Physcion prevents high-fat diet-induced endothelial dysfunction by inhibiting oxidative stress and endoplasmic reticulum stress pathways.

High-fat diet (HFD)-induced obesity leads endothelial dysfunction and contributes to cardiovascular diseases. Palmitic acid (PA), a free fatty acid, is the main component of dietary saturated fat. Physcion, a chemical ingredient from Rhubarb, has been shown anti-hypertensive, anti-bacteria, and anti-tumor properties. However, the effects of physcion on endothelial dysfunction under HFD-induced obesity have not been reported. The purpose of the present study was to define the protective effect of physcion on HFD-induced endothelial dysfunction and its mechanisms involved. Obesity rat model was induced by HFD for 12 weeks. A rat thoracic aortic ring model was used to investigate the effects of physcion on HFD-induced impairment of vasorelaxation. Endothelial cell injury model was constructed in human umbilical vein endothelial cells (HUVECs) by treating with PA (0.25 mM) for 24 h. The results revealed that physcion reduced body weight and the levels of plasma TG, prevented impairment of endothelium-dependent relaxation in HFD-fed rats. In PA-injured HUVECs, physcion inhibited impaired viability, apoptosis and inflammation. Physcion also suppressed PA-induced both oxidative stress and ER stress in HUVECs. Furthermore, physcion increased PA-induced decrease in the activation of eNOS/Nrf2 signaling in HUVECs. These findings suggest that physcion has a significant beneficial effect on regulating HFD-induced endothelial dysfunction, which may be related to the inhibition of oxidative stress and ER stress through activation of eNOS/Nrf2 signaling pathway.

Prevalence of depression, anxiety in China during the COVID-19 pandemic: an updated systematic review and meta-analysis.

Background: Mental health risks associated with the aftermath of the COVID-19 pandemic are often overlooked by the public. The aim of this study was to investigate the effects of the COVID-19 pandemic on depression and anxiety disorders in China. Methods: Studies were analyzed and extracted in accordance with the PRISMA 2020 flowchart. The studies were screened and extracted using electronic databases including PubMed, Web of Science, Embase, Cochrane Library, and ClinicalTrials.gov according to the predefined eligibility criteria. The Cochrane Review Manager software 5.3.1 was used for data analysis and the risk of bias assessment. Results: As of 2023, a total of 9,212,751 Chinese have been diagnosed with COVID-19 infection. A total of 913,036 participants in 44 studies were selected following the eligibility criteria, the statistical information of which was collected for meta-analysis. The pooled prevalence of depression and anxiety were 0.31 (95% CI: 0.28, 0.35; I2 = 100.0%, p < 0.001) and 0.29 (95% CI: 0.23, 0.36; I2 = 100.0%, p < 0.001), respectively. After performing a subgroup analysis, the prevalence of depression among women, healthcare workers, students, and adolescents was 0.31 (95% CI: 0.22, 0.41), 0.33 (95% CI: 0.26, 0.44), 0.32 (95% CI: 0.26, 0.39), and 0.37 (95% CI: 0.31, 0.44), respectively. Conclusion: The prevalence of depression and anxiety among the Chinese was overall high. Monitoring and surveillance of the mental health status of the population during crises such as sudden global pandemics are imperative. Systematic review registration: https://clinicaltrials.gov/, identifier [CRD42023402190].

Losartan attenuates upstream vasculopathy in a modified piglet model of pulmonary vein stenosis: contribution of the Hippo pathway.

Background: Diffuse pulmonary vein stenosis (PVS) is an intractable congenital heart disease for which the underlying mechanism remains unclear. In this study, we investigated the effect of losartan and the role of the Hippo pathway in PVS. Methods: A total of 19 neonatal piglets were divided into 3 groups: a sham group (n=7), a banded group (n=6) with the left upper pulmonary vein and common trunk of both lower pulmonary veins banded, and a losartan group (n=6) with losartan treatment (1 mg/kg/d) after the banding operation. After 8 weeks, the piglets underwent hemodynamic measurement and harvesting. The upstream pulmonary veins were collected for histological staining and molecular biological analysis. Losartan and/or angiotensin II (stepwise concentrations from 0.1 to 100 µmol/L) were added to a human umbilical vein endothelial cell culture to investigate the potential mechanism in vitro. Results: The modified model demonstrated the main characteristics of patients with PVS, including pulmonary hypertension and intimal hyperplasia in the upstream veins. Upregulation of yes-associated protein (YAP) and angiotensin II type 1 receptor was observed in the neointima (P<0.01). Losartan treatment improved the pathological changes in piglets and decreased YAP expression in the neointima (P<0.01). In vitro, losartan suppressed angiotensin II-induced cell proliferation by inhibiting dephosphorylation and nuclear translocation of YAP in human umbilical vein endothelial cells (P<0.05). Conclusions: Losartan treatment ameliorates intimal hyperplasia and inhibits YAP activation. The activation of the Hippo-YAP pathway is involved in the vasculopathy of progressive PVS. These findings may contribute to the development of new approaches for treating PVS.

