzed in patients who underwent off-pump minimally invasive coronary artery bypass grafting via a left small thoracotomy. METHODS: We retrospectively reviewed the invasive angiography findings and clinical data of 186 consecutive patients who underwent off-pump minimally invasive coronary artery bypass grafting via a left small thoracotomy. The left internal thoracic artery and saphenous vein were used to bypass two or more of three coronary artery systems: the left anterior descending artery, left circumflex artery, or right coronary artery. Before hospital discharge, invasive angiography was performed to assess graft patency. Clinical variables during hospitalization and follow-up were collected and analyzed. RESULTS: All 186 patients successfully underwent off-pump minimally invasive coronary artery bypass grafting without conversion to sternotomy or assistance of cardiopulmonary bypass. The mean graft number was 2.81 per patient (range, 2-5), and the total number of grafts was 522. The in-hospital mortality rate was 1.6% (3 of 186). A total of 181 of 186 (97.3%) patients underwent postoperative invasive angiography. Among the 510 grafts assessed by angiography, the total graft patency rate was 96.3% (491 of 510) (98.3% [171 of 174] for left internal thoracic artery grafts and 95.2% [318 of 334] for saphenous vein grafts). The rate of complete revascularization was 99.5% (185 of 186). CONCLUSIONS: Minimally invasive coronary artery bypass grafting using left internal thoracic artery and saphenous vein grafts provides acceptable graft patency and completeness of revascularization for selected patients with multivessel disease.

Experience with porcine beating heart simulator for coronary artery bypass surgery residency training.

OBJECTIVE: To evaluate the effect of our uniquely designed beating heart simulator for coronary artery bypass surgery residency training. METHODS: The balloon of intra-aortic balloon pump (IABP) was inserted into the left ventricle of an isolated porcine heart to form a beating heart simulator. This model simulated off-pump coronary artery bypass grafting (OPCABG), and the nonbeating heart model simulated the on-pump coronary artery bypass grafting (ONCABG) for training of surgeons. From 2017 to 2019, 60 trainees were randomly divided into nonbeating and beating heart simulator training groups. The training period was 3 months. The performance of anastomosis was evaluated at the beginning (after 1 month), midpoint (after 2 months), and at the end of the assessment (after 3 months). RESULTS: Trainees improved their performance of coronary artery anastomosis respectively after 3 months of training, whether they were trained on beating heart simulator or nonbeating heart simulator (P < .05). On both nonbeating and beating heart simulator test, trainees in the beating group performed better than those in the nonbeating group in the use of microsurgical instruments, anastomotic quality, and anastomotic speed after 3 months of training (P < .05). CONCLUSIONS: The effect of our uniquely developed beating heart simulator training was better than those of nonbeating heart simulator for OPCABG and ONCABG training of surgeons during residency.

Simulation Training in Minimally Invasive Direct Coronary Artery Bypass Grafting.

BACKGROUND: To evaluate the effect of minimally invasive direct coronary artery bypass (MIDCAB) simulator for cardiac residency training. METHODS: A total of 26 resident surgeons who had never trained for coronary artery anastomosis participated in this training program. They received coronary artery anastomosis training on off-pump coronary artery bypass grafting (OPCAB) simulator for 15 h. After training, their performance of anastomosis was evaluated on the OPCAB simulator according to 12 items and a 5-point global rating scale. Based on the total score of assessment, those with an individual score of 12-36 formed group A, while group B was composed of the remaining trainees. The two groups then received another 15 h coronary artery anastomosis training on the MIDCAB simulator, and the performance was assessed. RESULTS: Trainees improved their performance of coronary artery anastomosis after training on the OPCAB simulator. Group A was composed of 7 trainees with an individual with a total score of 12-36 points and group B was composed of the remaining 19 trainees. After MIDCAB simulator training, significant differences were noted in the pre- and post-training values in the A group (P < .001), and the assessment value of group A was significantly better than those of group B (P < .05). No significant difference was detected between pre- and post-training values in group B after MIDCAB simulator training (P > .05). CONCLUSION: We concluded that trainees who performed well in OPCAB simulation training can also perform better in MIDCAB, and our designed MIDCAB simulator was useful for residency training.

Hemodynamic effects of pulsatile unloading of left ventricular assist devices (LVAD) on intraventricular flow and ventricular stress.

