Inhibition of valve mesenchymal stromal cell calcium deposition by bFGF through alternative polyadenylation regulation of the CAT gene.

OBJECTIVE: Calcific aortic valve disease (CAVD) is the leading cause of angina, heart failure, and death from aortic stenosis. However, the molecular mechanisms of its progression, especially the complex disease-related transcriptional regulatory mechanisms, remain to be further elucidated. METHODS: This study used porcine valvular interstitial cells (PVIC) as a model. We used osteogenic induced medium (OIM) to induce calcium deposition in PVICs to calcify them, followed by basic fibroblast growth factor (bFGF) treatment to inhibit calcium deposition. Transcriptome sequencing was used to study the mRNA expression profile of PVICs and its related transcriptional regulation. We used DaPars to further examine alternative polyadenylation (APA) between different treatment groups. RESULTS: We successfully induced calcium deposition of PVICs through OIM. Subsequently, mRNA-seq was used to identify differentially expressed mRNAs for three different treatments: control, OIM-induced and OIM-induced bFGF treatment. Global APA events were identified in the OIM and bFGF treatment groups by bioinformatics analysis. Finally, it was discovered and proven that catalase (CAT) is one of the potential targets of bFGF-induced APA regulation. CONCLUSION: We described a global APA change in a calcium deposition model related to CAVD. We revealed that transcriptional regulation of the CAT gene may contribute to bFGF-induced calcium deposition inhibition.

Mitral valve repair and concomitant maze procedure versus catheter ablation in the treatment of atrial functional mitral regurgitation.

BACKGROUND: To compare mitral valve (MV) repair and concomitant maze procedure with catheter ablation in treating patients with atrial functional mitral regurgitation (AFMR). METHODS: We retrospectively identified 126 patients with AFMR from January 2012 to December 2015. Of these patients, 60 patients underwent MV repair and concomitant maze procedure, and 66 patients received catheter ablation. Patients were followed up for 7.98 ± 2.01 years. The survival, readmission of heart failure (HF), persistent atrial fibrillation (AF), persistent moderate-severe mitral regurgitation (MR) and tricuspid Regurgitation (TR), and echocardiographic data were analyzed in the follow-up. Predictors of readmission of HF were analyzed. RESULTS: There was no significant difference in baseline and echocardiographic characteristics, in-hospital mortality, and other adverse events postoperatively between two groups. The surgical group was associated with lower rates of MR > 2 + grade either at discharge (P = 0.0023) or in the follow-up (P = 0.0001). There was no significant difference in the incidence of overall survival between the two groups. The surgical group was associated with a lower rate of readmission of HF and AF in the follow-up. Univariable and multivariable analysis confirmed AF at discharge, moderate-severe MR at discharge, no MV surgery, moderate-severe TR at discharge, and LA volume as predictors of readmission of HF. Both groups experienced significant reverse cardiac remodeling. CONCLUSIONS: Our results suggest that for the treatment of AFMR with persistent or long-standing persistent AF and moderate-severe MR, MV repair and concomitant maze procedure may achieve a better outcome than catheter ablation procedure.

MicroRNA-124 controls human vascular smooth muscle cell phenotypic switch via Sp1.

Phenotypic switch of vascular smooth muscle cells (VSMCs) plays an important role in the pathogenesis of atherosclerosis and aortic dissection. However, the mechanisms of phenotypic modulation are still unclear. MicroRNAs have emerged as important regulators of VSMC function. We recently found that microRNA-124 (miR-124) was downregulated in proliferative vascular diseases that were characterized by a VSMC phenotypic switch. Therefore, we speculated that the aberrant expression of miR-124 might play a critical role in human aortic VSMC phenotypic switch. Using quantitative RT-PCR, we found that miR-124 was dramatically downregulated in the aortic media of clinical specimens of the dissected aorta and correlated with molecular markers of the contractile VSMC phenotype. Overexpression of miR-124 by mimicking transfection significantly attenuated platelet-derived growth factor-BB-induced human aortic VSMC proliferation and phenotypic switch. Furthermore, we identified specificity protein 1 (Sp1) as the downstream target of miR-124. A luciferase reporter assay was used to confirm direct miR-124 targeting of the 3'-untranslated region of the Sp1 gene and repression of Sp1 expression in human aortic VSMCs. Furthermore, constitutively active Sp1 in miR-124-overexpressing VSMCs reversed the antiproliferative effects of miR-124. These results demonstrated a novel mechanism of miR-124 modulation of VSMC phenotypic switch by targeting Sp1 expression.NEW & NOTEWORTHY Previous studies have demonstrated that miR-124 is involved in the proliferation of a variety of cell types. However, miRNAs are expressed in a tissue-specific manner. We first identified miR-124 as a critical regulator in human aortic vascular smooth muscle cell differentiation, proliferation, and phenotype switch by targeting the 3'-untranslated region of specificity protein 1.

