[Robotic internal thoracic artery harvesting and the mid-term follow up of arterial graft patency].

OBJECTIVE: To summarize our experience of robotic internal thoracic artery (ITA) skeletonized harvesting in Asian patients and evaluate the learning curves of robotic ITA harvesting and ITA graft patency. METHODS: A total of 200 patients underwent totally robotic ITA takedown at our department from April 2007 to August 2012. ITA was harvested in a skeletonized fashion and learning curve estimated. Coronary artery bypass grafting was completed in minimally invasive direct coronary artery bypass graft (MIDCAB) or totally endoscopic coronary bypass graft on beating heart (BH-TECAB) manners after robotic ITA harvesting. The coronary angiography or 64-MSCT was performed to evaluate the patency of ITA graft before discharge and at Year 1-5 postoperatively. RESULTS: One patient underwent median sternotomy for severe plural adhesion. Left ITA (LITA, n = 190), right ITA (RITA, n = 5) and double-ITA (n = 4) were harvested. The mean duration of single ITA harvesting was 18-70 (35.8 ± 10.7) min. A significant learning curve was observed: y (min) = 58.0 - 5.3×ln(x) (r(2) = 0.33, P < 0.01). ITA patency was 98.1% at Year 1 and 97.8% at Year 2 postoperatively respectively. And there was no recurrence of ITA occlusion at Years 3-5. CONCLUSIONS: Robotic ITA takedown is a prerequisite for totally endoscopic coronary bypass graft and can be performed safely and within an acceptable time after overcoming a learning curve. ITA graft patency has comparable outcomes of conventional surgery.

[Intraoperative transesophageal echocardiography in robotic perimembranous ventricular septal defect repair].

OBJECTIVE: To explore the role of intraoperative transesophageal echocardiography (TEE) in robotic perimembranous ventricular septal defect (VSD) repair. METHODS: A retrospective analysis was conducted with intraoperative TEE data of 18 consecutive patients who underwent robotic perimembranous VSD repair from January 2009 to August 2012. (1) Before cardiopulmonary bypass (CPB), TEE was performed to document the anatomic types, numbers, and the size of VSD. The procedures were predetermined by the surgeon according to TEE information. (2) During the establishment of peripheral CPB, TEE was used to guide the placement of cannulae in inferior vena cava (IVC), superior vena cava (SVC), and ascending aorta (AAO). (3) After weaning from CPB, TEE was conducted to evaluate the effect of the procedure. RESULTS: (1) Accuracy of TEE was 100% for diagnosing the anatomic types of VSD. All the surgical procedures were performed based on the predetermined information. (2) Under TEE guidance, all the cannulae in the SVC, IVC and AAO were located in correct positions. (3) In all patients, TEE confirmed successful VSD repair. CONCLUSION: TEE is a useful tool in the assessment of robotic perimembranous VSD repair.

[Clinical experiences on correction of congenital heart diseases with robotic technology: a report of 160 cases].

OBJECTIVE: To summarize the clinical experiences on correction of congenital heart disease with robotic technology at a single center. METHODS: Between January 2007 and May 2012, this retrospective study recruited 160 consecutive patients undergoing robotic surgery for congenital heart diseases. There were 74 males and 86 females with a median age of 35 years (range: 11-62). The procedures included secundum-type atrial septal defect repair (n = 130), ostium primum defect repair (n = 1), perimembranous ventricular septal defect repair (n = 21), mitral valve repair for anterior leaflet cleft (n = 7) and mitral valve repair plus left atrial myxoma resection (n = 1). Cardiopulmonary bypass graft was established through cannulation of right femoral artery, vein and right internal jugular vein under the guidance of transesophageal ultrasound. Myocardial protection was performed with cold blood cardioplegic solution or HTK solution and a transthoracic Chitwood clamp was used to occlude ascending aorta. Via three 8-mm ports and one 15-mm port in right chest, the microscopic instruments were manipulated to complete defect closure or mitral valve plasty, utilizing da Vinci S or da Vinci SI robotic system. Echocardiography was performed intraoperatively and at pre-discharge. Routine follow-ups were conducted. The clinical data of operating time, cardiopulmonary bypass time and follow-up examinations were retrospectively analyzed. RESULTS: All cases were treated successfully without a conversion into median sternotomy. No operative mortality or severe surgical complications were observed. Seventy-six cases of secundum-type atrial septal defect were completed on beating heart. The learning curves were noted for operating time of beating heart group and cross clamp time of arrest heart group. No residual shunt, malignant arrhythmia or mitral valve regurgitation was detected on intraoperative or postoperative echocardiography and during a median follow-up period of (29.1 ± 16.3) months. CONCLUSION: Robotic minimal access is technically feasible and it may be applied in selective patients with atrial septal defect, perimembranous ventricular septal defect and mitral valve cleft.

