Prognostic value of perioperative change of neutrophil elastase and myeloperoxidase in coronary circulation on perioperative myocardial injury and clinical outcome of patients underwent surgical valve replacement / 中华心血管病杂志

Objective: To investigate the clinical value of observing perioperative changes of myeloperoxidase (MPO) and neutrophil elastase (NE) in coronary artery circulation in patients underwent valve replacement surgery. Methods: This perspective cohort study was performed in patients who underwent valvular surgery in Nanjing Drum Tower Hospital and Fuwai Hospital from June 2021 to June 2022. Patients were divided into perioperative myocardial injury group and age-, sex- and type of cardiac procedure-matched non-perioperative myocardial injury control group in the ratio of 1∶1. Perioperative myocardial injury was defined as cardiac troponin T (cTnT)>0.8 μg/L on the first postoperative day (POD), and the cTnT level on the second POD increased by more than 10% compared with the cTnT level on the first POD. During the operation, blood samples were collected from the coronary sinus before clamping ascending aorta, and within 5 minutes after de-clamping ascending aorta. Then, the levels of MPO and NE on coronary sinus were continuously measured. The death, severe ventricular arrhythmia, pneumonia, re-intubation, repeat cardiac surgery, extracorporeal membrane oxygenation (ECMO), intra-aortic balloon pump (IABP), continuous renal replacement therapy (CRRT), mechanical ventilation time and the duration of intensive care unit (ICU) were recorded. The levels of MPO and NE and the incidence of clinical outcomes were compared between the myocardial injury group and the control group. The independent risk factors of myocardial injury were analyzed by multivariate logistic regression. Results: A total of 130 patients were enrolled, aged (60.6±7.6) years old, with 59 males (45.4%). There were 65 patients in the myocardial injury group and 65 patients in the control group. During hospitalization, there was no death, ECMO, IABP and CRRT cases in both groups. Compared with the control group, the incidence of severe ventricular arrhythmia (13.8%(9/65) vs. 3.1%(2/65), P=0.03), pneumonia (20.0%(13/65) vs. 3.1%(2/65), P=0.03), re-intubation (6.2%(4/65) vs. 0, P=0.04) was significantly higher in myocardial injury group. The mechanical ventilation time (16.8(10.7, 101.7) h vs. 7.5(4.7, 15.1) h, P<0.01), and the duration of ICU (3.7(2.7, 18.9) vs. 2.7(1.8, 6.9)d, P<0.01) were significantly longer in myocardial injury group compared with the control group. There was no significant difference in the levels of MPO and NE in coronary sinus blood between the two groups before aortic clamping (all P>0.05). However, MPO ((551.3±124.2) μg/L vs. (447.2±135.9) μg/L, P<0.01) and NE ((417.0±83.1)μg/L vs. (341.0±68.3)μg/L, P<0.01) after 5 min aortic de-clamping were significantly higher in myocardial injury group than in the control group. Multivariate logistic regression analysis showed that the levels of NE (OR=1.02, 95%CI: 1.01-1.02, P<0.01), MPO (OR=1.00, 95%CI: 1.00-1.01, P=0.02) and mechanical ventilation time (OR=1.03, 95%CI: 1.01-1.06, P=0.02) were independent risk factors of myocardial injury in patients after surgical valvular replacement. Conclusion: Perioperative myocardial injury is related poor clinical outcomes, perioperative NE and MPO in coronary artery circulation are independent risk factors of perioperative myocardial injury in patients undergoing valve replacement surgery.

The incidence and related factors of coronary events among 40-49 years old patients undergoing cardiac thoracotomy without preoperative CAG / 中华心血管病杂志

