Is oxygen therapy beneficial for normoxemic patients with acute heart failure? A propensity score matched study.

BACKGROUND: The clinical efficiency of routine oxygen therapy is uncertain in patients with acute heart failure (AHF) who do not have hypoxemia. The aim of this study was to investigate the association between oxygen therapy and clinical outcomes in normoxemic patients hospitalized with AHF using real-world data. METHODS: Normoxemic patients diagnosed with AHF on ICU admission from the electronic ICU (eICU) Collaborative Research Database were included in the current study, in which the study population was divided into the oxygen therapy group and the ambient-air group. Propensity score matching (PSM) was applied to create a balanced covariate distribution between patients receiving supplemental oxygen and those exposed to ambient air. Linear regression and logistic regression models were performed to assess the associations between oxygen therapy and length of stay (LOS), and all-cause in-hospital as well as ICU mortality rates, respectively. A series of sensitivity and subgroup analyses were conducted to further validate the robustness of our findings. RESULTS: A total of 2922 normoxemic patients with AHF were finally included in the analysis. Overall, 42.1% (1230/2922) patients were exposed to oxygen therapy, and 57.9% (1692/2922) patients did not receive oxygen therapy (defined as the ambient-air group). After PSM analysis, 1122 pairs of patients were matched: each patient receiving oxygen therapy was matched with a patient without receiving supplemental oxygen. The multivariable logistic model showed that there was no significant interaction between the ambient air and oxygen group for all-cause in-hospital mortality [odds ratio (OR) 1.30; 95% confidence interval (CI) 0.92-1.82; P = 0.138] or ICU mortality (OR 1.39; 95% CI 0.83-2.32; P = 0.206) in the post-PSM cohorts. In addition, linear regression analysis revealed that oxygen therapy was associated with prolonged ICU LOS (OR 1.11; 95% CI 1.06-1.15; P <  0.001) and hospital LOS (OR 1.06; 95% CI 1.01-1.10; P = 0.009) after PSM. Furthermore, the absence of an effect of supplemental oxygen on mortality was consistent in all subgroups. CONCLUSION: Routine use of supplemental oxygen in AHF patients without hypoxemia was not found to reduce all-cause in-hospital mortality or ICU mortality.

LncRNA-LINC00472 contributes to the pathogenesis of atrial fibrillation (Af) by reducing expression of JP2 and RyR2 via miR-24.

BACKGROUND: Dysregulated methylation of the promoter of lncRNA LINC00472 reduces the expression of LINC00472 and subsequently up-regulates the expression of its competing endogenous RNA miR-24. In addition, JP2 can stabilize the expression of RyR2, whereas the deregulation of RyR2 expression may contribute to the pathogenesis of atrial fibrillation (AF). In this study, we aimed to study the role of LINC00472 in the pathogenesis of AF. METHODS: 125 AF patients and 168 healthy controls were enrolled to compare their expression of miR-24, LINC00472, JP2 and RyR2. A dual-luciferase reporter gene assay accompanied by real-time PCR, Western blot and IHC assay was subsequently conducted to evaluate the regulatory relationship among miR-24, LINC00472, JP2 and RyR2 in HCM and H9C2 cells. RESULTS: AF patients were associated with an increased level of miR-24 expression and reduced level of LINC00472 expression. Also, the level of DNA methylation in LINC00472 was increased in AF patients. MiR-24 could negatively regulate the expression of LINC00472 and JP2 by directly binding to them. CONCLUSIONS: LINC00472 could regulate the progression of AF via modulating the LINC00472/miR-24/JP2/RyR2 signaling pathway.

Chinese expert consensus on echelons treatment of thoracic injury in modern warfare.

The emergency treatment of thoracic injuries varies of general conditions and modern warfare. However, there are no unified battlefield treatment guidelines for thoracic injuries in the Chinese People's Liberation Army (PLA). An expert consensus has been reached based on the epidemiology of thoracic injuries and the concept of battlefield treatment combined with the existing levels of military medical care in modern warfare. Since there are no differences in the specialized treatment for thoracic injuries between general conditions and modern warfare, first aid, emergency treatment, and early treatment of thoracic injuries are introduced separately in three levels in this consensus. At Level I facilities, tension pneumothorax and open pneumothorax are recommended for initial assessment during the first aid stage. Re-evaluation and further treatment for hemothorax, flail chest, and pericardial tamponade are recommended at Level II facilities. At Level III facilities, simple surgical operations such as emergency thoracotomy and debridement surgery for open pneumothorax are recommended. The grading standard for evidence evaluation and recommendation was used to reach this expert consensus.