[Comparison of sternotomy off-pump coronary artery bypass and minimally invasive technique for isolated single vessel grafting].

OBJECTIVE: To compare the outcomes of minimally invasive coronary artery bypass grafting operation performed via a small thoracotomy versus da Vinci S system (Endo-A-CAB) with sternotomy off-pump coronary artery bypass grafting (OPCAB) for single vessel lesion. METHODS: From April 2000 to August 2011, a total of 194 patients with single coronary artery stenosis accepted CABG on beating heart were divided into 2 groups by different surgical approaches. Group A (n = 99) received sternotomy OPCAB while Group B (n = 95) underwent Endo-A-CAB. All patients had a history of unstable angina and coronary arteriography showed severe stenosis in left anterior descending artery (LAD). The procedure performed in Group B included robotic internal mammary artery (IMA) harvesting and single manual anastomosis to LAD and/or diagonal branch through small incision thoracotomy. IMA flow was evaluated by the Doppler flow meter after the completion of anastomosis. Grafting patency was evaluated postoperatively by computed tomography angiography (CTA) or angiography. RESULTS: The ventilation time and postoperative drainage volume in Group B were less than those in Group A ((5.1 ± 2.1) vs (10.1 ± 5.8) h, P = 0.03; (411 ± 295) vs (605 ± 244) ml, P = 0.000). No significant difference existed in blood flow, mortality and postoperative complication morbidity between two groups. All symptoms of angina disappeared. CONCLUSION: As a new advanced modality of revascularization, in comparison with OPCAB, Endo-A-CAB procedure is a less invasive and safer method of coronary artery bypass grafting for single vessel lesion.

[Acute kidney injury early after cardiac surgery with cardiopulmonary bypass: clinical analysis].

OBJECTIVE: To explore the occurrence of acute kidney injury (AKI) in early stage after cardiac surgery under cardiopulmonary bypass (CPB) and discuss the perioperative risk factors and its impact on clinical outcome. METHODS: Retrospective analysis was performed among 1472 adult patients undergoing cardiac surgery with CPB between January 2008 and April 2011. The postoperative occurrence of AKI following cardiac surgery was stratified according to the RIFLE criteria. And the perioperative risk factors of AKI and its impact on clinical outcome were analyzed. RESULTS: AKI occurred in 437 patients (29.7%) within 72 hours postoperation. Of these, 292 (19.8%) fulfilled AKI-Risk, 110 (7.5%) AKI-Injury and 35 (2.4%) AKI-Failure. Logistic regression analysis showed that age, hypertension, chronic renal insufficiency, reoperation, aortic surgery, CPB duration, intraoperative transfused erythrocyte volume and perioperative use of intra-aortic balloon pump were independent risk factors for AKI. A postoperative elevation of AKI level was associated with a prolonged duration of mechanical ventilation, intensive care unit stay, postoperative hospital stay, delayed extubation, extubation failure and death. Receiver operator characteristic (ROC) curve showed that AKI classification was a postoperative predictor of delayed extubation, extubation failure and death. CONCLUSION: As a common complication after cardiac surgery, AKI is associated with many perioperative risk factors. And the AKI classification is predicator of delayed extubation, extubation failure and death.

[Impact of prior percutaneous coronary intervention on outcome of coronary artery bypass graft surgery].

