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@#Objective To evaluate the feasibility, safety, and short-term effect of minimally invasive ascending aorta surgery through a right anterior thoracotomy via the second intercostal incision. Methods The clinical data of 13 patients who underwent minimally invasive ascending aorta surgery (including minimally invasive Bentall operation in 7 patients, minimally invasive Wheat operation in 2 patients, and minimally invasive ascending aorta replacement in 4 patients) through a right anterior thoracotomy via the second intercostal incision in our center from October, 2019 to September, 2020 were retrospectively analyzed. There were 12 males and 1 female at age of 19-69 (52.4±13.7) years. Results The aortic cross-clamping time was 84.3±18.3 min. Three patients received blood transfusion, with the rate of 23.1%. The drainage volume in the first 24 hours after operation was 214.5±146.3 mL, with no redo for bleeding. The duration of mechanical ventilation was 19.0±11.3 hours and the length of intensive care unit stay was 1.8±1.3 days. The drainage tube was removed 2.5±1.0 days after operation. All the 13 patients recovered and discharged 6.4±2.0 days after operation, with no dead patients found. All patients survived with New York Heart Association (NYHA) functional classⅠandⅡduring a median follow-up of 8 months. Conclusion Minimally invasive ascending aorta surgery through a right anterior thoracotomy via the second intercostal incision may be a safe and effective method with less injury and quick recovery.
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Objective To explore the prognostic value of Acute Kidney Injury Network (AKIN)criteria combined with Acute Physiology and Chronic Health Evaluation Ⅱ (APACHE Ⅱ)and Sequential Organ Failure Assessment(SOFA)scoring system in acute kidney injury(AKI)after cardiac surgery. Methods Clinical data of patients who underwent open-heart surgery in Zhongshan Hospital,Fudan University from April 2009 to August 2009 were prospectively collected.AKI after cardiac surgery was classified by AKIN staging system.APACHE Ⅱ and SOFA scores were evaluated according to the worst value of physiologic variables in the 1st 24 h after surgery.Discrimination and calibration of these three models were assessed by receiver operating characteristic(ROC) curve and Hosmer-Lemeshow goodness-of-fit test.Besides,their effects on inhospital mortality were evaluated by multivariate Logistic regression analysis. Results Of the 993 admissions,309 patients developed AKI and the incidence was 31.1%.The median time that developed postoperative AKI and reached the Scr peak were 1 d and 2 d respectively.Either APACHE Ⅱ or SOFA scores,which was positively correlted with the severity of AKI(APACHEⅡr=0.37,P<0.01;SOFA r=0.42,P<0.01)was higher in AKI patients compared with that in nonAKI patients(P<0.01).The mortality rose corresponding to the severity of kidney injury.However,the predicted death rate-adjusted(PDR-A)calculated by APACHE Ⅱ scoreS Was higher than the actual value in non-AKI patients and AKIN stage 1(P<0.01),while it was lower in AKIN stage 3 (P<0.01).The areas under the ROC curve of APACHEⅡ,SOFA and AKIN criteria were all above 0.8 and the results of Hosmer-Lemeshow goodness-of-fit test indicated good calibration of three models.Multivariate analysis showed that APACHE Ⅱ≥19(OR=4.26)and AKIN stage 3(OR=76.151 were independent predictors of in-hospital mortality. Conclusions AKI can be classified by AKIN criteria in the early stage after cardiac surgery and the AKIN staging system may serve the prediction of prognosis.The APACHE Ⅱ and SOFA scores just evaluated in the 1st 24 h after operation can discern the severity of patients'illness.Three models all present good discrimination and calibration in predicting patients'outcome.APACHE Ⅱ≥19 along with AKIN stage 3 are found to be the independent predictors of in-hospital mortality.It should be noticed that the deviation between PDR-A and the actual mortality in subgroups,dynamic evaluation may raise the accuracy of scoring system.
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Objective To examine whether speckle tracking imaging(STI) could provide for the assessment of acute cardiac rejection. Methods Hearts from Brown Norway rats or Lewis rats were transplanted into other Brown Norway rats. Isografts and groups of allografts either untreated or treated with cyclosporin A (CsA) at a low dose (3 mg ·kg-1 ·d-1) or high dose (10mg · kg-1 ·d-1) from 1 day before transplantation were compared at posttransplantation day 7. Results Echocardiography-derived left ventricular post wall thickness was increased only in untreated allografts. The left ventricular eject fraction was significant lower in the allografts compared with isograft, but allografts treated without or with low-dose CsA showed similar results. The radial systolic radial strain rate showed a lower value in untreated allografts than other grafts,but there was no significant differences between allograft treated with high- or low-dose CsA and isografts. The circumferential strain and circumferential strain rate was comparable among the 4 groups. However the radial strain exhibited a clear gradient in these groups [(2. 8 ± 1.3)％ in untreated allografts, (5.2 ± 0.9)％ in allografts treated with low-dose CsA, (6.3 ± 1.8 )％ in allografts treated with high-dose CsA,and (12.7 ± 7.9) in isografts, P＜0.001]. The radial strain exhibited a clear correlation with the severity of rejection ( r =-0.812, P＜ 0.0000). Conclusions The radial strain decreased as the severity of rejection worsen. STI offers promise as a noninvasive method for detecting transplant allograft rejection.