Individualized strategy of minimally invasive cardiac surgery in congenital cardiac septal defects.

BACKGROUND: Intracardiac septal defect is repaired using median sternotomy in most centers; however, there are several reports using minimally invasive surgery in both children and adults. This study summarized our strategy of minimally invasive therapy using various lateral mini-thoracotomies in patients with congenital septal defect. METHODS: In this study, 472 patients who underwent minimally invasive repair of intracardiac septal defects (atrial septal defect, (ASD), ventricular septal defect, (VSD), and atrioventricular septal defect, (AVSD)) from January 2012 to June 2020 were retrospectively reviewed. Those who underwent device closure were excluded. The minimally invasive strategy included three groups: the right sub-axillary vertical incision (RSAVI) group (N = 335, including192 ASDs, 135 VSDs and 8 AVSDs); the right anterolateral thoracotomy (RALT) group (N = 132, including 77 ASDs, 51 VSDs and 4 AVSDs); and the left anterolateral thoracotomy (LALT) group (N = 5, all subpulmonary VSDs). RESULTS: Concomitant surgeries included nine cases of right ventricular outflow tract obstruction relief, nine cases of mitral repairs and 37 cases of tricuspid repairs. There was one transition from thoracotomy to sternotomy. Three patients required second pump run for residual lesions (two residual VSD shunts and one mitral regurgitation). The age and body weight of the RSAVI group were significantly lower than those of the RALT and LALT groups (all P < 0.01). No postoperative death was observed. Postoperative complications included one case of chest exploration for bleeding, one case of reoperation due to patch dehiscence during the same admission, one case of transient neural dysfunction, three cases of diaphragmatic paresis and 13 cases of atelectasis. The median stay in the intensive care unit was two days, while the median postoperative hospitalization duration was six days. The echocardiography results before discharge indicated no significant residual lesions. No reoperation, no new onset of chest deformities and no sclerosis were observed during the follow-up. CONCLUSIONS: Intracardiac septal defects can be safely and effectively repaired by minimally invasive surgery with good cosmetic results. RSAVI is suitable in infants and children, while RALT is more commonly used in adolescents and adults. LALT is an alternative incision to repair subpulmonary VSD.

Modified Nuss procedure with a novel steel bar in patients with pectus excavatum post-congenital heart surgery.

OBJECTIVES: Pectus excavatum (PE) can be secondary in patients who underwent sternotomy for cardiac surgery. Retrosternal adhesions increase the complexity and risk of traditional Nuss repair. Thus, we summarized the outcomes of our modified Nuss procedure using a newly designed bar. METHODS: A retrospective analysis was performed on 35 patients who underwent modified PE repair after open heart surgery from January 2011 to July 2019. The surgery was performed using a novel bar with no need for intraoperative reshaping and rotation, assisted by thoracoscopy and subxiphoid incision when necessary. RESULTS: There were 19 males and 16 females with a median age of 5.3 years (interquartile range, 4.1-10.9) at PE repair. All patients underwent the modified procedure uneventfully with no death. The median operating time was 70 min. Twenty-nine (82.9%) patients required subxiphoid incision assistance. There was 1 case (2.8%) with unexpected sternotomy due to intraoperative bleeding. The median length of postoperative hospital stay was 4 days. During the median 3.5 years of follow-up, no bar dislocation was found and 30 (85.7%) patients had their bars removed with no recurrence recorded. After PE repair, the Haller index improved significantly (2.6 ± 0.4 vs 4.9 ± 1.3, P < 0.05) and further decreased till the time of bar removal (2.5 ± 0.4 vs 2.6 ± 0.4, P < 0.05). All patients were satisfied with the cosmetic outcome. CONCLUSIONS: The novel bar can be placed and removed easily with a low rate of adverse events. This modified Nuss procedure seems to be a safe, effective and convenient approach for the management of PE after cardiac surgery.

Photosensitizer-loaded cell membrane biomimetic nanoparticles for enhanced tumor synergetic targeted therapy.