OBJECTIVE: To determine the impact of prior percutaneous coronary intervention (PCI) on outcome of coronary artery bypass graft (CABG) surgery. METHODS: Perioperative data were collected from 1306 patients undergoing CABG from January 2002 to November 2010, including 117 patients with prior PCI and 1 189 patients without prior PCI. Among 117 patients with prior PCI, 99 patients had a single PCI procedure and 18 had multiple PCI procedures. The surgical outcomes including in-hospital mortality and major adverse cardiac events were compared between two groups. RESULTS: Patients with prior PCI were younger, less likely to have triple vessel and left main stem disease, and less recent myocardial infarction. Interval time between PCI and CABG was (13.39 ± 13.81) months. There were no significant difference in in-hospital mortality (1.7% compared with 0.5 % P=0.156) and major adverse cardiac events (including postoperative myocardial infarction, stroke, and in-hospital death,2.6% compared with 1.1% P=0.167) between two groups. CONCLUSION: There was no association between prior PCI and isolated CABG. Good outcomes can be obtained in the group of patients undergoing CABG who have had previous PCI.

[Surgical treatment with modified Morrow procedure in hypertrophic obstructive cardiomyopathy].

OBJECTIVE: To summarize the experience of ventricular septal myectomy (modified Morrow procedure) in patients with hypertrophic obstructive cardiomyopathy (HOCM). METHODS: From June 2003 to March 2011, 38 patients (26 male and 12 female) with HOCM underwent modified Morrow procedure. The mean age was 36.3 years (ranging from 18 to 64 years). The diagnosis was made by echocardiography and spiral CT. The mean systolic gradient between the left ventricle and the aorta from transthoracic echocardiography (TTE) was (89±31) mmHg (ranging from 50 to 184 mmHg, 1 mmHg=0.133 kPa) before operation. There was moderate or severe systolic anterior motion (SAM) in 38 cases and mitral regurgitation in 29 cases. Ventricular septal myectomy with modified Morrow procedure was performed in all 38 cases. TEE was used intraoperatively to evaluate the results of the surgical procedures. After 1 to 2 weeks of operation, TTE was performed to evaluate the effect of operation. All patients were followed up with TTE after operation. RESULTS: All patients were discharged without complications. Intraoperative TEE showed that the mean systolic gradient between the left ventricle and the aorta was decreased from (95±36) mmHg before procedures to (14±11) mmHg after operation (t=13.265, P=0.000), and the thickness of ventricular septum was decreased from (28±8) mm to (12±3) mm (t=11.656, P=0.000). TTE showed that the mean systolic gradient between the left ventricle and the aorta was decreased from (89±31) mmHg preoperatively to (18±13) mmHg (t=12.729, P=0.000) in 1 to 2 weeks after operation. Mitral regurgitation and SAM were significantly improved or disappeared (t=7.930, t=5.213, both P=0.000). During the follow-up, all patients promptly became completely asymptomatic or complained of mild effort dyspnea only and syncope was abolished, and TTE showed that the pressure gradient was kept on the postoperative level or slightly decreased (P=0.494). CONCLUSIONS: Ventricular septal myectomy with modified Morrow procedure is a mostly effective method for patients with HOCM. Good surgical exposure and the hypertrophied septum thoroughly excised are paramount for successful surgery.

[Early and midterm outcomes of coronary artery bypass grafting in octogenarians].

OBJECTIVE: To investigate the early and midterm postoperative outcomes and analyze risk factors of coronary artery bypass grafting (CABG) in octogenarians. METHODS: Clinical data of 38 patients aged 80 years or greater receiving isolated coronary artery bypass grafting from September 2001 to November 2010 were reviewed. There were 33 male and 5 female patients, aging from 80 to 87 years with a mean of (82.6 ± 1.2) years. Twelve patients underwent conventional (on-pump) CABG and 26 patients underwent off-pump CABG. The number of bypass grafts was 1 to 5 (mean 2.5 ± 1.1). Left internal mammary artery was used in 37 (97.3%) patients. RESULTS: The perioperative mortality was 2.6% (1/38). Postoperative complications included stroke (4 cases), respiratory infection (1 case). The atrial arrhythmias occurred in 25 patients. Intensive care unit and hospital length of stay lasted (3.8 ± 1.4) days and (15 ± 6) days, respectively. Totally 38 patients were followed up for 4 to 70 months. Six patients died during the follow-up period. The 92.6% patients recovered without any cardiac events. CONCLUSIONS: Isolated CABG can be performed safely with acceptable postoperative morbidity and mortality in octogenarians. Appropriate surgical strategy and intensive perioperative treatment must be enhanced in octogenarians who underwent CABG.