Objective: To investigate the long-term incidence of coronary events and related factors in patients undergoing cardiac thoracotomy without preoperative coronary angiography (CAG). Methods: This was a retrospective study. The clinical data of patients, aged between 40 and 49 years old, who underwent cardiothoracic surgery, including heart valve surgery, congenital heart disease surgery, cardio great vessels surgery and other non-coronary artery disease (CAD) surgery, in Nanjing Drum Tower Hospital from December 2009 to May 2017, were enrolled. Patients with suspected CAD, or patients with coronary CTA defined calcified coronary arteries received CAG examination prior operation, and the rest patients did not receive routine CAG examinations. The patients who did not receive routine CAG examinations were followed up by telephone. The primary endpoints include death related to coronary arteries, coronary artery bypass graft (CABG) or percutaneous coronary intervention (PCI). The secondary endpoints include the new onset angina, clinically diagnosed CAD or receiving the first and second prevention for CAD. The other outcome events included cardiac death and all-cause mortality. The primary and secondary endpoints were all regarded as coronary events. The patients without preoperative CAG were divided into two groups: the positive group and the negative group, according to the incidence of coronary events during follow-up. Clinical data were compared between the two groups. Results: A total of 952 patients were included. The age was (45.2±2.7) years old, 406(42.65%) patients were male. Preoperative CAG was performed in 73 patients, among whom 9 (12.32%) patients underwent simultaneous CABG. Among the 879 cases who did not undergo coronary angiography before the operation, 18(2.05%) died during perioperative period (hospitalization and within 30 days after discharge). The patients were followed up for (61.6±25.8) months, and 28(3.25%) patients were lost to follow up. During long-term follow up, there were no fatal cases due to severe coronary events and no cases of CABG or PCI. Only 4.41% (38/861) patients had the secondary endpoints, namely the occasional onset of atypical angina. The incidence rate of the long-term coronary events, all-cause mortality and cardiac death were 4.41% (38/861), 1.16% (10/861), 0.46% (4/861) during long-term follow-up. The prevalence of hypertension was significantly higher in positive group than negative group (34.21% (13/38) vs. 20.89% (164/785), P=0.045). Conclusions: It is feasible not to perform preoperative CAG examination for non-CAD patients aged 40-49 years who will undergo cardiac thoracotomy. However, we need to be aware the risk of coronary events in the patients complicating with risk factors of CAD, such as hypertension.

Cardiac surgery ERAS system and practical effects / 医学研究生学报

Objective Enhanced recovery after surgery (ERAS) refers to a series of evidence-based medical evidence that has been used to confirm the effective treatment measures in perioperative period, which contributes to speed up the recovery of patients. We aimed to explore the effect of preoperative ERAS for patients undergoing cardiac surgery. Methods Patients with cardiac surgery of a single-center (third-class hospital in cardiac surgery intensive care unit) were compared 6 months before the implementation of ERAS (n =704) and 6 months after implementation (n = 685), and followed up for 1 month. The primary outcomes were acute renal failure, re-intubation, stroke and 30-day mortality. The secondary outcomes included re-operation rates, bloating, wound infections and lung infections. Results After the implementation of ERAS, the mechanical ventilation time decreased significantly from the median of 6 hours to 4.5 hours (P<0.001). The ICU stay time and hospitalization time after ICU transfer were significantly shorter (P<0.001), and the incidence of adverse events, postoperative abdominal distension and lung infection was significantly lower (P<0.05). Addictionally, the hospitalization cost decreased (P<0.05), and the satisfaction increased (P<0.05). Conclusion ERAS for patients undergoing heart surgery can effectively promote their postoperative recovery, decrease postoperative complications, shorten the length of hospitalization, reduce the cost of hospitalization, then improve patients’ satisfaction. The transformation and application of ERAS in cardiac surgery has important clinical value.

Preliminary characterization of acute aortic dissection in the mainland of China / 中华医学杂志(英文版)

<p><b>OBJECTIVE</b>To explore the differences in the characteristics of acute aortic dissection (AAD) among less and more economically developed countries with various cultures and races.</p><p><b>DATA SOURCES</b>Reports from the International Registry of Acute Aortic Dissection (IRAD) and the mainland of China (MC) were collected by searching the PubMed Database and the Chinese Journal Full-text Database from January 2000 to March 2009.</p><p><b>STUDY SELECTION</b>Those reports from IRAD and MC containing larger numbers of cases and complete patients' information were selected, which focused on concrete issues of diagnosing or managing AAD were excluded if they were not able to reflect the overall characteristics of this condition. And the data from the article containing the largest number patients reported by the same medical center in MC were taken into statistics.</p><p><b>RESULTS</b>AAD patients from MC were significantly younger than IRAD countries and the percentage of male patients in the Chinese group was higher than IRAD countries (80.7% vs. 68.6%, P < 0.001). Patients in MC were less likely to present with typical symptoms and signs except for any focal neurological deficits. Different from the IRAD group, Chinese patients were prone to undergo magnetic resonance imaging (MRI) to make the diagnosis of AAD (45.5% vs. 11.6%, P < 0.001). The in-hospital mortality was similar between 2 groups but only smaller proportion of AAD patients in MC underwent surgical or medical treatment.</p><p><b>CONCLUSIONS</b>The general characteristics of AAD patients in MC were shown and differences in some clinical variables between MC and IRAD groups still existed.</p>