Outcome of Patients with Low-Flow/Low-Gradient Severe Aortic Stenosis Who Underwent Aortic Valve Replacement.

BACKGROUND: It is well-documented that stroke volume and gradient are indexed to classify patients with aortic stenosis into several phenotypes. The purpose of the present study was to estimate the impact of stroke volume and gradient on the clinical outcome of patients with AS who have undergone aortic valve replacement. Methods: A total of 154 consecutive patients were studied. They all had severe aortic stenosis (aortic valve area [AVA] ≤ 1 cm², left ventricular ejection fraction [LVEF] ≥ 50%) and underwent aortic valve replacement (AVR) from January 1, 2004 to December 31, 2010. Clinical and echocardiography data was collected. According to stroke volume index (SVi), low flow (LF, SVi < 35 mL/m²) and normal flow (NF, SVi ≥ 35 mL/m²) were defined, and according to transvalvular pressure gradient, low gradient (LG, gradient < 40 mmHg) and high gradient (HG, gradient ≥ 40 mmHg) were also defined. Based on the above classification, patients were separated into four groups: NF/HG (59 patients), NF/LG (30 patients), LF/HG (40 patients) and LF/LG (25 patients). To estimate the discrepancy between patients with bicuspid aortic valve (BAV) and normal 3-leaflets aortic valve, 154 cases were divided into 2 groups: BAV group and 3-leaflets group. In-hospital mortality and overall survival were followed up. The risk factors of in-hospital mortality and overall survival were estimated by logistic regression analysis and Cox regression analysis. Results: The mean follow-up time was 59 ± 32 months of 154 patients among whom the in-hospital mortality of NF/HG was 1.7% compared with NF/LG (6.7%), LF/HG (12.5%) and LF/LG (10.5%). The overall survival rates among the four groups were NF/HG (72%), NF/LG (92%), LF/HG (55%) and LF/LG (84%). The 5-year survival rate was lower in the BAV group than in the 3-leaflets group (78% and 93%; P < .05). The independent value for the in-hospital mortality included atrial fibrillation, concomitant coronary artery bypass graft, cardiac index, and bicuspid aortic valve. The independent factors for the overall survival included valvulo-arterial impedance, time of cardiopulmonary bypass, atrial fibrillation, bicuspid aortic valve, and concomitant coronary artery bypass graft. Conclusion: The in-hospital outcome of LF/LG is worse than NF/HG and NF/LG, but similar to LF/HG. For the overall outcome, LF/LG is better than NF/HG and LF/HG, but worse than NF/LG. Patients with BAV exhibit worse survival compared to 3-leaflets aortic valve.

CLINICAL APPLICATION OF EARLY POSTOPERATIVE NUTRITIONAL SUPPORT IN PATIENTS WITH HIGH-RISK VALVULAR HEART DISEASE.

ABSTRACT: Background : The treatment strategy of early nutritional support after cardiac surgery has gradually been adopted. However, there are no scientific guidelines for the timing and specific programs of early nutritional support. Methods: A retrospective, single-center analysis (2021-2023) was carried out including elderly patients who were admitted for valvular heart disease and received open-heart valve replacement surgery. We designated patients who started the optimized nutritional support after surgery as the optimized enteral nutritional support strategy TN (EN) group and those who received traditional nutritional support as the traditional nutritional support strategy (TN) group. The nutritional and immune indexes, postoperative complications, length of hospital stay, and hospitalization cost of the two groups were compared and analyzed. Results: We identified 378 eligible patients, comprising 193 (51%) patients in the EN group and 185 (49%) patients in the TN group. There was no significant difference in hospital mortality between the two groups, but the proportion of nosocomial pneumonia was significantly lower in the EN group than in the TN group ( P < 0.001). In the Poisson regression analysis, EN was not associated with an increase in gastrointestinal complications ( P = 0.549). The EN group also seemed to have shorter hospital stays and lower hospitalization expenses ( P < 0.001). In the comparison of postoperative gastrointestinal complications, fewer patients experienced diarrhea ( P = 0.021) and abdominal distension ( P = 0.033) in the EN group compared with the TN group. Conclusion: The optimal nutritional support strategy could effectively improve the clinical outcome of high-risk patients with valvular heart disease.