Synergistic Anticancer Activity of Combined Use of Caffeic Acid with Paclitaxel Enhances Apoptosis of Non-Small-Cell Lung Cancer H1299 Cells in Vivo and in Vitro.

BACKGROUND/AIMS: Caffeic acid (CA) is known to possess multiple biological activities including anti-cancer activities. However, the molecular mechanisms underlying these activities in non-small-cell lung cancer (NSCLC) cells are not fully understood. We attempted to clarify whether CA could enhance paclitaxel (PTX)-induced cytotoxicity in H1299 cells. METHODS: First, we tested the cytotoxic effects in both H1299 cells and normal human Bease-2b cells by cell proliferation experiments. Next, we use Annexin V/propidium iodide apoptosis analysis and flow cytometric analysis to investigate apoptosis and cell cycle arrest under the treatments mentioned above. To further pinpoint changes in apoptosis, we tested the caspase-associated apoptotic pathway, which involves the activities of caspase-3 and caspase-9. Moreover, apoptosis-related proteins and MAPK pathway proteins were examined by western blot. An H1299 xenograft nude mice model was used to further evaluate the tumor-suppressing effects of CA and PTX in vivo. RESULTS: Combination treatment with low-dose CA and PTX decreased the proliferation of NSCLC H1299 cells but not normal Beas-2b cells. Flow cytometry showed that H1299 cells were arrested in the sub-G1 phase and apoptosis was significantly increased in H1299 cells after CA treatment. Caspase-3 and caspase-9 activities were both increased after CA treatment. Furthermore, CA increased the PTX-induced activation of Bax, Bid, and downstream cleaved PARP, and phosphorylation of extracellular signal regulated kinase1/2 and c-Jun NH2-terminal protein kinase1/2. An in vivo tumor-suppression assay demonstrated that CA and PTX combined treatment exerted a more effective suppressive effect on tumor growth in H1299 xenografts without causing significant adverse effects. CONCLUSIONS: Our results indicated that CA inhibited NSCLC H1299 cell growth by inducing apoptosis and CA and PTX combined produced a synergistic anti-cancer effect in H1299 cells.

Activation of TGF-ß1/α-SMA/Col I Profibrotic Pathway in Fibroblasts by Galectin-3 Contributes to Atrial Fibrosis in Experimental Models and Patients.

BACKGROUND/AIMS: This study aimed to evaluate whether galectin-3 (Gal-3) contributes actively to atrial fibrosis both in patients and experimental atrial fibrillation (AF) models. METHODS: Mouse HL-1 cardiomyocytes were subjected to rapid electrical stimulation (RES) to explore Gal-3 expression and secretion levels by western blotting (WB) and enzyme linked immunosorbent assay (ELISA). Neonatal rat cardiac fibroblasts were treated with conditioned culture medium and recombinant human Gal-3 to evaluate the activation of the transforming growth factor (TGF)-ß1/α-smooth muscle actin (SMA)/collagen I (Col I) profibrotic pathway (WB) and fibroblast proliferation with a Cell Counting Kit-8 (CCK-8). Furthermore, in the rapid atrial pacing (RAP) rabbit AF model, atrial Gal-3 expression and its effects on the profibrotic pathway were evaluated (WB and Masson's trichrome staining). Moreover, 44 consecutive patients who underwent single mitral valve repair/replacement were included, consisting of 28 patients with persistent AF (PeAF) and 16 with sinus rhythm (SR). Coronary sinus blood was also sampled to test circulating Gal-3 levels (ELISA), and atrial myocardium Gal-3 and its downstream TGF-ß1/α-SMA pathway were also measured by WB and immunohistochemical staining. RESULTS: Gal-3 expression in HL-1 cells and its secretion level in culture medium were greatly increased after 24 h RES. Treatment of neonatal rat cardiac fibroblasts with conditioned media collected from the RES group or recombinant human Gal-3 protein (10 and 30 µg/mL) for 72 h induced the activation of the TGF-ß1/α-SMA/Col I profibrotic pathway. RAP increased Gal-3 levels and activated the TGF-ß1/α-SMA/Col I pathway in rabbit left atria, while the Gal-3 inhibitor N-acetyllactosamine, injected at 4.5 mg/kg every 3 days, mitigated these adverse changes. Furthermore, Gal-3 levels in coronary sinus blood samples and myocardial Gal-3 expression levels were higher in the PeAF patients than in the SR patients, and higher level profibrotic pathway activation was also confirmed. CONCLUSIONS: Activation of Gal-3 expression in the atria can subsequently activate the TGF-ß1/α-SMA/Col I pathway in cardiac fibroblasts, which may enhance atrial fibrosis.