SERPINE1 Gene Is a Reliable Molecular Marker for the Early Diagnosis of Aortic Dissection.

With the acceleration of population aging, the detection rate of aortic dissection has increased. The incidence rate of aortic dissection has increased year by year and has become a serious threat to human health. However, the current clinical treatment of aortic dissection is mainly limited to surgery (including intracavity), but the complexity of the disease and the high risk of surgery seriously affect the overall treatment effect of the disease. Therefore, an in-depth study of the pathogenesis of aortic dissection and the development of early diagnosis methods is not only expected to control the development of aortic dissection but also to improve the existing clinical treatment effect. Based on the bioinformatics analysis of the related mRNA sequence data of aortic dissection in GEO database, the gene expression regulatory network of aortic dissection was constructed. Through the screening of key node genes, the key factors (molecular markers) that may affect the occurrence of aortic dissection were obtained, and their functions were tested in human aortic smooth muscle cells (HAoSMC). Finally, it was concluded that SERPINE1 gene is a reliable molecular marker for the early diagnosis of aortic dissection.

[Clinical analysis of robotic mitral valve repair].

OBJECTIVE: To determine the safety and efficacy of robotic mitral valve repair using da Vinci S Surgical system. Method From January 2007 to April 2011, over 400 cases of robotic cardiac surgery have been performed, in which 60 patients with isolated mitral valve insufficiency underwent robotic mitral valve repair, including 42 male and 18 female patients with a mean age of (44 ± 13) years (ranging from 14 to 70 years). Forty-eight patients were in NYHA class I-II and 12 patients in class III. Fourteen patients were concomitant with atrial fibrillation. Surgery approach was achieved through 4 right chest ports with femoral perfusion and Chitwood aortic occlusion. Antegrade cold blood cardioplegia was administered directly via chest for myocardial protection. The transesophageal echocardiography was used intraoperatively to estimate the surgical results. RESULTS: All patients had successful valve repair including quadrangular resections, sliding plasties and chordal replacement. There was no conversion to median sternotomy. The mean cardiopulmonary bypass and arrested heart time were (132 ± 30) min and (88 ± 22) min. One patient had hemolysis after operation, and required mitral valve replacement. Echocardiographic follow-up revealed trace to mild regurgitation in 2 patients with a mean of (16 ± 9) months. CONCLUSION: Robotic mitral valve repair is safe and efficacious in the patients with isolated mitral valve insufficiency.

[The empirical study on paracrine communication of bone marrow mesenchymal stem cells].

OBJECTIVE: To study the influence of (60)Co gamma exposure on paracrine effect of marrow mesenchymal stem cells (MSC). To evaluate the function and construction after early stage of acute myocardial infarction (AMI) by injection of supernatant liquid. To discuss the mechanism of prarcrine communication initially. METHODS: MSC were radiated by (60)Co gamma with different dosage. The culture solution was collected peri-irradiation. The changes of Vascular endothelial growth factor (VEGF), basic fibroblast growth factor (bFGF), Interleuki-1beta (IL-1beta) in supernatant liquid were checked by ELISA. Using a rat model of AMI, the supernatant liquid and control medium were injected intramyocardially and intraperitoneally according to the project. After 4 weeks, the cardiac dimension and functions were assessed, the microvessel density were detected. RESULTS: Three cytokines decreased significantly after irradiation, with the increasing in dosage of irradiation, the secretory volume of cytokines decreased greatly. When compared with the control group (group A 6.6 +/- 0.6) and medium group (group C 5.7 +/- 0.7), the microvessel density in supernatant liquid group (group B 10.8 +/- 2.9) increased obviously, contributing to improvement in cardiac function and dimension. (Left ventricular internal dimension in diastolic (LVDd) postoperation: A 8.1 mm +/- 1.5 mm, B 7.0 mm +/- 1.5 mm, C 7.7 mm +/- 1.1 mm; Eject fraction (EF) postoperation: A 43.8% +/- 8.9%, B 51.5% +/- 7.8%, C 45.6% +/- 8.1%. CONCLUSIONS: (60)Co gamma radiation exposure can degrade MSC' ability of paracrine communication. The paracrine effect which should take important role in improving the cardiac function after AMI. The mechanism of prarcrine is complex, neovascularization is the important link.