Long-term outcomes after aortic valve surgery in patients with aortic regurgitation with preserved ejection fraction and left ventricular dilation.

OBJECTIVES: This study aims to assess the long-term outcomes and prognostic predictors of asymptomatic patients with severe aortic regurgitation (AR) accompanied by left ventricular ejection fraction (LVEF) ≥ 55% and left ventricular end-diastolic diameter (LVEDD) > 65 mm undergoing aortic valve replacement (AVR). METHODS: We retrospectively studied 291 consecutive asymptomatic patients with severe AR accompanied by LVEF ≥ 55% and LVEDD > 65 mm undergoing AVR from January 2000 to December 2013. The long-term outcomes and prognostic predictors were evaluated. RESULTS: There were 2 (0.7%) in-hospital deaths caused by multiple organ failure. The overall survival rate was 95.2% at 5 years, 89.9% at 10 years, 85.9% at 15 years, and 85.9% at 20 years. The left ventricular end-systolic volume index (LVESVi) was an independent predictor of overall mortality, with 59 ml/m2 being the best cut-off value. The left ventricular (LV) dimension decreased within 1 year after surgery and sustained thereafter. There were 15.5% of patients had incomplete LV reverse remodeling. LVESVi was an independent predictor of incomplete LV reverse remodeling, with 56 ml/m2 being the best cut-off value. CONCLUSIONS: AVR can be performed with an acceptable outcome in patients with severe AR accompanied by LVEF ≥ 55% and LVEDD > 65 mm. The LVESVi has the best predictive value for prognosis and the cut-off value is 59 ml/m2, and has the best predictive value for incomplete LV reverse remodeling and the cut-off value is 56 ml/m2.

[Methods and results of surgical treatment for aortic root pathology due to Stanford A aortic dissection].

OBJECTIVE: To investigate the effectiveness of surgical approaches, outcomes and prognosis of aortic root pathology due to Stanford A aortic dissection. METHODS: Retrospective analysis the clinical data of 161 patients (122 male and 39 female, mean age of (44 ± 21) years) underwent surgical treatment for Stanford A aortic dissection between January 2001 and June 2011. There were 146 patients of acute aortic dissection and 15 patients of chronic aortic dissection. All the patients had aortic root pathologies that included commissural prolapsed in 140 cases, more than moderate aortic insufficiency in 75 cases, aortic sinus intima rupture in 15 cases, right and/or left coronary artery tearing in 8 cases, right and/or left coronary artery dissection in 16 cases, aortic root aneurysm in 31 cases. RESULTS: Aortic root replacement (Bentall procedures) were used in 72 cases, aortic root remodeling (including aortic valve replacement) in 80 cases, aortic root reimplantation (David procedure) in 9 cases. The cardiopulmonary bypass time was shorter in aortic root remodeling group ((193 ± 42) minutes) than the other two groups ((210 ± 61) minutes, (197 ± 34) minutes, F = 3.22, P = 0.04). The in-hospital mortality was 8.1% (13 cases), 5 cases (6.9%) in aortic root replacement group, 7 cases (8.8%) in aortic root remodeling group, 1 case in aortic root reimplantation. The cause of death included respiratory failure (4 cases), permanent neurological deficits (3 cases), multiple organ failure (4 cases), acute renal failure (2 cases). The survivors were followed up for 6 months to 6 years. There was no patient required reoperation for aortic root pathologies. There was no statistically significant difference between aortic root remodeling group and reimplantation group (P > 0.05). CONCLUSIONS: The surgical treatment for aortic root pathology due to Stanford A aortic dissection is challenging. Appropriate procedures according to the specialty of aortic root pathology can be performed with favorable functional results.

Crosslinking and functionalization of acellular patches via the self-assembly of copper@tea polyphenol nanoparticles.