Risk factors for embolism in cardiac myxoma: a retrospective analysis.

BACKGROUND: Myxomas are the most common primary heart tumors and are closely associated with embolic events. Cardiac myxomas typically arise from the interatrial septum at the border of the fossa ovalis in the left atrium. Any other location is considered atypical. Embolism, one of the complications of myxoma, is associated with high morbidity and mortality. The aim of this study was to investigate the risk factors for embolism in patients with cardiac myxoma. MATERIAL AND METHODS: In this retrospective study, a cohort of 162 patients with cardiac myxomas was surgically treated between January 1998 and June 2014 at 3 cardiac centers in China. Preoperative data, including platelet count, sex, age, and the tumor (size, location, surface, and attachment), were compared between embolic and non-embolic groups of patients. RESULTS: No significant differences in vascular risk factors were seen between the 2 groups. However, the percentage of higher platelet count (>300 × 10(9)/L) and mean platelet volume in the embolic group were significantly higher than in the non-embolic group (P=0.0356, and 0.0113, respectively). Irregular surface and atypical location of the myxomas were also independently associated with increased risk of embolic complications. CONCLUSIONS: Tumor location, macroscopic appearance, mean platelet volume, and high platelet count are strong risk factors for embolic events in patients with cardiac myxomas.

Can dexmedetomidine be a safe and efficacious sedative agent in post-cardiac surgery patients? a meta-analysis.

INTRODUCTION: The aim of this study was to explore the use of dexmedetomidine as a safe and efficacious sedative agent in post-cardiac surgery patients. METHODS: A systematic literature search of MEDLINE, EMBASE, the Cochrane Library and Science Citation Index until January 2012 and review of studies was conducted. Eligible studies were of randomized controlled trials or cohort studies, comparing dexmedetomidine with a placebo or an alternative sedative agent in elective cardiac surgery, using dexmedetomidine for postoperative sedation and available in full text. Two reviewers independently performed study selection, quality assessment, and data extraction. RESULTS: The search identified 530 potentially relevant publications; 11 met selection criteria in this meta-analysis. Our results revealed that dexmedetomidine was associated with a shorter length of mechanical ventilation (mean difference -2.70 [-5.05, -0.35]), a lower risk of delirium (risk ratio 0.36 [0.21, 0.64]), ventricular tachycardia (risk ratio 0.27 [0.08, 0.97]) and hyperglycemia (risk ratio 0.78 [0.61, 0.99]), but may increase the risk of bradycardia (risk ratio 2.08 [1.16, 3.74]). But there was no significant difference in ICU stay, hospital stay, and morphine equivalents between the included studies. Dexmedetomidine may not increase the risk of hypotension, atrial fibrillation, postoperative nausea and vomiting, reintubation within 5 days, cardiovascular complications, postoperative infection or hospital mortality. CONCLUSIONS: Dexmedetomidine was associated with shorter length of mechanical ventilation and lower risk of delirium following cardiac surgery. Although the risk of bradycardia was significantly higher compared with traditional sedatives, it may not increase length of hospital stay and hospital mortality. Moreover, dexmedetomidine may decrease the risk of ventricular tachycardia and hyperglycemia. Thus, dexmedetomidine could be a safe and efficacious sedative agent in cardiac surgical patients.