Assessment of early mortality risk factors undergoing coronary artery bypass graft surgery / 中华外科杂志

<p><b>OBJECTIVE</b>To analyze early mortality risk factors and clinical characteristics in our patients undergoing coronary artery bypass graft (CABG) surgery.</p><p><b>METHODS</b>Clinical data of 310 consecutive patients undergoing CABG from January 2005 to March 2007 were collected. Twenty-two risk factors were evaluated by univariate and multivariate Logistic stepwise regression analysis.</p><p><b>RESULTS</b>Univariate statistical analysis revealed that factors significantly correlated with early death were 12 variables including age, diabetes, neurological dysfunction, old myocardial infarction, acute myocardial infarction, ejection function, left main artery stenosis, emergency procedure, cardiopulmonary bypass time, aortic cross-calming time, and mechanical ventilation time. Logistic stepwise regression analysis showed that emergency procedure, ejection function, age, cardiopulmonary bypass time, and mechanical ventilation time were independent risk factor of early mortality after procedure.</p><p><b>CONCLUSION</b>Emergency procedure, ejection function, age, cardiopulmonary bypass time, and mechanical ventilation time are independent risk factors of early mortality after CABG procedure.</p>

Diagnosis of 22q11 deletion and duplication in congenital heart disease by multiplex ligation dependent probe amplification / 中国当代儿科杂志

<p><b>OBJECTIVE</b>To investigate the clinical utility of multiplex ligation-dependent probe amplification (MLPA) for detecting 22q11 deletion and duplication in congenital heart disease (CHD) cases and to study the incidence of 22q11 deletion and duplicaton in different kinds of CHD.</p><p><b>METHODS</b>Forty eight probes of which 25 located in 22q11 low copy number region (LCR 22s A-H), 7 in 22q11 surrounding region (CES, 22q13) and 16 in chromosomes 4, 8, 10 and 17 were selected to detect 22q11 deletion and duplication in 181 preoperative children with CHD and 14 fetuses with serious CHD or CHD with multiple malformations. In these cases, karyotype analysis was also performed.</p><p><b>RESULTS</b>MLPA demonstrated that 7 cases had 22q11 deletion [6 cases from CLTCL1 to LZTR1(LCR A-D) and 1 case from CLTCL1 to PCQAP (LCR A-C)] and that 1 case had 22q11 duplication,spanning from ZNF74 to LZTR1(LCR B-D). The phenotypes of heart defect included ventricular septal defect, atrioventricular septal defect, pulmonary stenosis and tetralogy of Fallot. Karyotype analysis showed that 1 case had 21q deletion [46, XY, 21q], 1 case had mosaic trisomy 8 [47,XY, +8/46, XY(1:2)] and 4 cases had trisomy 21. One of the 4 cases with trisomy 21 had concurrent 22q11 duplication.</p><p><b>CONCLUSIONS</b>MLPA is a rapid, sensitive, site specific and relatively inexpensive method for diagnosis of 22q11 deletion and duplication in CHD. 22q11 deletion and duplication may cause various kinds of CHD, suggesting that genetic detection should be performed routinely in CHD patients.</p>

The clinical effect and long-term follow-up of minimally invasive direct coronary artery bypass grafting via left anterior small thoracotomy / 中华外科杂志