The role of pulsatile unloading in hemodynamic changes in intraventricular flow and ventricular wall stress remains unknown. In this study, a finite element model of the left ventricle (LV) is proposed to calculate the mechanical response. The constitutive model of the LV is composed of a quasi-incompressible transversely isotropic model and an active contraction of the myocardium model. Pulsatile unloading is provided by the left ventricular assist device (LVAD), which is implanted between the aortic root and aortic arch. Support models (constant speed and co-pulse) were utilized to study the effect of pulsatile unloading on intraventricular flow and ventricular stress. The result indicates that the formation time of the vortex increases under pulsatile unloading. The area rate of high time-averaged wall shear stress (TAWSS) increased after pulsatile unloading. The area of the high oscillatory shear index (OSI) region (OSI > 0.375) was calculated for heart failure, constant speed, and co-pulse (9.9 cm2, 9.6 cm2, and 9.2 cm2, respectively). The maximum value of the stress that reflects the level of stretch declined after pulsatile unloading (66.4 kPa, 30.9 kPa, and 21.3 kPa, respectively). Besides, pulsatile unloading impacts the maximum value of thickness at the ventricular wall (-0.75 mm, -1 mm, and -1.25 mm, respectively). The change ratios of the thickness are 10%, 14%, and 17%, respectively. In conclusion, pulsatile unloading contributes to the distribution of intraventricular flow and the formation time of the vortex. Co-pulse support significantly reduces the maximum value of the ventricular wall stress and the area of high stress on the ventricular wall.

Stem cell-derived cell sheet transplantation for heart tissue repair in myocardial infarction.

Stem cell-derived sheet engineering has been developed as the next-generation treatment for myocardial infarction (MI) and offers attractive advantages in comparison with direct stem cell transplantation and scaffold tissue engineering. Furthermore, induced pluripotent stem cell-derived cell sheets have been indicated to possess higher potential for MI therapy than other stem cell-derived sheets because of their capacity to form vascularized networks for fabricating thickened human cardiac tissue and their long-term therapeutic effects after transplantation in MI. To date, stem cell sheet transplantation has exhibited a dramatic role in attenuating cardiac dysfunction and improving clinical manifestations of heart failure in MI. In this review, we retrospectively summarized the current applications and strategy of stem cell-derived cell sheet technology for heart tissue repair in MI.

Numerical analysis of aortic hemodynamics under the support of venoarterial extracorporeal membrane oxygenation and intra-aortic balloon pump.

BACKGROUND AND OBJECTIVE: A gap still exists in the hemodynamic effect of intra-aortic balloon pump (IABP), venoarterial extracorporeal membrane oxygenation (VA-ECMO), and VA-ECMO plus IABP on the blood perfusion of the coronary artery, brain, and lower limb; the relation between heart flow and ECMO flow; and the wall stress of vessels. METHODS: A finite-element model of the aorta, ECMO, and IABP was proposed to calculate the mechanical response via fluid-structure interaction. Heart failure (HF), IABP, ECMO, and ECMO plus IABP were utilized to study the effect of support models. RESULTS: For the pressure curve, VA-ECMO weakened the dicrotic notch of pressure compared with HF and the pulsatile index (0.494 vs. 0.706 vs. 0.471 vs. 0.613). IABP, ECMO, and ECMO plus IABP increased the perfusion of the coronary, brain, and renal artery compared with HF. However, ECMO and ECMO plus IABP clearly reduced the blood flow of the left arteria femoralis compared to that of the right arteria femoralis (ECMO: 194.04 vs. 730.80 mL/min; ECMO plus IABP: 342.15 vs. 947.22 mL/min). In addition, the flow of ECMO accessed the renal artery more than the left ventricular flow. Greater ventricular flow perfused to the renal artery at a diastolic period for ECMO plus IABP, especially at the time points of 2.192 s and 2.304 s. Compared to the velocity distribution with ECMO, the flow of the right arteria femoralis was increased in the process of IABP-on. According to these four cases, the stress of the vascular wall was increased for ECMO support at the systolic period. The peak wall stress of ECMO is increased by 20% at 1.68 s. CONCLUSIONS: ECMO plus IABP is more conducive to the blood supply than other cases from the result of numerical simulation. The location of blood intersection was generated in the region of the renal artery, which is estimated carefully.

Mid-term follow-up outcomes of 2-staged hybrid coronary revascularization compared with off-pump coronary artery bypass for patients with multivessel coronary artery disease.