[Reoperative valve replacement in patients undergoing cardiac reoperation: a report of 104 cases].

OBJECTIVE: To review the experience of reoperative valve replacement for 104 patients. METHODS: From January 2002 to December 2009, 104 patients underwent heart valve replacement in reoperations, accounting for 2.92% of the total patient population (3557 cases) who had valve replacement during this period. In this group, 53 male and 51 female patients were included with a median age of 46 years (ranged from 13 to 72 years). The reasons of reoperation included 28 cases suffered from another valve lesion after valve replacement, 10 cases suffered from valve lesion after mitral valvuloplasty, 19 cases suffered from perivalvular leakage after valve replacement, 18 cases suffered from valve lesion after previous correction of congenital heart defect, 7 cases suffered from bioprosthetic valve decline, 10 cases suffered from prosthetic valve endocarditis, 9 cases suffered from dysfunction of machine valve, and 3 cases suffered from other causes. The re-operations were mitral and aortic valve replacement in 2 cases, mitral valve replacement in 59 cases, aortic valve replacement in 24 cases, tricuspid valve replacement in 16 cases, and Bentall's operation in 3 cases. The interval from first operation to next operation was 1 month-19 years. RESULTS: There were 8 early deaths from heart failure, renal failure and multiple organ failure (early mortality 7.69%). Major complications were intraoperative hemorrhage in 2 cases, re-exploration for mediastinal bleeding in 2 cases and sternotomy surgical site infection in 1 case. Complete follow-up (3 months-7 years and 2 months) was available for all patients. Two patients died, one patient died of intracranial hemorrhage, and another cause was unknown. CONCLUSION: Satisfactory short-term and long-term results can be obtained in reoperative valve replacement with appropriate timing of operation control, satisfactory myocardial protection, accurate surgical procedure and suitable perioperative treatment.

Conclusion is more encouraging than data.

We read the article entitled "Scientific publications in cardiology journals from Chinese authors in various parts of North Asia: 10-year survey of literature" and found that the methodology in that study was not appropriate. Clarification or revision on some raised concerns will make this article much convinced.

Surgical treatment of multivalvular endocarditis: twenty-one-year single center experience.

OBJECTIVE: Little information is available about surgical outcomes in patients with multivalvular endocarditis. The aim of this article is to review the 21-year experience with surgical treatment of patients with multivalvular endocarditis at our institution and, in particular, to determine the incidence, pathologic status, diagnosis, surgical strategies, and outcomes of patients with this disease. METHODS: From January 1986 to December 2006, a total of 48 patients (40 men, 8 women), with a mean age of 42 +/- 12 years, underwent surgery for multivalvular endocarditis. Endocarditis was active in 32 patients and healed in 16. Preoperative transthoracic echocardiographic evaluation was performed in all 48 patients with addition of transesophageal echocardiography in 22 (45.8%). Intraoperative findings showed that the endocarditis involved mostly the mitral and aortic valves (40/48 patients). Triple or quadruple valve involvement was found in 1 and 2 patients, respectively. Preoperative, perioperative, and postoperative data were retrospectively analyzed and risk factors for early and late survival were determined. RESULTS: In only 24 (50.0%) patients was multivalvular endocarditis diagnosed by preoperative transthoracic echocardiography; 17 (77.3%) patients had multivalvular endocarditis confirmed by preoperative transesophageal echocardiography. The 30-day hospital mortality was 12.5% (n = 6). Preoperative renal failure, New York Heart Association class IV, and emergency surgery were identified as independent risk factors for hospital mortality. Overall long-term survival was 74% +/- 6% at 5 years and 62% +/- 3% at 10 years. Multivariate analysis revealed that renal failure and recurrent endocarditis were associated with increased late mortality. Ten-year freedom from recurrent endocarditis was 74% +/- 5% and 10-year freedom from reoperation was 73% +/- 6%. CONCLUSIONS: In our institution, multivalvular endocarditis was diagnosed by transthoracic echocardiography in only half of the patients. Intraoperative transesophageal echocardiography provided a more effective means to identify this disease. Radical resection of all infected tissues for patients with multivalvular endocarditis and additional intraoperative interventions, depending on the intraoperative pathologic condition, produced satisfactory in-hospital and long-term results, similar to those in patients with a single infected heart valve.