Effect of subzero-balanced ultrafiltration on postoperative outcome of patients after cardiopulmonary bypass.

OBJECTIVE: To evaluate the effect of a new ultrafiltration technique - subzero-balanced ultrafiltration technique - on early postoperative outcomes of adult patients undergoing cardiac operations with cardiopulmonary bypass. METHODS: A total of 120 patients who required cardiopulmonary bypass for cardiac surgery were randomized into two groups, 60 in each group. Patients in the treatment group received subzero-balanced ultrafiltration during cardiopulmonary bypass, while patients in the control group received routine cardiopulmonary bypass. Postoperative outcomes, including hospital mortality and morbidity of the two groups, were analyzed. RESULTS: Hospital mortality was 0% (0 of 60) in the treatment group versus 1.8% (1 of 60) in the control group (P=1.000). Total hospital complications was lower in the treated patients (11 of 60 [18.3%] versus 22 of 60 [36.7%], P=0.025). Duration of intubation time was shorter and transfusion volume within 24 hours postoperatively was less in patients having received subzero-balanced ultrafiltration during cardiopulmonary bypass (14.35 + or - 1.66 versus 18.64 + or - 1.57 h, P=0.036 and 1.54 + or - 1.56 versus 3.64 + or - 2.67 U/patient, P=0.032). Length of stay on the intensive care unit, duration of hospital stay, need for infusion of inotropic agent and drainage volumes within 24 h postoperatively between the two groups were comparable. CONCLUSIONS: Subzero-balanced ultrafiltration during cardiopulmonary bypass can effectively decrease the patients' hospital morbidity and the volume of blood transfusion: it also may promote early postoperative recovery of patients. Routine application of subzero-balanced ultrafiltration during adult cardiac operations should not be necessary, but the technique should be compared to other techniques, e.g. MUF, in further studies.

[The empirical study in transplantation of bone marrow mesenchymal stem cells for acute myocardial infarction].

OBJECTIVE: To study the effect of (60)Co gamma ray on proliferation and differentiation potency of MSC. To evaluate the function of heart after early stage of acute myocardial infarction (AMI) in rats by transplantation of MSC. METHODS: Irradiated MSC was cultured with the method of adherent culture, the ability of its proliferation was detected by Methyl thiazolyl tetrazolium (MTT) shade selection test. The express of Cardiac troponin T (C-TNT) and beta-myosin heavy chain (beta-MHC) in MSC were detected by Reverse transcriptase-polymerase chain reaction (RT-PCR), which was induced by 5-azacytidine. Using a rat model of AMI, irradiated and unirradiated MSC were transplanted into myocardium after infarction. At 4 weeks, the cardiac dimension and functions were assessed by echocardiography and hemodynamics, the microvessel density were detected after VIII factor immunohistochemistry stain. RESULTS: The ability of proliferation in 4Gy group was depressed. C-TNT and beta-MHC expressed somewhat in unirradiated group. When compared with the control group (6.6 +/- 0.6), the microvessel density in both transplanted groups (12.7 +/- 2.2, 11.5 +/- 2.1) increased, contributing to improvement in cardiac function and dimension. CONCLUSION: MSC with or without differentiation potency can improve cardiac function equally at the early stage of AMI.

[Minimally invasive robotic coronary bypass on the beating heart using da Vinci S system].