Decellularization is a promising technique to produce natural scaffolds for tissue engineering applications. However, non-crosslinked natural scaffolds disfavor application in cardiovascular surgery due to poor biomechanics and rapid degradation. Herein, we proposed a green strategy to crosslink and functionalize acellular scaffolds via the self-assembly of copper@tea polyphenol nanoparticles (Cu@TP NPs), and the resultant nanocomposite acellular scaffolds were named as Cu@TP-dBPs. The crosslinking degree, biomechanics, denaturation temperature and resistance to enzymatic degradation of Cu@TP-dBPs were comparable to those of glutaraldehyde crosslinked decellularized bovine pericardias (Glut-dBPs). Furthermore, Cu@TP-dBPs were biocompatible and had abilities to inhibit bacterial growth and promote the formation of capillary-like networks. Subcutaneous implantation models demonstrated that Cu@TP-dBPs were free of calcification and allowed for host cell infiltration at Day 21. Cardiac patch graft models confirmed that Cu@TP-dBP patches showed improved ingrowth of functional blood vessels and remodeling of extracellular matrix at Day 60. These results suggested that Cu@TP-dBPs not only had comparable biomechanics and biostability to Glut-dBPs, but also had several advantages over Glut-dBPs in terms of anticalcification, remodeling and integration capabilities. Particularly, they were functional patches possessing antibacterial and proangiogenic activities. These material properties and biological functions made Cu@TP-dBPs a promising functional acellular patch for cardiovascular applications.

Aspirin plus ticagrelor or clopidogrel on graft patency one year after coronary bypass grafting: a single-center, randomized, controlled trial.

BACKGROUND: Dual antiplatelet therapy (DAPT) improves early post-operative graft patency, but the optimal DAPT strategy for the patients after coronary artery bypass grafting (CABG) has not been confirmed. We sought to evaluate the effect of aspirin plus ticagrelor versus aspirin plus clopidogrel on saphenous vein graft (SVG) patency within 1 year after CABG. METHODS: Between October 2017 and December 2018, 147 consecutive patients undergoing elective CABG at Changhai Hospital were randomized into two groups: group AT, receiving aspirin 100 mg/d plus ticagrelor 2×90 mg/d; group AC, receiving aspirin 100 mg/d plus clopidogrel 75 mg/d. Both DAPTs should be administered within 24 h when clinical stability was ensured. 64-multislice computed tomography angiography (MSCTA) was used to assess the graft patency at 12 months after CABG.CYP2C19 gene variants were measured to assess the clopidogrel efficacy on graft patency. RESULTS: Among the 147 participants who completed the study, one (0.7%) patient from the AC group died at 5 weeks after surgery due to severe infection. All other patients were treated with DAPT for 12 months and underwent 64-MSCTA according to schedule. There were no significant differences in pre-operative characteristics and intraoperative transit-time flow measurement findings between the two groups. Besides, no significant differences in the incidence of major adverse cardiac events (MACEs) and major bleeding were observed. A 64-MSCTA showed that SVG patency was 91.0% (141 of 155) in the AT group and 89.9% (161 of 179) in the AC group (P=0.751). No significant associations were found between different CYP2C19 genotypes and SVG patency (P>0.05). CONCLUSIONS: Either aspirin plus ticagrelor or aspirin plus clopidogrel can maintain a fairly high graft patency rate in the early phase after CABG, regardless of CYP2C19 genotypes.

[Surgical treatment of congenital quadricuspid aortic valve].

OBJECTIVE: To improve the understanding of congenital quadricuspid aortic valve (QAV), explore its echocardiographic diagnostic value and summarize the methods and outcomes of surgical treatments. METHODS: The clinical data of 11 QAV patients from January 2000 to December 2008 were retrospectively analyzed. There were 9 males and 2 females with a mean operative age of (32±16) years (range: 4-55). RESULTS: In 766 patients undergoing aortic valve surgery, 11 were of congenital quadricuspid aortic valve (1.4%); cardiac pathology: infective endocarditis (n=1), left superior vena cava (n=1), aortic aneurysm (n=1), mitral prolapse (n=1) and tricuspid insufficiency (n=1). The patients of congenital QAV deformity was diagnosed by echocardiography (n=7), misdiagnosed as single valve (n=1), misdiagnosed as bicuspid valve (n=1) and misdiagnosed as rheumatic heart disease (n=2). Type B (n=7), Type A (n=2), Type F (n=1) and Type G (n=1). Eleven patients underwent the procedure of aortic valve replacement. And the concomitant procedures were aortic root broadening (n=1), ascending aortoplasty (n=1), mitral valvuloplasty (n=1) and tricuspid valvuloplasty (n=1). CONCLUSION: Quadricuspid aortic valve is rare in clinical practice. And echocardiography plays an important diagnostic role. Surgical replacement of aortic valve is the first-line therapy for these patients.