Photodynamic therapy (PDT) has the advantages of low toxicity and specificity, but photosensitizers usually fail to accumulate efficiently at the tumor site. In this study, a new multifunctional nano-drug delivery system was exploited by a biomimetic strategy to improve the PDT effects. The self-assembled methoxy poly(ethylene glycol)-poly(lactide-co-glycolide) (mPEG-PLGA) nanoparticles encapsulated with the photosensitizer chlorin e6 (Ce6) by microfluidics were employed as the nano-core, followed by coating red blood cell (RBC) membranes as the biomimetic agent to prolong the circulation time in vivo. In order to boost the therapeutic effect, doxorubicin (Dox) was preloaded into RBC nanovesicles. The cell membrane surface was modified with folic acid (FA) to further enhance the tumor targeting efficiency. The prepared biomimetic nanoparticles with a homogeneous size (70 nm) can trigger sufficient reactive oxygen species (ROS), leading to significant tumor ablation without side effects. In addition, the system had high tumor targeting efficiency, with an increase of 25% compared with no FA-modified nanoparticles. Therefore, this biomimetic multifunctional nanodrug delivery system possesses a prolonged circulation time and higher tumor targeting efficiency and can exert better tumor cytotoxicity for improved PDT due to homophilic targeting in vivo.

Reconstruction of right ventricular outflow tract with self-made single-valve conduit for complex congenital heart disease / 中国胸心血管外科临床杂志

@#Objective    To summarize the experience of right ventricular outflow tract reconstruction with self-made single-valve conduit for the treatment of complex congenital heart disease, and to explore the key points of operation, and to evaluate the short-term and medium-term results of the treatment. Methods    We retrospectively analyzed the clinical data of 65 patients with complex congenital heart disease treated by self-made single-valve conduit from January 2006 to June 2018. There were 42 males and 23 females aged 5-23 (9.9±4.2) years with weight 15-65 (26.2±9.9) kg. There were 19 patients with single valve artificial blood vessel (an artificial vascular group), and 46 patients with single valve bovine pericardium tube (a bovine pericardial tube group). There were 48 patients of ventricular septal defect (VSD) with pulmonary atresia (PA), 10 patients of corrective transposition of great artery with pulmonary artery stenosis, 5 patients of tetralogy of Fallot with single coronary artery malformation, 2 patients of double outlet of right ventricle with pulmonary artery stenosis and single coronary artery malformation. Results    Two patients died early after operation, both of them were VSD/PA patients who underwent radical treatment of extravascular prosthesis. The right ventricular outflow tract pressure difference was 13-37 (25.2±4.9) mm Hg in the artificial vascular group and 5-23 (10.5±3.3) mm Hg in the bovine pericardial tube group. No obvious reflux was found at discharge. The patients were followed up for 8 months to 13 years. One patient was lost. During the follow-up period, there were 5 patients of moderate tricuspid regurgitation, 32 patients of moderate intraductal regurgitation, 7 patients of severe right ventricular outflow  tract obstruction, 11 patients of moderate obstruction and 25 patients of mild obstruction. There was no late death. Heart function classification of all patients was in New York Heart Association classⅠtoⅡ. Conclusion    The self-made single-valve conduit used to reconstruct right ventricular outflow tract shows good clinical effect. Using bovine pericardium tube has less pressure difference of outflow tract in comparison with artificial blood vessel. Bovine pericardium tube is more recommended for young and low weight patients.

Minimally invasive and conventional surgical treatment of primary benign cardiac tumors.

BACKGROUND: Primary cardiac tumors are rare and the majorities are benign. Conventional surgical treatment uses median sternotomy, while minimally invasive surgery from right anterolateral minithoracotomy has become an alternative method in recent years. In this study, we summarized the surgical outcomes of both approaches. METHODS: From January 2008 to August 2018, 50 patients with primary benign cardiac tumors underwent either conventional or minimally invasive surgery in our department. The baseline data were collected. The peri-operative data and follow up results were compared between the two groups. RESULTS: There were19 men and 31 women enrolled in this study with a mean age of 55.0 ± 17.5 years. The most common site of the tumor was left atrium (n = 40, 80%), followed by right atrium (n = 8, 16.0%), right ventricle (n = 1, 2.0%) and left ventricle (n = 1, 2.0%). All patients underwent surgery uneventfully, including 33 cases (66.0%) of median sternotomy and 17 cases (34.0%) of right anterolateral minithoracotomy. No significant differences were found between the two groups in terms of cardiopulmonary bypass time, aortic cross-clamp time, postoperative intubation time, intensive care unit days and length of the hospital stay. Patients with right anterolateral minithoracotomy had less post-operative chest drainage (536 ± 159 vs 773 ± 255 ml, P < 0.01) and transfusion rate (5.9% vs 33.3%, P = 0.033) than those who had sternotomy. There was no peri-operative death, and all the patients were alive and free of recurrence at the latest follow-up. CONCLUSIONS: Surgical resection of primary benign cardiac tumors is safe, effective and durable. The right anterolateral minithoracotomy provides the same postoperative recovery as standard median sternotomy, but less transfusion. It can be considered as a promising alternative approach.