INTRODUCTION: Two-staged hybrid coronary revascularization (HCR) is a novel procedure in selected patients with multivessel coronary artery disease. However, few studies are available on the mid-term or long-term outcomes of this 2-staged procedure as compared to off-pump coronary artery bypass (OPCAB). AIM: To compare in-hospital and mid-term follow-up outcomes of 2-staged HCR with OPCAB in patients with multivessel coronary artery disease. MATERIAL AND METHODS: The present retrospective study analyzed the data from 73 patients who underwent the 2-staged HCR (HCR group) during 2012-2014 at the heart center. Three hundred and eighty-three patients who underwent conventional OPCAB by the same surgeon were selected for the comparative analysis performed on in-hospital and mid-term follow-up outcomes between the two groups. RESULTS: No significant difference was observed in the preoperative outcome between the two groups. The HCR group had a shorter operation duration (152.9 ±43.8 vs. 262.6 ±51.8 min, p < 0.05), less bleeding (558.6 ±441.3 vs. 1035.5 ±613.3 ml, p < 0.05), shorter mechanical ventilation (9.4 ±7.4 vs. 19.0 ±18.3 h, p < 0.05), and less blood transfusion (12 (16.4%) vs. 200 (52.2%), p < 0.05). The mean follow-up duration was 25.0 ±9.6 months in the HCR group and 22.8 ±10.6 months in the OPCAB group. The incidence of major adverse cardiac or cerebrovascular events (MACCE) was similar in both groups (4 (5.5%) vs. 10 (2.8%), p = 0.408). The estimated 3-year survival was similar in both groups (log-rank χ2 = 1.041, p = 0.308). CONCLUSIONS: The 2-staged HCR is a safe and effective surgical procedure and may offer similar mid-term follow-up outcomes to OPCAB.

Minimally invasive direct coronary artery bypass for left anterior descending artery revascularization - analysis of 300 cases.

INTRODUCTION: Minimally invasive direct coronary artery bypass (MIDCAB) grafting is performed via small, left anterolateral thoracotomy. The left internal mammary artery was grafted to the left anterior descending (LAD) artery in 300 consecutive patients. AIM: In-hospital results were evaluated and compared with the conventional, off-pump coronary artery bypass graft procedure. MATERIAL AND METHODS: One hundred and sixty-three (54.33%) of 300 patients underwent staged hybrid coronary revascularization, 93 (31%) were treated for a single LAD lesion, and 44 (14.67%) were treated for multi-vessel disease with reasonably incomplete revascularization. Major in-hospital cardiac adverse events and postoperative data were compared between groups. RESULTS: Preoperative data were similar between groups. However, the difference in left ventricular ejection fraction (p < 0.001) was significant. No conversions to sternotomy occurred during the primary MIDCAB procedures. Shorter operation time (p < 0.001), shorter postoperative mechanical ventilation time (p < 0.001), shorter intensive care unit stay (p < 0.001), and less red blood cell transfusion (p < 0.001) were noted in the MIDCAB group. Postoperative coronary angiography conducted in the MIDCAB group within one week after the operation showed that 2 of 163 patients developed graft occlusion. These patients underwent conventional CABG and recovered well. No significant differences were observed in postoperative MI, delayed wound healing or 30-day in-hospital mortality between the two groups. CONCLUSIONS: The use of a chest wall lifting system and modified stabilizer makes the MIDCAB procedure safer and easier. The MIDCAB procedure is demonstrated to be a feasible and minimally invasive alternative for patients with coronary artery disease involving LAD lesions.

Minimally invasive direct coronary artery bypass grafting with an improved rib spreader and a new-shaped cardiac stabilizer: results of 200 consecutive cases in a single institution.

BACKGROUND: Performing minimally invasive direct coronary artery bypass (MIDCAB) grafting via small chest incisions on a beating heart is challenging. We report our experiences of MIDCAB with the utilization of both an improved rib spreader to harvest the left internal mammary artery (LIMA) and a new-shaped cardiac stabilizer to facilitate LIMA-left anterior descending (LAD) coronary anastomosis. METHODS: Between May 2012 and June 2104, a total of 200 patients who were consecutively operated on in this period were enrolled in this study. Data reported included demographic information, preoperative clinical and cardiac status, LIMA harvest time, postoperative in-hospital outcomes, and 30-day mortality. RESULTS: The average LIMA harvest time was 43 min. The mean age was 62.59 ± 10.19 years, and 45 of the 200 were females. The 30-day mortality was 0.5% (one patient) due to perioperative myocardial infarction. Duration of mechanical ventilation and length of stay in intensive care unit was 9.27 ± 7.65 and 24.27 ± 17.85 h, respectively. The unit of packed RBC transfusion was 0.79 ± 1.58. Postoperative atrial fibrillation was observed in 14 (7%) patients. There was no postoperative stroke, renal failure, or incision complication. CONCLUSION: Performing MIDCAB with the improved retractor and stabilizer utilized in this study showed favorable outcomes in terms of harvesting the LIMA, postoperative morbidities, and 30-day mortality.