Ebstein's anomaly of the tricuspid valve with rheumatic mitral stenosis and aortic incompetence.

The case is reported of Ebstein's anomaly of the tricuspid valve with rheumatic mitral stenosis and aortic incompetence. In this extremely rare clinical entity, right ventricular dysfunction and respiratory dysfunction occur due to severe mitral stenosis and tricuspid regurgitation. The present case was managed with aortic and mitral valve replacement and Danielson's repair of the tricuspid valve. The general management issues of the condition are also discussed in detail.

[Experiences on surgical treatment of severe aortic valve stenosis: a report of 171 cases].

OBJECTIVE: To analyze the experiences on surgical treatment of severe aortic valve stenosis. METHODS: From December 1990 to December 2006, 171 patients with severe aortic valve stenosis underwent aortic valve replacement (AVR). There were 135 males and 36 females aged from 10 to 75 years old, with a mean of (45.8 +/- 15.6) years old. The intervals between the first episode of exertion dyspnea and administration to operation were 2 months to 52 years. The pathological lesions of the group were rheumatic aortic valve stenosis in 75 cases, calcified aortic stenosis in 66 cases, bicuspid aortic valve in 26 cases and other congenital aortic valve stenosis in 4 cases. One hundred and twenty-four patients underwent AVR, 7 AVR combined with replacement of the ascending aorta, 5 AVR with coronary artery bypass grafting, 19 AVR with mitral valve plasty (MVP), 8 AVR with plasty of the ascending aorta and 8 AVR with enlargement of the aortic root. RESULTS: The averaged operation time was (4.4 +/- 0.6) h. Cardiopulmonary bypass (CPB) time was (124.7 +/- 38.5) min and the aorta clamp time was (78.3 +/- 21.7) min. The averaged blood loss during operation was (754.5 +/- 518.4) ml. All the procedures were successfully performed and all patients were weaned off CPB uneventfully. The indication of early complications was 12.3% (21/171), including low cardiac output syndrome in 7 cases, multi-organ failure in 3 cases, endocarditis in 1 case, renal dysfunction in 4 cases, ventricular fibrillation in 1 case, excessive bleeding in 2 cases, III atrial-ventricular block in 2 cases, and mediastinal infection in 1 case. The total mortality was 5.8% (10/171) with the main causes as cardiac failure for 4 cases, arrhythmia for 1 case, multi-organ failure for 4 cases, and infectious endocarditis for 1 case. CONCLUSIONS: Successful management of severe aortic valve stenosis requires sophisticated surgical techniques and experienced peri-operative care. Satisfactory results can be achieved if valve replace surgery is performed adequately.

[Aortic valve replacement: the experiences of 1026 cases].

OBJECTIVE: To study the changes in pathogenic causes and the prognosis of aortic valve replacement (AVR). METHODS: The clinical data of 1026 patients undergoing AVR from December 1980 to December 2006 were analyzed retrospectively. The mortality, morbidity, changes in pathogenic causes and risk factors were analyzed. RESULTS: The postoperative mortality and complication morbidity were 4.3% and 10.6% respectively within 30 days followed operation. Main causes of operative death were heart failure, multi organ failure and endocarditis. The major risk factors for operative death were left ventricle ejection fraction less than 0.4, endocarditis, valve regurgitation and emergency operation before AVR. Late mortality was 0.54% patient-year (3.4%), most of whom died of heart failure, endocarditis and arrhythmias. Patients underwent reoperation 0.22% patient-year (1.4%), with the causes of endocarditis and perivalvular fistula. CONCLUSIONS: Morbidity of rheumatic damage in aortic valve has decreased, while valve degeneration has increased gradually in the recent years. Avoiding prosthesis-patient mismatch, good postoperatively guide and prevention of endocarditis can improve the prognosis of AVR.

[Expression of mineralocorticoid receptor and 11-beta-hydroxysteroid dehydrogenase type 2 in human atria during chronic atrial fibrillation: study of 25 cases].