Efficacy of cardiovascular surgery for Marfan syndrome patients: a single-center 15-year follow-up study.

BACKGROUND: Most Marfan syndrome (MFS) patients have thoracic aortic diseases which is the major cause of death. The aim of the study is to analyze the impact of different surgical procedures on prognosis of MFS patients. METHODS: We retrospectively analyzed the results of hospitalization and long-term follow-up of MFS patients who underwent surgical intervention in our center. RESULTS: Of the 135 MFS patients, 11 died during hospitalization (8.1%). There were no statistical differences in in-hospital mortality between the proximal surgery group and the distal surgery group (P=0.11). Compared to patients who underwent proximal aortic surgery, patients who underwent arch and distal surgery were more likely to have postoperative respiratory dysfunction (P=0.008). The type of surgical procedure was not associated with the incidence of complications during hospitalization. Pre-surgical New York Heart Association (NYHA) Functional Classification IV (P=0.047), EF <50% (P=0.047), pre-surgical atrial fibrillation (P=0.042), and the injury of dissection propagating onto coronary arteries (P=0.02) were independent risk factors for post-surgical mortality. After 15 years of follow-up, there were no deaths in the David group, while the 15-year survival rate for patients in the Bentall group was 73%±13.5%, and 71%±13.9% for patients in the arch surgery group (P=0.42). The probability of patients in the David group not requiring re-surgery after 15 years was 58.9%±20%, while it was 58.7%±12.1% for patients in the Bentall group, 71.5%±10.5% for patients in the Bentall + Arch group, and 12.5%±11.7% for patients in the Arch + Stent group (P=0.007). CONCLUSIONS: The David procedure was the most beneficial and had the highest long-term patient survival rates.

Staged repair of chronic type A aortic dissection with small true lumen at the descending aorta.

BACKGROUND: Surgical strategy for treating chronic type A dissection with small true lumen at the descending aorta has not been reported. In this retrospective study, we reviewed our experience of applying a two-stage procedure for treating chronic type A dissection with small true lumen at the descending aorta. METHODS: Between February 2016 and December 2019, seven patients suffering from chronic type A dissection with small true lumen at the descending aorta underwent this procedure. Preoperative computed tomographic angiography (CTA) was performed to carefully assess the diameter of the descending aorta, tear site, and visceral arteries. The interval between the two procedures is determined by the condition of the patients' recovery and illustration of postoperative CTA after the first stage procedure. RESULTS: All patients underwent first- and second-stage procedures. No mortality was observed among the seven patients. One patient who had a transient neurological deficit after the first stage recovered completely before hospital discharge. In two patients, the diameter of the descending aorta was enlarged postoperatively after the first-stage procedure. The interval between the two procedures was 2-3 months. However, no adverse events, such as stroke, paraparesis, visceral malperfusion, and lower extremity malfunction, were observed. CONCLUSIONS: The two-staged procedure for the repair of chronic type A dissection with small true lumen at the descending aorta is adaptable with low prevalence of mortality and complication.

Extra-anatomical bypass to treat aortic endograft infection after thoracic endovascular aortic repair.

This study aimed to report the case of 7 consecutive patients who underwent surgical treatment for aortic endograft infection after thoracic endovascular aortic repair (TEVAR). The management included the reconstruction of aorta using extra-anatomic prosthetic graft bypass (between the ascending aorta and the abdominal aorta), removal of the infected endograft with debridement of the infected tissue and sac drainage, followed by prolonged antibiotic therapy. This brief communication highlights that the reconstruction of aorta using extra-anatomic prosthetic graft bypass during surgical treatment for aortic endograft infection after TEVAR was reliable and effective.