[Results and predictors of long-term outcomes of off-pump coronary artery bypass grafting: 2 831 cases from a single center].

OBJECTIVE: To describe the long-term survival of off-pump coronary artery bypass grafting (CABG) and to analysis the risk factors of operative mortality and long-term survival. METHODS: From January 2001 to December 2012, 2 831 patients undergoing off-pump CABG in Peking University People's Hospital, 2 099 cases (74.1%) of them were male, the average age was (63±9) years. The perioperative data was retrospectively collected. Binary Logistic regression was used to find the risk factors which affect the operative mortality. Follow-up evaluation was completed regularly. Kaplan-Meier survival curve, Log-rank test and Cox regression model were used to find out factors which affect the long-term result. RESULTS: Totally 2 831 patients underwent isolating off-pump CABG, in whom 45 patients died perioperative, 2 786 patients discharged successfully. Binary Logistic regression showed that sex (female) (χ2=4.4, OR=2.307, P=0.035), peripheral vascular disease (χ2=17.4, OR=6.616, P=0.000), New York Heart Association (NYHA) class grade≥3 (χ2=10.5, OR=3.491, P=0.001), ejection fraction≤40% (χ2=16.9, OR=5.230, P=0.000), emergency surgery (χ2=11.9, OR=5.127, P=0.001) are risk factors of operative mortality. The follow-up time was (74±44) months. Totally 107 patients were lost from follow-up, 109 patients died in follow-up. The survival rate at 1, 3, 5 , 8 and 10 years was 97.2%, 95.5%, 94.3%, 93.6%, 92.1%, respectively. Univariate analysis showed that age (>65 years), hypertension, renal insufficiency, peripheral vascular disease, history of myocardial infarction, NYHA class grade≥3 and emergency surgery were risk factors of the long-term survival (χ2=8.150 to 88.241, P<0.05). Cox regression analysis showed that age (>65 years) (χ2=12.1, RR=2.295, P=0.000), renal insufficiency (χ2=12.3, RR=3.160, P=0.000), peripheral vascular disease (χ2=42.5, RR=5.626, P=0.000), NYHA class grade≥3 (χ2=9.1, RR=1.994, P=0.002) and emergency surgery (χ2=5.5, RR=2.247, P=0.019) were independent risk factors that affect the long-term survival. CONCLUSIONS: Sex (female), peripheral vascular disease, NYHA class grade≥3, ejection fraction≤40%, emergency surgery are risk factors of operative mortality. Age (>65 years), renal insufficiency, peripheral vascular disease, NYHA class grade≥3 and emergency surgery are independent risk factors that affect the long-term survival. Off-pump CABG has favorable perioperative and long-term outcome, and it definitely is a very safe and effective technique for coronary artery revascularization.

One center experience in China.

OBJECTIVE: To investigate the outcomes and prognostic factors for patients with coronary artery disease and low left ventricular ejection fraction (LVEF≤40%) undergoing off-pump coronary artery bypass grafting OPCAB). METHODS: From 2001 to 2004, 71 patients with low EF undergoing OPCABG in our hospital, the mean age is 65.0±9.0 years (from 37 to 81), 49 males and 16 females, the mean EF was 33.8±5.0%. Regular follow-up evaluation was completed. Draw the Kaplan-Meier survival curves, Use the log-rank test and Cox regression model to find out the factors that affect the long-term result. RESULTS: 71 low LVEF patients, 6 patients died perioperative, 63 patients discharged successfully, the follow-up time was 64.9±30.4 months. 6 patients lost of follow up, 19 patients died during follow-up including 10 patients (15.9%) who had cardiac-related death. The survival rate at 1, 3, 5 and 8 years was 95.1%, 93.3%, 86.3%, 77.7%, respectively. Univariate analysis shows EF≤30% and acute myocardial infarction within 30 days are risk factors for the long-term survival (P<0.05). Cox regression analysis showed that EF≤30% (RR=6.446, P<0.05) and acute myocardial infarction within 30 days (RR=5.993, P<0.05) are two independent risk factors for the cardiac-related death after discharge. CONCLUSIONS: The patients with low eject fraction ventricular have satisfactory outcomes after OPCAB. LVEF≤30% and acute myocardial infarction within 30 days are two independent risk factors that affect the long-term outcome.