Mid-term outcomes of individualized surgeries in patients with Ebstein's anomaly.

The variable anatomy of Ebstein's anomaly leads to its various surgical procedures. The long-term outcomes of different operations were not well established. Thirty-five patients with Ebstein's anomaly who underwent operations from 2006 to 2018 in our department were retrospectively reviewed. Individualized surgical plans were performed according to the preoperative echocardiography and surgeons' preference. Tricuspid repair, either Danielson's or Carpentier's technique, was the primary choice in patients who had sufficient tricuspid leaflets and adequate right ventricle, while tricuspid replacement was used when a reliable repair is not achievable. Additional bidirectional cavopulmonary shunt was performed in those who had unstable hemodynamics despite of high central venous pressure after separation from cardiopulmonary bypass. The perioperative and follow-up data were collected. The age was 26.9 (0.6-54) years [16 children (age < 14, and 19 adults (age ≥ 14)]. Preoperative tricuspid regurgitation was severe in 30, moderate in 4, and mild in the remaining 1 patient. Preoperative cardiac-associated malformations include 20 atrial septal defects, 2 ventricular septal defects, 2 pulmonary stenosis, and 1 sub aortic ridge, and these were operated simultaneously. Among all the surgical patients, 2 needed additional reoperation during the same admission, and ultimately, 29 patients had biventricular repair, including 21 tricuspid repair and 8 replacements. The other 6 patients had cavopulmonary connection and achieved 1.5 ventricular repair (3 tricuspid repair and 3 replacements). In all the 24 tricuspid repair patients, Danielson's procedure was used in 17, while Carpentier's technique was used in the other 7 patients. The average cardiopulmonary bypass time was 90 ± 28 min and cross-clamp time was 48 ± 24min. There were 2 perioperative deaths (5.7%) and no third-degree atrioventricular block. The postoperative in hospital stay was 13.7 ± 9.6 days. In the 33 survivors who were followed up at a median of 29.2 months, 6 patients had severe tricuspid regurgitation, and 2 of them underwent tricuspid replacement. The 5-year freedom from severe tricuspid dysfunction or reoperation was 78.5%, and no difference was found between children and adults, neither between different surgical choices. The surgeries of Ebstein's anomaly were variable, and individualized operation achieved reasonable short- and mid-term results. However, severe tricuspid regurgitation during the follow-up was not neglectable, and reoperation in such cases also achieved good outcomes. New repair strategy such as cone repair may be considered.

Correlates of haemodynamic flow characteristics of sequential saphenous vein grafts in coronary artery bypass grafting.

OBJECTIVES: A sequential bypass technique has been widely used in the saphenous vein grafts (SVGs) during coronary artery bypass grafting (CABG) surgery. The aim of the present study was to investigate the correlates of haemodynamic flow characteristics of sequential SVGs using transit-time flow measurement. METHODS: From January 2013 to December 2016, 235 patients underwent isolated CABG using 1 aortosequential SVG to non-left anterior descending targets and the left internal mammary artery to the left anterior descending coronary artery. Among them, 212 patients have completed computed tomography angiography at 1-year follow-up and were included in the present study. The intraoperative flow rate and pulsatility index (PI) of sequential SVGs were assessed with transit-time flow measurement. The univariable and multivariable stepwise linear regression analyses of the possible correlating variables, including distal-end coronary artery (DECA) characteristics, were performed. RESULTS: For sequential SVGs, the mean proximal flow rate was 45.8 ± 19.2 ml/min, and the mean PI was 3.17 ± 1.00. We assessed the following correlates for proximal flow rate and PI: patient characteristics and DECA characteristics. Independent correlates of proximal flow rate were triple sequential SVG (by 21.0 ± 2.5 ml/min; P < 0.001), the DECA with more severe proximal stenosis (3.6 ± 1.3 ml/min per 10% increase; P = 0.007) and the DECA with larger diameter (≥1.5 mm) (by 4.8 ± 2.3 ml/min; P = 0.038). For PI, independent correlate was triple sequential SVG (by -0.55 ± 0.15; P < 0.001), and the DECA with larger diameter (≥1.5 mm) showed a strong trend (P = 0.069). The flow rate plotted against the logarithmic transformation of PI showed a significant inverse relationship in the linear regression analysis (P < 0.001). At 1-year follow-up, the patency of the proximal segment (between the aorta and the first side-to-side anastomosis) was 99.5% (211 of 212). CONCLUSIONS: Triple sequential SVG, the DECA with a larger diameter and more severe proximal stenosis were associated with higher proximal flow rate, whereas triple sequential SVG was associated with lower PI. These findings provide new data on flow characteristics and may guide subsequent studies towards improving sequential SVG patency.

