A Prospective Cohort Study of Inter-Alpha-Trypsin Inhibitor Heavy Chain 4 as a Serologic Marker in Relation to Severity and Functional Outcome of Acute Intracerebral Hemorrhage.

Background: The inter-alpha-trypsin inhibitor heavy chain 4 (ITIH4) may regulate immunity and inflammation. The current study was conducted to determine its role as a biomarker for reflecting the severity and predicting outcomes of intracerebral hemorrhage (ICH). Methods: In this prospective cohort study, 185 patients with supratentorial ICH were enrolled, among whom 62 had blood obtained not only at admission but also on days 1, 3, 5, 7, 10, and 14. In addition, 62 healthy controls underwent blood collection at the start of the study. The serum ITIH4 levels were then quantified. We recorded early neurological deterioration (END) and poor prognosis (modified Rankin Scale [mRS] scores of 3-6]) six months after ICH. Results: Serum ITIH4 levels decreased prominently in the early phase after ICH, continued to decline until day 5, then gradually increased until day 14, and were significantly lower during 14 days in patients than in controls. Serum ITIH4 levels on admission were independently associated with serum C-reactive protein levels, National Institutes of Health Stroke Scale (NIHSS) scores and hematoma volume. Admission serum ITIH4 levels were independently associated with mRS scores, END, and poor prognosis. No substantial differences existed in the areas under the receiver operating characteristic curve of END and poor prognosis prediction between the serum ITIH4 levels, NIHSS scores, and hematoma volume. Prediction models, in which serum ITIH4 levels, NIHSS scores, and hematoma volume were integrated, were relatively reliable and stable using a series of statistical methods. In addition, the prediction model of poor prognosis had a higher discriminatory ability than the NIHSS scores and hematoma volume alone. Conclusion: A dramatic decline in serum ITIH4 levels during the early period following ICH is independently related to the inflammatory response, stroke severity, and poor neurologic outcomes, suggesting that serum ITIH4 may be a useful prognostic biomarker of ICH.

A Partially Randomized Patient Preference Trial to Assess the Quality of Life and Patency Rate After Minimally Invasive Cardiac Surgery-Coronary Artery Bypass Grafting: Design and Rationale of the MICS-CABG PRPP Trial.

Background: Minimally invasive cardiac surgery-coronary artery bypass grafting (MICS-CABG) has emerged as a safe alternative to standard cardiac surgery. However, treatment preferences can decrease the generalizability of RCT results to the clinical population (i.e., reduce external validity) and influence adherence to the treatment protocol and study outcomes (i.e., reduce internal validity). However, this has not yet been properly investigated in randomized trials with consideration of treatment preferences. Study Design: In this study, patients with a preference will be allocated to treatment strategies accordingly, whereas only those patients without a distinct preference will be randomized. The randomized trial is a 248-patient controlled, randomized, investigator-blinded trial. It is designed to compare whether treatment with MICS-CABG is beneficial in comparison to CABG. This study is aimed to establish the superiority hypothesis for the physical component summary (PCS) accompanied by the non-inferiority hypothesis for overall graft patency. Patients with no treatment preference will be randomized in a 1:1 fashion to one of the two treatment arms. The primary efficacy endpoints are the PCS score at 30 days after surgery and the overall patency rate of the grafts within 14 days after surgery. Secondary outcome measures include the PCS score and patency rate at different time points. Safety endpoints include major adverse cardiac and cerebrovascular events, complications, bleeding, wound infection, death, etc. Conclusions: This trial will address essential questions of the efficacy and safety of MICS-CABG. The study will also address the impact of patients' preferences on external validity and internal validity.

Graft patency and completeness of revascularization in minimally invasive multivessel coronary artery bypass surgery.