OBJECTIVE: To investigate the mRNA and protein expression of mineralocorticoid receptor (MR) and 11-beta-hydroxysteroid dehydrogenase type 2 (11betaHSD2), which plays a crucial role in the human heart to confer specificity on MR, in patients with chronic atrial fibrillation. METHODS: Twenty-five patients of rheumatic heart valve disease, 12 with sinus rhythm, and 13 with chronic atrial fibrillation for 6 months or over, underwent transthoracic echocardiography and mitral/aortic valve replacement operation during which right atrial lateral wall tissue samples were obtained and left atrial lateral wall tissue samples were obtained from 14 of them in addition. Realtime quantitative PCR was used to determine the mRNA expression of MR and 11betaHSD2 and Western blotting was employed to detect the protein expression of MR and 11betaHSD2 in the atrial myocardium. RESULTS: The left atrial diameters increased markedly in the atrial fibrillation group as compared to the sinus rhythm group (P < 0.01). The mRNA expression of MR in the right atrium of the patients with atrial fibrillation was 5.37 +/- 1.15, significantly higher than that of the patients with sinus rhythm (2.67 +/- 1.09, P < 0.01), the mRNA expression of MR in the left atrium of the patients with atrial fibrillation was 5.19 +/- 1.14, significantly higher than that of the patients with sinus rhythm (270 +/- 0.82, P < 0.01). The mRNA expression of 11betaHSD2 in the right atrium of the patients with atrial fibrillation was 0.86 +/- 0.14, significantly higher than that of the patients with sinus rhythm (0.33 +/- 0.12, P < 0.01), and the mRNA expression of 11betaHSD2 in the left atrium of the patients with atrial fibrillation was 0.95 +/- 0.15, significantly higher than that of the patients with sinus rhythm (0.37 +/- 0.10, P < 0.01). The protein expression of MR in the right atrial tissue of the patients with atrial fibrillation was 1.65 +/- 0.72, significantly higher than that of the patients with sinus rhythm (0.86 +/- 0.33, P < 0.01); and the protein expression of MR in the left atrial tissue of the patients with atrial fibrillation was 1.72 +/- 0.62, significantly higher than that of the patients with sinus rhythm (0.97 +/- 0.37a, P < 0.05). The protein expression of 11betaHSD2 in the right atrial tissue of the patients with atrial fibrillation was 1.18 +/- 0.64, significantly higher than that of the patients with sinus rhythm (0.71 +/- 0.21, P < 0.05); and the protein expression of 11betaHSD2 in the left atrial tissue of the patients with atrial fibrillation was 1.36 +/- 0.58, significantly higher than that of the patients with sinus rhythm (0.85 +/- 0.15, P < 0.05). The mRNA expression and protein expression of MR and 11betaHSD2 were not significantly different between the left atria and right atria both in the fibrillation and sinus groups (all P > 0.05). CONCLUSION: The mRNA expression and protein expression of MR and 11betaHSD2 are upregulated in atrial fibrillation and aldosterone antagonists may be effective to arrest the development of sustained atrial fibrillation.

[Study on expression of mineralocorticoid receptor in human atria during atrial fibrillation].

OBJECTIVE: To investigate the mRNA and protein expression of mineralocorticoid receptor (MR) in patients with atrial fibrillation. METHODS: Twenty-five patients with rheumatic heart valve disease, 12 in sinus rhythm and 13 in chronic atrial fibrillation (>or= 6 months), underwent transthoracic echocardiography and right and left atrial lateral wall tissue samples were obtained from these patients during mitral/aortic valve replacement operation. Realtime quantitative PCR and Western blot were used to determine the mRNA and protein expression of MR in atria specimens. The distribution of MR in human atria was analyzed by specific immunohistochemical staining. RESULTS: The left atrial diameters increased markedly in atrial fibrillation group compared with that in sinus rhythm group (P<0.01). And the results showed that the level of mRNA and protein of MR were increased significantly in atrial fibrillation group compared with those in sinus rhythm group (P<0.01 or 0.05), whereas the expression of mRNA and protein of MR were found to be no difference between left atria and right atria both in fibrillation and sinus groups (all P>0.05). The special immunohistochemical staining demonstrated that MR was abundant in the human atrial myocardium and MRs were located mainly in the cytoplasm of atrial cells, which were more evident in atrial fibrillation group than those in sinus rhythm group. CONCLUSION: These findings suggested that MRs were upregulated in atrial fibrillation and aldosterone antagonists may be effective in treating atrial fibrillation.