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Objective Stanford type A acute aortic dissection is a life-threatening medical condition with high rates of morbidity and mortality that requires surgical repair, on an emergency basis. The extent of aortic arch repair that should be carried out during emergency surgery of this type is controversial. This study was conducted to report clinical experience on aortic arch repair and determine surgical indication, optimal operative procedures and strategy for Stanford type A acute aortic dissection. Methods 210 consecutive patients with acute Stanford A aortic dissection who underwent aortic arch replacement combined with implantation of stented elephant trunk into the descending aorta between August 2005 and August 2010. Surgical procedures included hemi-aortic arch replacement in 92 patients, subtotal aortic arch replacement in 50 patients and total aortic arch replacement in 68 patients. All operations were performed with the aid of deep hypothermic circulatory arrest and selective antegrade cerebral perfusion (SACP). Enhanced computed tomography scanning was performed to evaluate the postoperative outcomes, particularly the fate of the false lumen remaining in the descending thoracic aorta by aortic arch replacement combined with implantation of stented elephant trunk during follow up. Results Average cardiopulmonary bypass time was (146 ±52) min. The average cross clamp time was(93 ±25)min and average selective cerebral perfusion and circulatory arrest time was(35 ±14)min. The overall in-hospital mortality was 4. 8% (10/210) and morbidity was 8. 6% ( 18/210). Postoperative complications included acute renal failure, stroke, mediastinitis and respiratory insufficiency. During the follow-up period [mean (27 ± 18) months, ranged 2 to 60 months], 1 patient underwent reoperation due to the descending thoracic and abdominal aortic aneurysm. There was no late death. Follow-up enhanced CT scanning showed about 74% false lumens obliterated at the level of the distal border of the stent graft post operation. Conclusion Open aortic arch replacement is an effective approach and provides acceptable outcomes for type A acute aortic dissection. Optimal treatment strategy is the key factor to success in emergency surgical intervention.
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Objective To investigate changes in the number of endothelial progenitor cells (EPC) from peripheral blood and pathological feature in the development of transplant arteriosclerosis in mouse abdominal aortic allografts, and discuss their correlations. Methods A segment of abdominal aorta was transplanted orthotopically from C57BL/6 to Balb/c mice. The grafts were harvested at 3rd day, 2nd week, 4th week and 6th week after the operation and studied by light and electronic microscopy. Regional changes in the lumen and intima were measured with computer imaging analysis system. EPC from peripheral blood were quantified by flow cytometry. Results Endothelium injury and inflammatory cells infiltration were seen in the aortic allografts at 3rd day after transplantation.Neointimal lesions and acute rejection were observed as early as 2nd week after surgery. The lumen of allografts was significantly narrowed due to neointima hyperplasia and had progressed at 4th and 6th week postoperatively. The number of circulation EPC was increased from 1 st day after operation and reached the peak at 3rd day. Thereafter the number of EPC was decreased rapidly and significantly less at 14th and 28th day postoperation than that pre-operation. Conclusion Abdominal aortic transplantation from C57BL/6 to Balb/c mice presents typical pathological feature of transplant arteriosclerosis. The number of EPC from peripheral blood is related to the process of injured endothelial repair and neointima formation of aortic grafts. EPC count may be considered a novel biological marker and therapeutic intervention for transplant arteriosclerosis.
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Objective Acute renal failure (ARF) requiring renal replacement therapy (RRT) was reported in 0.33％to 9.5％ patients after cardiac surgery.This study was designed to assess the clinical usefulness and accuracy of 3 clinical tools for the prediction of ARF after cardiac surgery in Chinese patients.Methods Five hundred and four eligible patients with complete clinical data in our institution received prospective assessment for RRT and acute kidney injury (AKI) between June,2009 and November,2010.The clinical tools used were Cleveland ARF Score,acute kidney injury prediction following elective cardiac surgery(AKICS) and Simplified Renal Index(SRI).Hosmer—Lemeshow goodness-of-fit test was used to estimate the calibration.Discrimination was determined with receiver operating characteristic (ROC) curves and area under a ROC curve (AUC).Results Follow-up was completed in all 504 patients.The overall incidence of postoperative RRT was 3.17％(16/504) with a mortality of 37.5％,and the incidence of AKI was 5.36％ ( 27/504 ).Discrimination for the prediction of RRT and AKI was good for SRI measured with AUROCs:0.759 (95％ CI,0.643-0.874) for RRT and 0.773 (95％ CI,0.677-0.868 ) for AKI.SRI score performed better in terms of discrimination than Cleveland ARF score and AKICS in our study,which did not consist with results reported by other centers.Conclusion SRI scoring system is the most useful among three tools for predicting postoperative RRT and should be the first choice in Chinese patients for whom a cardiac surgery is planned.It can also be used in predicting the composite end point of AKI with an extended application in patients at risk for postoperative kidney dysfunction.