OBJECTIVES: Graft patency and completeness of revascularization were analyzed in patients who underwent off-pump minimally invasive coronary artery bypass grafting via a left small thoracotomy. METHODS: We retrospectively reviewed the invasive angiography findings and clinical data of 186 consecutive patients who underwent off-pump minimally invasive coronary artery bypass grafting via a left small thoracotomy. The left internal thoracic artery and saphenous vein were used to bypass two or more of three coronary artery systems: the left anterior descending artery, left circumflex artery, or right coronary artery. Before hospital discharge, invasive angiography was performed to assess graft patency. Clinical variables during hospitalization and follow-up were collected and analyzed. RESULTS: All 186 patients successfully underwent off-pump minimally invasive coronary artery bypass grafting without conversion to sternotomy or assistance of cardiopulmonary bypass. The mean graft number was 2.81 per patient (range, 2-5), and the total number of grafts was 522. The in-hospital mortality rate was 1.6% (3 of 186). A total of 181 of 186 (97.3%) patients underwent postoperative invasive angiography. Among the 510 grafts assessed by angiography, the total graft patency rate was 96.3% (491 of 510) (98.3% [171 of 174] for left internal thoracic artery grafts and 95.2% [318 of 334] for saphenous vein grafts). The rate of complete revascularization was 99.5% (185 of 186). CONCLUSIONS: Minimally invasive coronary artery bypass grafting using left internal thoracic artery and saphenous vein grafts provides acceptable graft patency and completeness of revascularization for selected patients with multivessel disease.

Simulation Training in Minimally Invasive Direct Coronary Artery Bypass Grafting.

BACKGROUND: To evaluate the effect of minimally invasive direct coronary artery bypass (MIDCAB) simulator for cardiac residency training. METHODS: A total of 26 resident surgeons who had never trained for coronary artery anastomosis participated in this training program. They received coronary artery anastomosis training on off-pump coronary artery bypass grafting (OPCAB) simulator for 15 h. After training, their performance of anastomosis was evaluated on the OPCAB simulator according to 12 items and a 5-point global rating scale. Based on the total score of assessment, those with an individual score of 12-36 formed group A, while group B was composed of the remaining trainees. The two groups then received another 15 h coronary artery anastomosis training on the MIDCAB simulator, and the performance was assessed. RESULTS: Trainees improved their performance of coronary artery anastomosis after training on the OPCAB simulator. Group A was composed of 7 trainees with an individual with a total score of 12-36 points and group B was composed of the remaining 19 trainees. After MIDCAB simulator training, significant differences were noted in the pre- and post-training values in the A group (P < .001), and the assessment value of group A was significantly better than those of group B (P < .05). No significant difference was detected between pre- and post-training values in group B after MIDCAB simulator training (P > .05). CONCLUSION: We concluded that trainees who performed well in OPCAB simulation training can also perform better in MIDCAB, and our designed MIDCAB simulator was useful for residency training.

Identification of Vinculin as a Potential Diagnostic Biomarker for Acute Aortic Dissection Using Label-Free Proteomics.

Acute aortic dissection (AAD) is an emergent vascular disease. Currently, its diagnosis depends on clinical and radiological investigations but lacking of serum biomarkers. In this study, we aimed to identify potential serum biomarkers for AAD using label-free proteomics approach. A total of 90 serum samples were collected from three groups: patients with acute aortic dissection (AAD, n = 30), patients with acute myocardial infarction (AMI, n = 30), and healthy controls (n = 30), and the first four samples from each group were selected for label-free proteomics analysis. Using label-free approach, a total of 22 differentially expressed proteins were identified in the serum samples of the AAD group, of which 15 were upregulated and 7 were downregulated as compared to the AMI and healthy control groups. The most prominent increased protein was vinculin, which was selected to validate in total samples. The level of vinculin was significantly elevated in AAD patients (15.8 ng/ml, IQR: 9.3-19.9 ng/ml) than that in AMI patients (8.6 ng/ml, IQR:5.3-11.4 ng/ml) and healthy volunteers (5.3 ng/ml, IQR:2.8-7.6 ng/ml), P < 0.0001. Furthermore, the concentration of vinculin both increased in type A and B dissection. At the early stage of AAD, vinculin maintained a high level to 48 hours compared with that of AMI. Our study demonstrated that vinculin may play a role in the early diagnosis of AAD.