OBJECTIVE: To summarize the experience of minimally invasive robotic coronary bypass on beating heart using da Vinci S in China. METHODS: Fifty-six patients underwent selected robotic coronary bypass on beating heart from April 2007 to December 2008. All the patients had history of angina and the coronary arteriography showed severe stenosis in the left anterior descending artery (LAD), of which 10 cases had right coronary artery or left circumflex coronary (LCX) stenosis. The age was 33 to 74 years old, with a mean of (55.8 +/- 9.4) years old. The weight was (71.4 +/- 13.2) kg. All the patients had good lung function and had no medical history of pleurisy and thoracic surgery. CT scan of double internal thoracic artery (ITA) was routinely checked preoperatively. The procedures included: (1) The robotically assisted endoscopic atraumatic coronary artery bypass surgery. The approach was via a small left anterior thoracotomy (6 to 8 cm) after robotic ITA was taken down. The ITA was manually anastomosed to the LAD or LCX on beating heart. (2) Totally endoscopic coronary bypass graft on beating heart. After ITA harvesting, the endo stabilizer was inserted via the fourth port in the xiphoid area under endoscopic vision. The left ITA to the LAD grafting was done using U-clips on beating heart in a totally endoscopic manner using da Vinci S system through 4 ports. For all patients the ITA flow was checked by the Doppler flowmeter after anastomosis was completed. After the surgery was completed, the thoracic port was checked carefully to avoid bleeding. The operating procedures and a variety of clinical parameters were recorded and analyzed. (3) Stent placement after robotic surgery in a hybrid manner. The graft patency rate was evaluated by CT or arteriography. RESULTS: All patients successfully accepted robotic minimally invasive coronary bypass on the beating heart using da Vinci S surgical system without complications. The mean graft flow was (23.2 +/- 16.7) ml/min. And there was no surgical conversion and surgical death. Fifty-three patients received ITA to LAD grafts and 3 patients received double coronary artery bypass grafts as well. Ten cases received stent placement in separate session. The CT scan and angiography revealed patent grafts in all patients. There were no post-operative complications. All patients were discharged from hospital. CONCLUSIONS: As a new advanced approach of revascularization, robotic ITA harvesting and coronary anastomoses can be safely performed with the da Vinci S system. The procedure is minimally invasive and can offer enhanced ability to control precise and stable operative manipulations.

[Identification of differentially expressed genes in myocardium of patients with heart failure by human whole genomic oligonucleotide microarray-assisted pathways analysis].

OBJECTIVE: To identify the differentially expressed gene profiles in myocardium of patients with heart failure using human whole genomic oligonucleotide microarray-assisted pathway analysis. METHODS: Phalanx whole genomic oligonucleotide microarrays were used to detect the gene expression profiles of myocardium in four patients died of heart failure and 4 brain died patients without heart diseases. The microarray findings were confirmed by real-time quantitative reverse transcriptase-polymerase chain reaction. The genes with a threshold of 1.2 times fold-change were selected and BioCarta Pathway and KEGG (Kyoto Encyclopaedia of Genes and Genomes) pathway databases were used to identify functionally related gene pathways. RESULTS: A total of 2806 genes with differentially expression were detected between the failing and non-failing heart samples, expression changes of 399 genes were more than 2-folds. Eleven pathways were identified by BioCarta pathway database and sixteen pathways were identified by KEGG PATHWAY Database. CONCLUSION: Genomic microarray-assisted pathway analysis could help to identify gene expression profiles in failing heart.

[Effect of non-restrictive external stent on the expression of platelet-derived growth factor in vein grafts of rabbits].