Risk factors of chronic left ventricular dysfunction after cardiac valve surgery.

BACKGROUND: To analyze the risk factors of chronic left ventricular dysfunction (LVD) after cardiac valve surgery. METHODS: A retrospective analysis of 860 patients who underwent heart valve surgery in our center from January 2017 to December 2018, including 650 males and 210 females, aged 58±5.8 years. Inclusion criteria: (I) the patient was clinically diagnosed with heart valve disease and met the surgical indications for mitral valve replacement (MVR), mitral valve repair (MVP), aortic valve replacement (AVR) and double valve replacement (DVR); (II) if atrial fibrillation, coronary artery disease, and tricuspid regurgitation are combined before surgery, radiofrequency ablation, coronary bypass and tricuspid angioplasty were performed contemporarily. Exclusion criteria: (I) preoperative LVEF <50%; (II) aortic dissection underwent Bentall and right heart valve replacement procedures; (III) cardiopulmonary resuscitation and death during perioperative period and 6 months after operation; (IV) postoperative CRRT, IABP, or ECMO assistance; (V) postoperative cardiac dysfunction due to valvular dysfunction, perivalvular leak, or infective endocarditis. Patients were divided into LVD group (LVEF <40%) and control group (LVEF ≥40%) based on cardiac LVEF at 6 months after surgery. Logistic regression was used to analyze the risk factors of postoperative LVD. RESULTS: There were 126 cases in LVD group and 734 cases in control group. There were significant differences in preoperative coronary artery disease, atrial fibrillation, pulmonary hypertension, NYHA classification, left ventricular end diastolic diameter (LVEDD), and left ventricular end systolic diameter (LVESD) between the two groups (P<0.05). The differences in the changes of LVEDD and LVESD before and after operation between the two groups were statistically significant (P<0.05). Logistic regression analysis showed that preoperative LVEDD >55 mm, preoperative LVESD >40 mm, preoperative combined atrial fibrillation, preoperative combined pulmonary hypertension, preoperative NYHA III-IV, and preoperative combined coronary artery disease were the risks of postoperative chronic LVD. CONCLUSIONS: The left ventricular diameter, preoperative coronary artery disease, NYHA III-IV, preoperative atrial fibrillation, and preoperative pulmonary hypertension are risk factors for chronic LVD after heart valve surgery.

Outcomes and risk factors of postoperative hepatic dysfunction in patients undergoing acute type A aortic dissection surgery.

BACKGROUND: Postoperative hepatic dysfunction (HD) increases the morbidity and mortality risk after cardiac surgery; however, only a few studies have specifically focused on acute type A aortic dissection (AAAD) surgery. We explored the possible risk factors and outcomes of early postoperative HD in patients with AAAD undergoing surgery. METHODS: All patients who underwent AAAD surgery at our institution from April 2015 to April 2017 were retrospectively evaluated. Postoperative model for end-stage liver disease (MELD) score was used to define HD. Independent risk factors for HD were determined by multivariate logistic analysis. RESULTS: Two hundred fifteen patients with AAAD met the inclusion criteria. The incidence rate of early postoperative HD was 60.9%, and the rate of in-hospital mortality was 16.8%. Patients with a high postoperative MELD score had longer mechanical ventilation time, longer durations of intensive care unit (ICU) stay, and higher in-hospital mortality. During the postoperative period, patients with AAAD complicated by HD needed continuous renal replacement therapy (CRRT), reintubation, tracheostomy, and blood transfusion more frequently. Aortic cross clamp (ACC) time [per 10 min higher; odds ratio (OR): 1.216, 95% confidence interval (CI): 1.017-1.454, P=0.032], postoperative leucocytes (per 2×109/L higher; OR: 1.161, 95% CI: 1.018-1.324, P=0.026), postoperative respiratory dysfunction (OR: 3.176, 95% CI: 1.293-7.803, P=0.012), and postoperative low cardiac output syndrome (LCOS) (OR: 12.663, 95% CI: 1.432-111.998, P=0.022) were independent risk factors associated with HD in patients undergoing AAAD surgery. CONCLUSIONS: Postoperative HD prolongs mechanical ventilation time and ICU stay, and is associated with increased in-hospital mortality among patients who undergo AAAD surgery. Several factors are associated with a high postoperative MELD score.