Early- and mid-term results of emergent aortic arch replacement using moderate hypothermic circulatory arrest and unilateral selective antegrade cerebral perfusion / 中国胸心血管外科临床杂志

@#Objective    To investigate the results of emergent aortic arch replacement using moderate hypothermic circulatory arrest and unilateral antegrade cerebral perfusion (MHCA+UACP). Methods    We retrospectively analyzed the clinical data of 146 patients who underwent emergent aortic arch replacement using MHCA+UACP in our institution from January 2008 to June 2018. There were 111 males and 35 females aged 60.3±7.2 years. According to different surgical approaches, patients were divided into two groups: a total arch replacement (TAR) group (n=104) and a semi arch replacement (SAR) group (n=42). Right axillary artery was cannulated for cardiopulmonary bypass (CPB) and cerebral perfusion. Core temperature at the onset of MHCA was 23.4±1.4 ℃. UACP was initiated at 18-22 ℃ with the flow of 5-10 ml/(kg·min). Flow was adjusted to maintain cerebral perfusion pressure of 50–60 mm Hg. Results    CPB time was 235.0±42.0 min. Aortic clamp time was 154.0±29.0 min. Circulatory arrest (CA) time was 48.1±13.0 min. The CPB time and CA time of the TAR group were longer than those of SAR group. Overall mortality rate was 9.6%. Complications included permanent neurological dysfunction (PND), temporary neurological dysfunction (TND), acute kidney injury (AKI) requiring dialysis and delayed extubation (mechanical ventilation time > 72 hours). Overall incidence of PND and TND was 2.7% and 6.8%, respectively. The incidence of AKI requiring dialysis was 4.1%. The incidence of delayed extubation was 21.9%. No difference of mortality rate or incidence of complications was found between the two groups. The average follow-up was 63.0±33.1 months. The 5-year survival rate was 72.6% in the TAR group and 85.5% in the SAR group. Conclusion    Emergent aortic arch replacement using MHCA+UACP can be accomplished with excellent results.

Atrial endocardial expression of von Willebrand factor and thrombomodulin is associated with recurrence after minimally invasive surgical atrial fibrillation ablation.

OBJECTIVES: We retrospectively analysed data from non-valvular atrial fibrillation (AF) patients who underwent minimally invasive surgical AF ablation at our centre. Our purpose was to explore the atrial endocardial expression of von Willebrand factor (vWF) and thrombomodulin (TM) and their association with rhythm results after the procedure. METHODS: From January 2014 to May 2015, 60 patients underwent minimally invasive surgical AF ablation at our centre. Left atrial appendage samples were obtained during the procedure and immunohistochemistry for endocardial markers including vWF and TM was performed and semi-quantitatively graded. All patients underwent postoperative rhythm documentation at 3, 6, 12 and 24 months. RESULTS: At the 2-year interval, 49 (82%) patients maintained sinus rhythm, and all patients were asymptomatic. Univariate analysis shows that patients with AF recurrence have higher vWF score 2/3 and longer AF duration (P < 0.05). In the multivariate analysis, AF duration, vWF score, TM score, left atrial diameter (LAD) and non-paroxysmal AF are included. The result suggests that higher vWF score 2/3, lower TM score 0/1 and non-paroxysmal AF are statistically significant (P < 0.05). In addition, higher vWF score 2/3 is associated with larger LAD (45.2 ± 5.6 mm vs 41.2 ± 7.6 mm, P = 0.032), while higher TM score 2/3, on the other hand, is associated with smaller LAD (44.6 ± 6.1 mm vs 39.9 ± 7.8 mm, P = 0.032). The Kaplan-Meier analysis shows that higher vWF score 2/3 and lower TM score 0/1 appear to be accompanied with higher recurrence rate (vWF: P = 0.021; TM: P = 0.036). CONCLUSIONS: Atrial endocardial expression of vWF and TM might be associated with recurrence after minimally invasive surgical AF ablation. Patients with AF recurrence seem to have elevated vWF expression and decreased TM expression.