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Objective Ascending aortic dissection(AAD),for which the pathogenesis remains unknown,is life-threatening.Matrix metalloproteinase-9(MMP-9)and the pathological changes of vascular smooth muscle cells(VSMCs)have been reported to have roles the pathogenesis.The study examined the expression of matrix metalloproteinase-9(MMP-9)and the pathological changes of,VSMCs in patients with AAD.Methods AAD samples were taken from 35 patients(disease group)in acute phase during aortic replacement operation for AAD and control samples were corresponding part of ascending aorta(control group,n=21)collected from the donor hearts for transplantation.Transmission electron microscepe,hematoxylin-eosin(H-E)staining.Mallory staining were used for observing the pathological changes of VSMCs and matrix in the affected aortic wall.The immunohistochemicai staining of MMP-9 was carried out in both groups and semi-quantified by staining intensity analysis.The affected patients were further grouped according to the diameter of dissected aorta as with a AAD of <55 mm or with a AAD of≥55 mm.The associations of clinical factors,such as smoking status,hypertensive disease and aneurysm diameter,with the expression of MMP-9 were analyzed.Results Increased synthetic function of VSMCs with decreased density,disrupted elastic fibers and fibrosis in the dissected aortic wall were observed in the disease group,but not in the control group.MMP-9 was scarcely expressed in the aortic wall of the patients in the control group,though it was notably expressed in the VSMCs of disease group.Both subgroups presented more MMP-9 than the control group(both P<0.001).In the disease group,sub-group with a AAD diameter of ≥55 mm presented more MMP-9 than that with a diameter of <55 mm(P<0.05).MMP-9 expression was positively correlated with a history of hypertension(P<0.01)or a great aneurysm diameter(P<0.05).MMP-9 expression was not associated with age,smoking status or other clinical factors.Conclusion Increased secretion of VSMCs and the expression of MMP-9 induced by elevated blood pressure may lead to the destruction of matrix proteins.The resulting fibrosis of the aortic wall would decrease the tensile strength of the wall.When the fibrotic aortic wall dilated further,the increased expression of MMP-9 would aggravate the damage to the wall.It can be speculated that acute AAD would occur as a result of partial tearing of the aortic intima.
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Objective To investigate the correlation between the expression of EG-1 in breast cancer and the clinicopathological factors and prognosis of breast cancer.Methods EG-1 mRNA expression in 72 malignant and 18 benign breast tissues were evaluated by RT-PCR method,and its correlation with clinical characteristics and prognosis were retrospectively analyzed.Results EG-1 expression level was higher in malignant tissue than in the corresponding benign breast tissue(71%vs.24%,P＜0.05).EG-1 expression was significantly correlated with lymph node metastasis and protein VEGF (P＜0.05)and was not significantly with age,menopause,tnmor size,grade,hormone status,protein Her2 and pS3.The metastastic rate and recurrence rate in EG-1 positive patients was higher than that in EG-1 negative patients.Multivariate Cox model showed that EG-1 positive was an independent factor affecting overall survival and disease free survival.Conclusions EG-1 expression was up-regulated in breast cancer and significantly correlated with lymph node metastasis and protein VEGF.
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Objective To investigate the impacts of long cold ischemic preservation time on the ultrastructural changes of donor heart and to provide the data for expanding the heart donor pool. Methods Heart was obtained from brain dead donor and preserved in the the University of Wisconsin (UW) solution at 4℃. Cardiac tissues were harvested at different time points of cold ischemic preservation (6, 8, 10, 12, 14 h) and observed under electron miscroscope. Results Donor heart did not have significant pathologied and ultrastructural changes when cold ischemic preservation time was 6 h. After that, time related impairment of myocardia and endothelium of coronary artery was seen.When ischemic time was longer than 12 h, focal myocardial necrosis and complete loss of the endothelium were detected. Conclusions Myocardial ultrastructure is an important index to evaluate the donor heart quality. Heart, which underwent 10 h of cold ischemia preservation time, causes no significant irreversible and pathological ultrastructural changes, and could be used for heart transplantation. When ischemia time was over 10 h, the donor heart presented with irreversible change and was nolonger unsuitable for transplantation.
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Objective To investigate the effect of paclitaxel on the intimal proliferation in rat aortic allografts and the possible mechanism on preventing graft arteriosclerosis.Methods Thirty-two inbred(Wista)r rats and 16 SD rats were divided into three groups:the isografts control group(Wistar/Wistar),the(allografts) control group ((Wistar)/SD) and test group(Wistar/SD) randomly(16 rats each groups).The rat abdominal aortic allograft model was used.The rats in test group were treated with paclitaxel after operation and those in control group with(0.9 %) normal saline.The grafts were removed and measured by means of pathology and immunohistochemistry 30 days later.Results The results showed that the thickness of the(aortic) intima,the degree of inflammatory cells infiltration in adventitia,stenosis ratio and the expression of(PCNA) were decreased in test group as compared with the allografts control group.Conclusions Paclitaxel can inhibit intimal proliferation in aortic allografts and prevent the graft arteriosclerosis.The mechanism is related to inhibition of vascular smooth(muscle) cell proliferation and alleviation of aortic allografts rejection.