OBJECTIVE: To investigate the potential mechanism of non-restrictive external stent in preventing re-stenosis of vein grafts. METHODS: Thirty-six rabbits underwent reversed bypass grafting of autologous external jugular vein into common carotid artery and then were randomly divided into two equal groups, stenting group (Group S), with an external stent 6 mm in diameter (Dacron vascular prosthesis) surrounding the vein graft, and control group (Group NS) , without stenting. The vein grafts were harvested 7, 14, and 28 days after the operation respectively. Immunocytochemistry was used to detect the platelet-derived growth factor B (PDGF-B) positive cells. The mRNA expression of PDGF-B was detected with RT-PCR. RESULTS: The PDGF-B positive cell percentages in the intima of Group S 7 and 14 days later were both significantly lower than those of Group NS (15.2% +/- 3.6% vs 21.6% +/- 4.6%, and 6.5% +/- 2.6% vs 12.5% +/- 4.4%, both P < 0.05) . The PDGF-B positive cell percentages in media 7, 14 and 28 days later of Group S were all significantly lower than those of Group NS (13.8% +/- 4.6% vs 25.4% +/- 6.2%, 21.3% +/- 4.4% vs 35.7% +/- 7.3%, and 7.2% +/- 3.2% vs 19.2% +/- 5.4%, all P < 0.01). The PDGF-B positive cell percentage in adventitia peaked 28 days later in Group S and 14 days later in Group NS, and the PDGF-B positive cell percentage in adventitia 28 days later of Group S was significantly higher than that of Group NS (42.5% +/- 8.6% vs 31.9% +/- 4.6%, P < 0.01). RT-PCR analysis revealed that PDGF-B amplification products (457 bp) appeared in both group S and NS from 7 to 28 days, and the PDGF-B mRNA expression levels 7, 14, and 28 days later of Group S were all significantly lower than those of Group NS (31.2% +/- 6.5% vs 45.4% +/- 8.4%, P < 0.05; 42.3% +/- 6.2% vs 65.2% +/- 11.5%, P < 0.01; and 21.3% +/- 5.6% vs 36.2% +/- 9.4%, P < 0.01). CONCLUSION: Non-restrictive external stenting can inhibit the synthesis of PDGF and change its distribution, which may be one of the mechanisms of external stent in preventing re-stenosis of vein grafts.

[The use of recombinant activated factor VII for blood loss after cardiovascular surgery].

OBJECTIVE: To describe the early experiences with rFVIIa in the management of bleeding after cardiovascular surgery. METHODS: From May 2006 through December 2007, 16 patients received rFVIIa during or after surgery despite conventional medical therapy and transfusion of blood products. There were 15 male patients and 1 female patients, aged from 36 to 77 years old with a mean of 52 years old. The surgical procedures include aortic procedures for 8 cases, valve replacement for 6 cases, pulmonary thromboendarterectomy for 1 case and atrial septal defect repair for 1 case. The data of these patients were reviewed and the safety and efficacy of rFVIIa after cardiovascular surgery were evaluated. RESULTS: rFVIIa was administered as a first dose of 27.6 to 54.5 microg/kg with a mean of 40.2 microg/kg. Six patients achieved hemostasis after the first dose. Nine patients received a second administration within 30 min, with a cumulative dose of 59.3 to 90.9 microg/kg, a mean of 80.3 microg/kg. Eight patients achieved hemostasis and 1 patient went to exploration. One patient received four doses of rFVIIa with a cumulative dose of 203.4 microg/kg and the bleeding stopped. Mean amount of chest drain loss and the amount of red blood cell, fresh frozen plasma, cryoprecipitate, and platelet transfusions decreased significantly after rFVIIa administration. The total amount of chest drain losses, transfusions of red blood cell and cryoprecipitate within 12 h postoperatively was positively correlated with the time from the end of bypass to administration of rFVIIa. No thromboembolic complications and other adverse reactions were noted. CONCLUSIONS: The use of rFVIIa is associated with reduced blood loss, rapid improvement of coagulation variables, and decreased need for blood products. rFVIIa is safe and efficacious in the management of refractory postcardiotomy bleeding.

[Diagnostic study on the coronary artery bypass grafts lesions using 64 multi-slice computed tomography angiography].

OBJECTIVE: To evaluate the diagnostic accuracy in the assessment of coronary artery bypass grafts using 64 multi-slice computed tomography angiography (64-MSCTA) technology. METHODS: There were 228 patients post coronary artery bypass grafting (CABG) underwent 64-MSCTA from July 2005 to April 2007. Thirty-one patients with 82 bypass grafts performed coronary angiography (CAG) because of angina or grafts lesion showed by 64-MSCTA. RESULTS: All bypass grafts could be visualized by 64-MSCTA. Thirteen bypass graft occlusions and fourteen significant stenosis were detected by 64-MSCTA and confirmed by CAG. One venous grafts distal anastomosis was missed and another one was miss diagnosed as stenosis. One false negative and one false positive CT-finding resulted in a sensitivity of 93.3%, a specificity of 98.1%, a positive predictive value of 93.3%, a negative predictive value of 98.1% and an accuracy of 97.1% for grafts stenosis. As to the grafts lesion, the sensitivity, specificity, positive predictive value, negative predictive value and accuracy for grafts occlusion were 96.4%, 98.1%, 96.4%, 98.1% and 97.6%, respectively. CONCLUSION: 64-MSCTA demonstrates high diagnostic accuracy in the assessment of graft patency and suitable for the follow-up of patients post CABG.