Predictive risk factors for recurrent atrial fibrillation after modified endoscopic ablation: A 2-year follow-up.

BACKGROUND: Our previous study reported a modified endoscopic procedure for nonvalvular atrial fibrillation (AF) that requires only 3 ports in the left chest wall. HYPOTHESIS: Certain preoperative variables might be predictive risk factors for AF recurrence among patients who underwent this procedure. METHODS: From October 2010 to April 2014, 114 patients with either paroxysmal AF (PAF) or nonparoxysmal AF (non-PAF) underwent the procedure and completed postoperative cardiac-rhythm measurement via electrocardiography and Holter monitoring. Univariate and multivariate analyses of the possible AF-related risk factors were conducted. RESULTS: During 2-year follow-up, 99 of 114 patients (86.8%) were free from atrial tachyarrhythmia. Results from univariate analyses showed that AF duration, left atrial diameter (LAD), left atrial minimum volume, left atrial empty fraction, left atrial expansion index, and left atrial active empty fraction (LAAEF) were significantly associated with postoperative AF recurrence. Results from multivariate analyses showed that AF duration (odds ratio [OR]: 1.194, 95% CI: 1.063-1.340, P = 0.003), LAD (OR: 1.101, 95% CI: 1.005-1.205, P = 0.039), and LAAEF (OR: 0.490, 95% CI: 0.277-0.865, P = 0.014) were independent risk factors. There was no difference in AF recurrence between patients with PAF and non-PAF (P = 0.250). CONCLUSIONS: Our 2-year follow-up study suggested that low LAAEF, long AF duration, and large LAD might be potential predictive risk factors for AF recurrence. Patients with PAF and non-PAF had a similar AF recurrence rate after modified endoscopic ablation.

Fontan Failure and Death in Contemporary Fontan Circulation: Analysis From the Last Two Decades.

BACKGROUND: We sought to evaluate the incidence of Fontan failure or complication and its relation to death in patients having contemporary Fontan strategies over 2 decades. METHODS: Five hundred patients who underwent Fontan completion (extracardiac, n = 326; lateral tunnel, n = 174) from 1985 to 2012 were reviewed. Patient characteristics, modes of Fontan failure/complication and death, and predictors for Fontan failure/complication and death were analyzed. RESULTS: There were 23 early deaths (4.6%) and 17 late deaths (3.4%), with no early death since 2000. Survival has improved over time (p < 0.001). Twenty-three of 40 patients who died were identified as Fontan failure before death, including ventricular dysfunction (n = 14), pulmonary vascular dysfunction (n = 4), thromboembolism (n = 2), and arrhythmia (n = 4). Mode of death was circulatory failure (n = 18), multiorgan failure (n = 6), pulmonary failure (n = 3), cerebral/renal (n = 5), and sudden death (n = 4). Modes of failure/complication were directly (65%) or conceivably (10%) related to death in 30 of 40 patients (75%). Forty-eight percent of survivors had late Fontan complication(s). Five-year freedom from late Fontan complication was lower among patients who died compared with patients who survived (29.4% versus 53.3%, p < 0.001). Ventricular dysfunction (p = 0.001) and higher pulmonary artery pressures (p < 0.001) after Fontan were predictors for death. Longer cardiopulmonary bypass time (p = 0.032) and reinterventions (p < 0.001) were predictors for late Fontan complication. CONCLUSIONS: Early death in the early era has been overcome. Yet the incidence and causes of late death remain unchanged. There was a strong causative relationship between the mode of Fontan failure/complication and death, indicating the importance of early recognition and treatment of Fontan failure/complication.

Endocardial Changes in Nonvalvular Atrial Fibrillation Without Atrial Thrombus-Thrombomodulin and Tissue Factor Pathway Inhibitor.

Atrial fibrillation (AF) is a well-known cause for thromboembolism. Although blood stasis in the left atrium and hypercoagulable state of the blood have been emphasized as important mechanisms, limited attention has been paid to the endocardial changes in maintaining the balance of local coagulation, which may also contribute to the thrombus formation in AF. In the present study, left atrial appendage samples were obtained at heart surgery from nonvalvular AF and non-AF patients without atrial thrombus. Immunohistochemistry for endocardial markers including thrombomodulin (TM) and tissue factor pathway inhibitor (TFPI) was performed and semiquantitatively graded. In immunohistochemistry analysis, decreased expression of TM was found in patients with nonvalvular AF compared with those without AF ( P < .001). There was no difference in TFPI expression between the 2 groups ( P = .213). Patients with TM score of 0 or 1 seemed to have larger left atrial diameter (LAD) than those with TM score of 2 or 3 (44.0 (7.9) vs 40.6 (3.9); P = .009), while no relationship between LAD and TFPI expression was found (43.4 (7.0) vs 42.9 (7.8); P = .485). In conclusion, TM expression in the atrial endocardium is decreased in nonvalvular AF without atrial thrombus, while TFPI expression is not. Downregulated TM expression might be associated with enlarged LAD.