Inflammation is related to preoperative hypoxemia in patients with acute Stanford type A aortic dissection.

BACKGROUND: Preoperative hypoxemia is a frequent complication of acute Stanford type A aortic dissection (ATAAD). The aim of the present study was to determine which factors were associated with hypoxemia. METHODS: A series of data were collected in a statistical analysis to evaluate preoperative hypoxemia in patients with ATAAD. After retrospectively analyzing data for 172 patients, we identified the risk factors for preoperative hypoxemia. Hypoxemia was defined by an arterial partial pressure of oxygen to fraction of inspired oxygen (PaO2/FiO2) ratio of 200 or lower. Subsequent to identifying the patient population, a prospective study was conducted using ulinastatin as a preoperative intervention. The ulinastatin group received ulinastatin at a total dose of 300,000 units prior to surgery. All the pertinent factors were investigated through univariate and multiple logistic regression analysis. RESULTS: The factors associated with preoperative hypoxemia in ATAAD comprised the following: body mass index (BMI) ≥25; white blood cell count (WBC) and neutrophil counts; levels of C-reactive protein (CRP), D-dimer, and interleukin-6 (IL-6); ATAAD involving the celiac trunk, renal artery, or mesenteric artery. Logistic regression analysis showed that CRP and IL-6 levels were independent predictive factors. We found that ulinastatin effectively could improve oxygenation, since compared to the control group the oxygenation in the ulinastatin group was significantly improved. CONCLUSIONS: Systemic inflammatory reactions played a vital role in preoperative hypoxemia after the onset of ATAAD. The oxygenation of the patient could be improved significantly by inhibiting the inflammatory response prior to surgery.

Risk factors for noninvasive ventilation failure in patients with post-extubation acute respiratory failure after cardiac surgery.

BACKGROUND: The effect of noninvasive ventilation (NIV) in patients with acute respiratory failure (ARF) after cardiac surgery is controversial. This study identified the feasibility of NIV and assessed the risk factors of NIV failure in patients with ARF after cardiac surgery. METHODS: We retrospectively reviewed data from 112 patients with ARF requiring NIV and categorized them into the NIV failure and success groups. Patient data were extracted for further analysis, the primary outcomes were the need for endotracheal intubation and NIV-related in-hospital mortality. The risk factors for NIV failure in patients with post-extubation ARF was analyzed. RESULTS: The median time from extubation to NIV was 11 hours. No difference in the EuroSCORE existed between the two groups. NIV failed in 38.4% of the patients. The NIV failure group had a higher in-hospital mortality and stay at the longer intensive care unit (ICU). Most cases of NIV failure occurred within 1-48 hours of the treatment. The main causes of early NIV failure were a weak cough reflex and/or excessive secretions and hemodynamic instability. A Sequential Organ Failure Assessment (SOFA) score ≥10.5, vasoactive-inotropic score ≥6, and pneumonia were predictors of NIV failure, whereas a body mass index (BMI) ≥25.0 kg/m2 predicted NIV success. CONCLUSIONS: NIV was effective in the study population. Multiple organ dysfunction, pneumonia, and significant inotropic drug support before NIV were associated with NIV failure, whereas a BMI ≥25 kg/m2 was a predictor of NIV success.

Risk factors and short-term prognosis of preoperative renal insufficiency in infective endocarditis.