[Surgical interventions for complex native valve endocarditis].

OBJECTIVE: To elucidate the early and long-term results of surgical treatment for complex infective endocarditis with prosthetic valve replacement. METHODS: Fifty-seven patients of complex native valve endocarditis, including 25 cases of aortic valve, 16 of mitral valve and 16 of double valves, who underwent operative interventions with prosthetic valve replacement between December 1988 and June 2002, were analyzed retrospectively. Intraoperative findings demonstrated aortic annular abscesses (n = 19), root abscesses (n = 4), mitral posterior annular abscesses (n = 11), myocardial abscesses (n = 6), massive leaflet destruction (n = 32) and valvular vegetations (n = 55). Complex reconstruction of the aortic and mitral annulus was required in 35 patients. Associated procedures included Bentall's procedure (n = 4), aortic valve replacement (n = 21), mitral valve replacement (n = 16) and double valve replacements (n = 16). RESULTS: The operative mortality was 11%. Complications included low cardiac output syndrome, recurrence of endocarditis, multiple organ failure, ventricular arrhythmia, bleeding, mediastinal infection, respiratory insufficiency and heart block. Follow-up was 100% complete at a mean of 5.93 years. There were five late deaths (3 prosthetic valve endocarditis, 2 valve-related). The NYHA functional status recovered to Class I in 17 patients, Class II in 27 and Class III in 2 at 1 year follow-up. Kaplan-Meier analysis showed the 5-year actuarial freedom from reoperation was (84 +/- 3)%, and actuarial survivorship at 5 years was (61 +/- 9)%. CONCLUSIONS: Urgent or even emergency operation is advocated for complex infective endocarditis. Proper intraoperative reconstruction of the aortic and mitral annulus and optimized perioperative management, especially the strategy for prevention of recurrent endocarditis, are of great importance in achieving satisfied early and long-term clinical outcomes.

[Long-term results of mitral-aortic valve replacement in 1,154 patients with rheumatic valvular disease].

OBJECTIVE: To analyze the early and long-term results after mitral-aortic valve replacement for rheumatic valvular disease and the determinant factors involved and subsequent therapies. METHODS: 1 154 patients receiving combined mitral-aortic valve replacement for rheumatic valvular disease from May 1981 to May 2001 were reviewed. The mean age of the patients was 41.48 +/- 10.00 years. Concomitant valve plasty was performed for associated tricuspid organic or significant functional lesions. Lateral tilting disc or bileaflet valve prostheses were used for replacement. New York Heart Association functional status showed Class III or IV in 91.77% of the patients. Moderate to severe pulmonary hypertension occurred in 29.38% of the patients. The duration of follow-up varied from 8 months to 20 years. RESULTS: The hospital mortality was decreased from 6.50% to 4.45%. The 5-, 10- and l5-year survival rates were 89.46% +/- 1.35%, 86.50% +/- l.91% and 67.86% +/- 6.16%, respectively. The 5-, 10- and l5-year thromboembolic event free rates were 97.80% +/- 0.74%, 88.31% +/- 2.20% and 94.08% +/- 2.29%, respectively. the 5-, 10- and l5-year anticoagulant related bleeding free rates were 94.80% +/- 1.09%, 89.32% +/- 2.10% and 83.12% +/- 3.57% respectively. Cardiac functional status returned to Class II in 98% patients and to Class III in 2% during follow-up. CONCLUSIONS: Both left and right ventricular functions may be impaired as a result of rheumatic valvular disease. Tricuspid valve should be explored during surgery and any significant tricuspid annular enlargement and regurgitation showed be corrected in concomitance. Long-acting penicillin regimen is needed for 3 - 5 years for the prevention of rheumatic fever relapse. A low intensity anticoagulant regimen after valve replacement with prothrombin time targeting at 1.5 - 2.0 times is advisable in lessening anticoagulant related bleeding yet optimizing sufficient prevention against thromboembolic complications.