Mid-term results of surgical treatment for prosthetic valve endocarditis / 中国胸心血管外科临床杂志

@#Objective    To analyze the mid-term results of surgical treatment for prosthetic valve endocarditis (PVE). Methods    We retrospectively analyzed the clinical data of 22 PVE patients operated in our institution from January 2006 to June 2016. There were 14 males and 8 females, aged 31-62 (49.6±11.8) years. PVE occurred following single valve replacements in 20 patients, including aortic valve replacements in 12 and mitral valve replacements in 8. Two patients suffered PVE after multi-valve replacement, which was aortic and mitral valves. Mechanical valves were used in all patients. Early PVE (<1 year after valve implantation) was detected in 10 patients, and late PVE (>1 year after valve implantation) in 12 patients. Blood culture was negative in 6 patients. Fifteen patients underwent emergent or urgent surgery (within one week after definite diagnosis) and 7 elective surgery. Paravalvular abscess was detected in 12 patients and repaired bovine pericardium. Results    Three patients (13.6%) died postoperatively in hospital, among whom two died of multiple systemic organ failure, and the other died of cerebral hemorrhage. Main postoperative complications included low cardiac output syndrome in 5 patients (22.7%), renal dysfunction in 6 (27.3%), respiratory failure in 5 (22.7%) and pulmonary infection in 4 (18.2%). During the follow-up of 6-120 (53.6±20.8) months, 2 deaths were observed in the middle term, including one sudden death and the other of cerebral infarction. No recurrent infection or valve-related surgery was observed during the follow-up. The survival rate was 86.4% in 1 year and 70.4% in 5 years. Conclusion    PVE is a very severe disease with high mortality. Early surgical treatment and complete removal of infectious tissues have preferable early- and mid-term results.

Risk factors and predictive value of the triple biomarkers for myocardial infarction in non-coronary cardiac surgery / 中国胸心血管外科临床杂志

@#Objective    To investigate the perioperative change and the predictive value of myoglobin, creatine kinase-MB (CK-MB), and cardiac troponin I (cTnI) in non-coronary cardiac surgery. Methods    The clinical data of 77 patients undergoing cardiac surgery for non-coronary lesions in the Shanghai Xinhua Hospital from March 2016 to November 2016 were retrospectively reviewed, including 37 males and 40 females with a median age of 2 years. There were simple congenital heart diseases in 45 patients, complicated congenital heart diseases in 10, and heart valve diseases in 22. The levels of myoglobin, CK-MB and cTnI were collected at the first postoperative day. The ventilation duration and the length of ICU stay were recorded. The recovery condition was accessed by senior surgeons. Results    The myoglobin, CK-MB and cTnI concentrations increased at the first postoperative day, and cTnI increased most significantly. The multivariate linear regression analysis indicated that these changes were only related to cardiopulmonary bypass time and aortic cross-clamping time (P<0.001). The high cTnI level was associated with prolonged ventilation duration and length of ICU stay. Fourteen patients (18.2%) did not recovered well, and their cTnI level was significantly higher than that of well-recovered patients (16.8±16.7 ng/ml vs. 5.1±4.4 ng/ml, P<0.001). The cTnI cutoff value of 5.33 ng/ml could predict whether patients had good postoperative recovery (area under the receiver operating characteristic  curve=0.862, P<0.001), and the predictive value of cTnI was superior to that of myoglobin and CK-MB. Conclusion    The increase levels of myoglobin, CK-MB and cTnI post non-coronary cardiac surgery are associated with prolonged cardiopulmonary bypass time and aortic cross-clamping time. cTnI on postoperative 24 h may predict good recovery, and it is a useful biomarker.

Pulmonary flow study predicts survival in pulmonary atresia with ventricular septal defect and major aortopulmonary collateral arteries.