[Totally robotic internal mammary artery harvest and beating heart coronary artery bypass].

OBJECTIVE: To summary the first 14 cases undergoing internal mammary artery (IMA) harvest using da Vinci S system and minimally invasive direct coronary artery bypass grafting (MIDCAB) on beating heart. METHODS: The average age of patients was (60.4 +/- 10.1) years old. One case was female and 13 male. All the patients had a history of angina. The coronary angiography showed severe stenosis of anterior descending branch in all patients, of which 2 cases had diagonal and circumflex branch stenosis. Four case had myocardial infraction history. All the patients had good lung function and had no medical history of pleurisy. Without sternotomy, the camera cannula was placed in the left, 3 cm lateral to nipple in the 4th intercostal space (ICS). Da Vinci instrument arms were inserted through two 1 cm trocar incisions. The right instrument generally was positioned 4 to 6 cm cephalad to camera cannula in the 2nd or 3rd ICS. The left instrument arm was positioned 4 to 6 cm caudal to the camera cannula in the 5th or 6th ICS. Arm trocar sites were maintained 6 cm apart at chest entry. The internal mammary artery was harvested in routine methods. Thirteen cases underwent left internal mammary artery harvest, one case underwent right internal mammary artery harvest, one case underwent double internal mammary harvest. MIDCAB was performed on beating heart in 14 cases and 1 case accepted the totally endoscopic coronary artery bypass (TECAB). RESULTS: All cases were accomplished successfully without complications. The average time of ICU was 20 hours. Robotic surgery had less draining than the conventional coronary bypass. CONCLUSIONS: Totally robotic internal mammary artery harvest and beating heart coronary artery bypass is less invasive, more precise, safe and efficient.

[Long-term outcomes of off-pump coronary artery bypass grafting in patients aged over 75 years].

OBJECTIVE: To investigate the long-term outcomes of off-pump coronary artery bypass grafting (OPCAB) in patients aged over 75 years and analyze the risk factors affecting the outcomes of the procedure. METHODS: Clinical data were reviewed for 97 consecutive patients aged 75 years or above receiving OPCAB at our center between November, 2000 and November, 2013. The perioperative data including length of ICU stay, duration of mechanical ventilation, incidence of postoperative complications and mortality rate of the patients were analyzed. The follow-up data of the patients were also analyzed including all-cause mortality rate and major adverse cardiac and cerebral events (MACCE, including myocardial infarction, cerebrovascular event, and repeated revascularization). RESULTS: The perioperative mortality rate was 3.09% (3/97) in these patients. Of the 97 patients analyzed, 91 (93%) were available for follow-up for 29-192 months (with a median of 95.61∓34.07 months). The 10-year survival rate of the patients was 62% with a 10-year MACCE-free survival rate of 47.4%. During the follow-up, 6 (6.8%) patients underwent repeated revascularization procedures, 12 (12.37%) had cerebrovascular accidents and 5 (5.15%) had myocardial infarction. Logistic regression analysis showed that hypertension (OR=1.388, P=0.043) and diabetes (OR=1.692, P=0.017) were independent predictors of MACCE, and incomplete revascularization did not increase the risk of postoperative MACCE. CONCLUSION: OPCAB is safe and effective in elderly patients with good long-term outcomes. Hypertension and diabetes are independent risk factors of MACCE, and adequate control of blood pressure and blood glucose can reduce the incidence of postoperative MACCE. Incomplete revascularization is not detrimental to the long-term outcomes of OPCAB in elderly patients.