BACKGROUND: The incidence of postoperative complications and the in-hospital mortality rate of infective endocarditis (IE) complicated with renal insufficiency are relatively high. This study aimed to analyze the clinical features, etiological characteristics, diagnosis and treatment, and prognosis of IE with renal insufficiency and to explore the risk factors for renal damage. METHODS: IE patients undergoing valvular surgery between 2008 and 2017 in two cardiac centers were retrospectively analyzed. They were divided into renal insufficiency (RI) [endogenous creatinine clearance rate (Ccr) <60 mL/min/1.73 m2] and normal renal function (NRF) (Ccr ≥60 mL/min/1.73 m2) groups. The disease conditions at admission, etiology, treatment, and prognosis were compared between the two groups. Multivariate regression analysis was performed for the related factors. RESULTS: A total of 8,055 cases of valvular surgery was performed during the study period. We analyzed 401 IE patients [average age 43.9±15 years; RI, n=56 (14%); NRF, n=345 (86%)], after the exclusion of 2 patients with primary glomerulonephritis. RI patients showed higher perioperative mortality (14.3% vs. 4.5%, P=0.042) and streptococcal infection (71.4% vs. 43.8%, P=0.001) rates. The RI group was also older and had worse heart function, greater decreases in hemoglobin and platelet levels, a higher rate of prosthetic valve involvement, more cases of postoperative dialysis, and worse prognosis (all P<0.05). Binary logistic multivariate regression analysis showed that the incidence of streptococcal infection [odds ratio (OR) =4.271, 95% confidence interval (CI), 1.846-9.884; P=0.001], age ≥51 years (OR =5.138, 95% CI, 2.258-11.694; P<0.001), and New York Heart Association (NYHA) functional class III-IV (OR =10.768, 95% CI, 2.417-47.972; P=0.002) were independent risk factors for preoperative renal insufficiency. CONCLUSIONS: IE patients with preoperative renal insufficiency had a high mortality rate and poor prognosis, with streptococcal infection predisposing to a higher risk of renal insufficiency. Moreover, older the age and worse heart function in IE resulted in a greater risk for renal insufficiency.

Long-term results of modified sandwich repair of aortic root in 151 patients with acute type A aortic dissection.

OBJECTIVES: Acute type A aortic dissection frequently induces aortic root disease; however, the optimal surgical strategy for aortic root dissection remains a challenge. The objective of this study was to introduce a novel technique for reconstruction of type A dissection to improve patient prognosis. METHODS: We performed a retrospective review of 791 consecutive patients with acute type A aortic dissection between January 2003 and July 2015. Among these patients, 151 were selected (72% men, age 51.7 ± 9.8 years) to have the modified sandwich repair of aortic root dissection. RESULTS: The in-hospital mortality rate of the 151 patients was 6.6% (10/151). During a mean follow-up period of 52.7 ± 28.6 months, the survival rate was 100, 89.1 and 69.7% at 1, 5 and 10 years, respectively. Echocardiography and computed tomographic angiography were performed every year to monitor the pathological change in the aortic root. Freedom from severe aortic regurgitation at 5 years was 100%. No patients required reintervention due to dissection or pseudoaneurysm of the proximal aortic root. CONCLUSIONS: Aortic valve resuspension and repair of the sinus of Valsalva with the modified sandwich technique using Teflon felt strips for acute type A dissection could be reliable and effective.

Left Subclavian Artery Fenestration: A Novel Treatment Strategy for Acute Type A Aortic Dissection.

BACKGROUND: The optimal surgical strategy for the left subclavian artery (LSA) during total arch replacement combined with stented elephant trunk implantation for acute type A aortic dissection remains a challenge. The objective of the study is to report a novel surgical technique aiming to simplify the revascularization procedure of total aortic arch replacement combined with stented elephant trunk implantation. METHODS: We retrospectively reviewed the result of 167 patients who underwent total aortic arch replacement combined with stented elephant trunk implantation between January 2000 and December 2012. Of the 167 patients, 51 were selected to undergo the simplified revascularization, which is to fenestrate a stent graft of the descending aorta instead of performing reconstruction of the LSA. Before performing the new LSA revascularization, we had performed the elephant trunk procedure whereby the tubular material completely covered the LSA. The ensuing revascularization was modified by removing a patch of the polyester fabric of the elephant trunk that was located at the origin of the LSA. Both perioperative variables and postoperative outcome of the surgery were assessed. RESULTS: The indication for adopting the LSA fenestration was under the circumstance of absence of dissection at the origin of the LSA. The nosocomial mortality of the 51 patients was 7.8% (multiorgan failure 2, renal failure 1, infection 1). During a mean follow-up period of 51.3 ± 27.6 months, the survival rate of the 47 patients was 100%, 90.8%, and 70.2% at 1, 5, and 10 years, respectively. No stroke and left limb ischemia were observed. No patients required reintervention because of anastomotic leak between the LSA and the descending aorta during follow-up. CONCLUSIONS: The LSA fenestration technique during total arch replacement combined with stented elephant trunk implantation for acute type A aortic dissection is reliable and effective for patients who have no dissection at the LSA. Furthermore, because the simplified surgical procedure largely shortens the time of operation, it effectively improves the patient's prognosis.