BACKGROUND: We hypothesized that mean pulmonary artery pressure (PAP) detected on a pulmonary flow study may predict medium-term survival and right ventricular systolic pressure (RVSP) in patients with pulmonary atresia (PA), ventricular septal defect (VSD), and major aortopulmonary collateral arteries (MAPCAs). METHODS: Fifty patients with PA/VSD/MAPCAs underwent unifocalization between 2000 and 2013, and 40 of these patients had a pulmonary flow study since 2003. Predictability of the mean PAP on VSD status, medium-term survival, reintervention, and RVSP were analyzed. RESULTS: Forty-seven of the 50 patients (94%) had complete unifocalization at a median age of 11 months (range, 1-194 months), and 37 patients (74%) achieved VSD closure. Among the 40 patients who underwent a pulmonary flow study, the VSD was closed in 34 (85%), with salvage VSD fenestration in 4 (10%), and was intentionally left open in 6 (15%). Survival was 85.5% at 1 year and 78.5% at 5 years. A mean PAP ≥25 mm Hg was associated with worse survival (P = .011). Cox regression analysis identified a mean PAP ≥25 mm Hg as the sole predictor for death (P = .037). Patients with an open VSD had an increased risk of reoperation (P = .001) and pulmonary artery reintervention (P = .010), and had a trend toward increased risk of death (P = .059), compared with those with a closed VSD. CONCLUSIONS: PAP obtained from the intraoperative pulmonary flow study is associated with medium-term survival and late RVSP in patients with PA/VSD/MAPCAs. VSD closure for patients with a mean PAP ≥25 mm Hg on a flow study is considered high risk, and sensible judgment and a low threshold for VSD fenestration are required.

Comparison of the Outcomes of Modified Artificial Chordae Technique for Mitral Regurgitation through Right Minithoracotomy or Median Sternotomy.

BACKGROUND: Right minithoracotomy (RM) has been proven to be a safe and effective approach for mitral valve surgery, but the differences of artificial chordae technique between RM and median sternotomy (MS) were seldom reported. Here, we compared the outcomes of modified artificial chordae technique for mitral regurgitation (MR) through RM or MS approaches. METHODS: One hundred and eighteen consecutive adult patients who received mitral valve repair with artificial chordae and annuloplasty for MR through RM (n = 58) or MS (n = 60) from January 2006 to January 2015 were analyzed. RESULTS: All of the selected patients underwent mitral valve repair successfully without any complication during the surgery. There was no significant difference between RM group and MS group in cardiopulmonary bypass time, aortic cross-clamp time, and early postoperative complications. However, compared with the MS group, the RM group had shorter hospital stay and faster surgical recovery. At a mean follow-up of 44.8 ± 25.0 months, the freedom from more than moderate MR was 93.9% ± 3.5% in RM group and 94.8% ± 2.9% in MS group at 3 years postoperatively. Log-rank test showed that there was no significant difference in the freedom from recurrent significant MR between the two groups (χ2 = 0.247, P = 0.619). Multivariate analysis revealed that the presence of mild MR at discharge was the independent risk factor for the recurrent significant MR. CONCLUSION: Right minithoracotomy can achieve the similar therapeutic effects with MS for the patients who received modified artificial chordae technique for treating MR.

Cardiopulmonary bypass increases pulmonary microvascular permeability through the Src kinase pathway: Involvement of caveolin-1 and vascular endothelial cadherin.

Changes in pulmonary microvascular permeability following cardiopulmonary bypass (CPB) and the underlying mechanisms have not yet been established. Therefore, the aim of the present study was to elucidate the alterations in pulmonary microvascular permeability following CPB and the underlying mechanism. The pulmonary microvascular permeability was measured using Evans Blue dye (EBD) exclusion, and the neutrophil infiltration and proinflammatory cytokine secretion was investigated. In addition, the activation of Src kinase and the phosphorylation of caveolin­1 and vascular endothelial cadherin (VE­cadherin) was examined. The results revealed that CPB increased pulmonary microvascular leakage, neutrophil count and proinflammatory cytokines in the bronchoalveolar lavage fluid, and activated Src kinase. The administration of PP2, an inhibitor of Src kinase, decreased the activation of Src kinase and attenuated the increase in pulmonary microvascular permeability observed following CPB. Two important proteins associated with vascular permeability, caveolin­1 and VE­cadherin, were significantly activated at 24 h in the lung tissues following CPB, which correlated with the alterations in pulmonary microvascular permeability and Src kinase. PP2 administration inhibited their activation, suggesting that they are downstream factors of Src kinase activation. The data indicated that the Src kinase pathway increased pulmonary microvascular permeability following CPB, and the activation of caveolin­1 and VE­cadherin may be involved. Inhibition of this pathway may provide a potential therapy for acute lung injury following cardiac surgery.