<p><b>OBJECTIVE</b>To estimate the clinical effect and long-term follow-up of minimally invasive direct coronary artery bypass grafting (MIDCAB) via left anterior small thoracotomy.</p><p><b>METHODS</b>MIDCAB via left anterior small thoracotomy approach was performed in 38 cases of coronary artery disease with single or multi-vessel involvement from January 2002 to October 2006. There were 25 males and 13 females with a mean age of (63.3 +/- 11.1) years old. The left internal mammary artery (LIMA) was harvested under direct vision or with the assistance of thoracoscopy. After heparinization the pericardium was directly opened to expose the target vessels. The coronary artery bypass grafting was completed on beating heart.</p><p><b>RESULTS</b>The procedure were smoothly completed in all the 38 cases. The LIMA was anastomosed to the left anterior descending artery (LAD) or the diagonal artery in 20 cases, while two bypass grafts were performed in 8 cases (including 3 cases of sequential grafting and 5 cases of LIMA-radial artery Y-shaped grafting). Hybrid procedure was performed on 10 patients. There were no serious postoperative complications and operative deaths found. All the 38 cases except one were followed for 26 to 82 (53.2 +/- 28.5) months and no myocardial infarction or death occurred. NYHA class were I in 26 cases and II in 12 cases. There were 3 recurrence of angina, 2 patients relieved their symptoms with medication while 1 patient received stent implantation because of anastomose stenosis confirmed by coronary angiography 2 years after surgery.</p><p><b>CONCLUSIONS</b>MIDCAB via left anterior small thoracotomy has low rate of mortality and adverse cardiac events. The long-term follow-up is good.</p>

The predictive values of EuroSCORE of early mortality in coronary artery bypass grafting patients / 中华外科杂志

<p><b>OBJECTIVE</b>To verify the predictive value of EuroSCORE of early mortality in coronary artery bypass grafting (CABG) patients.</p><p><b>METHOD</b>From January 2005 to March 2007, 310 consecutive patients were operated with CABG. Detailed data for the EuroSCORE risk factor were collected and all patients were scored according to the EuroSCORE additive model, retrospectively or prospectively. Expected or predicted mortality was calculated for individual patients using the EuroSCORE algorithms, arranged sequentially in order of predicted score. The population was divided into three clinically relevant risk categories according to the range of predicted mortality rate. Expected mortality was compared to observed or actual mortality for each risk category. Mortality was defined as death from any cause within 30 days of operation or within the same hospital admission.</p><p><b>RESULTS</b>Preoperative overall patients: low-risk group was 25.2% (78/310), middle-risk group was 48.4% (150/310), high-risk group was 26.4% (82/310). In the EuroSCORE model, predicted mortality was 1.4% for low-risk group, 2.7% for middle-risk group, 7.4% for high-risk group, and 3.6% for overall patients. Actual mortality was 0, 1.3% and 3.7% respectively, overall early mortality was 1.6%. Area under the ROC curve was 0.78.</p><p><b>CONCLUSION</b>The EuroSCORE yield good predictive value for hospital mortality of patients undergoing CABG, especially in off-pump CABG.</p>

Detection and related analysis to chromosome 22q11 microdeletion in patients with congenital heart diseases / 中华医学遗传学杂志

<p><b>OBJECTIVE</b>To ascertain 5 short tandem repeat (STR) markers as qualified tools for detecting chromosome 22q11 deletion and to understand the prevalence and clinical importance of the deletions in patients with congenital heart diseases (CHD) from Chinese Han population.</p><p><b>METHODS</b>The authors selected 5 new tetranucleotide repeat markers, 22D_4_1, 22D_4_2, 22D_4_3, 22D_4_4 and D22S873 located in the proximal region of chromosome 22q11 deletion. One hundred and sixty-three unselected CHD patients and their unaffected parents were analyzed by genotyping of these new tetranucleotide STR markers to detect 22q11 deletion. With fluorescence in situ hybridization (FISH, LSI dual color DNA probe), the deletion status was confirmed in all patients with deletions and some patients without deletions.</p><p><b>RESULTS</b>The heterozygosity of these STR markers in normal population was more than 0.7, except for 22D_4_1 and 22D_4_2 that were 0.65 and 0.52 respectively. Twelve cases of 163 CHD patients (7.36%) had the deletions at chromosome 22q11. The deletions were confirmed in 9 of 12 patients by FISH, except for 2 cases who had unique nested deletion and 1 case who had nested distal deletion. One hundred and ten patients were associated with ventricular septal defect (VSD); and 9 (8.18%) of these cases had microdeletion. Twenty-one patients were associated with tetralogy of Fallot (TOF); and 3 (14.3%) of these cases had microdeletion.</p><p><b>CONCLUSION</b>This study demonstrated that genotyping of 5 STR markers was a useful mean of detecting 22q11 microdeletion in clinical diagnosis owing to its rapid experimental procedure, cost effectiveness and high resolution. 22q11 deletion was common in CHD patients, particularly in VSD and TOF patients, from Chinese Han population.</p>