Mid-term follow-up outcomes of 2-staged hybrid coronary revascularization compared with off-pump coronary artery bypass for patients with multivessel coronary artery disease.

INTRODUCTION: Two-staged hybrid coronary revascularization (HCR) is a novel procedure in selected patients with multivessel coronary artery disease. However, few studies are available on the mid-term or long-term outcomes of this 2-staged procedure as compared to off-pump coronary artery bypass (OPCAB). AIM: To compare in-hospital and mid-term follow-up outcomes of 2-staged HCR with OPCAB in patients with multivessel coronary artery disease. MATERIAL AND METHODS: The present retrospective study analyzed the data from 73 patients who underwent the 2-staged HCR (HCR group) during 2012-2014 at the heart center. Three hundred and eighty-three patients who underwent conventional OPCAB by the same surgeon were selected for the comparative analysis performed on in-hospital and mid-term follow-up outcomes between the two groups. RESULTS: No significant difference was observed in the preoperative outcome between the two groups. The HCR group had a shorter operation duration (152.9 ±43.8 vs. 262.6 ±51.8 min, p < 0.05), less bleeding (558.6 ±441.3 vs. 1035.5 ±613.3 ml, p < 0.05), shorter mechanical ventilation (9.4 ±7.4 vs. 19.0 ±18.3 h, p < 0.05), and less blood transfusion (12 (16.4%) vs. 200 (52.2%), p < 0.05). The mean follow-up duration was 25.0 ±9.6 months in the HCR group and 22.8 ±10.6 months in the OPCAB group. The incidence of major adverse cardiac or cerebrovascular events (MACCE) was similar in both groups (4 (5.5%) vs. 10 (2.8%), p = 0.408). The estimated 3-year survival was similar in both groups (log-rank χ2 = 1.041, p = 0.308). CONCLUSIONS: The 2-staged HCR is a safe and effective surgical procedure and may offer similar mid-term follow-up outcomes to OPCAB.

Minimally invasive direct coronary artery bypass for left anterior descending artery revascularization - analysis of 300 cases.

INTRODUCTION: Minimally invasive direct coronary artery bypass (MIDCAB) grafting is performed via small, left anterolateral thoracotomy. The left internal mammary artery was grafted to the left anterior descending (LAD) artery in 300 consecutive patients. AIM: In-hospital results were evaluated and compared with the conventional, off-pump coronary artery bypass graft procedure. MATERIAL AND METHODS: One hundred and sixty-three (54.33%) of 300 patients underwent staged hybrid coronary revascularization, 93 (31%) were treated for a single LAD lesion, and 44 (14.67%) were treated for multi-vessel disease with reasonably incomplete revascularization. Major in-hospital cardiac adverse events and postoperative data were compared between groups. RESULTS: Preoperative data were similar between groups. However, the difference in left ventricular ejection fraction (p < 0.001) was significant. No conversions to sternotomy occurred during the primary MIDCAB procedures. Shorter operation time (p < 0.001), shorter postoperative mechanical ventilation time (p < 0.001), shorter intensive care unit stay (p < 0.001), and less red blood cell transfusion (p < 0.001) were noted in the MIDCAB group. Postoperative coronary angiography conducted in the MIDCAB group within one week after the operation showed that 2 of 163 patients developed graft occlusion. These patients underwent conventional CABG and recovered well. No significant differences were observed in postoperative MI, delayed wound healing or 30-day in-hospital mortality between the two groups. CONCLUSIONS: The use of a chest wall lifting system and modified stabilizer makes the MIDCAB procedure safer and easier. The MIDCAB procedure is demonstrated to be a feasible and minimally invasive alternative for patients with coronary artery disease involving LAD lesions.

A simultaneous minimally invasive approach to treat a patient with coronary artery disease and metastatic lung cancer.

Concurrent lung cancer and coronary artery disease requiring treatment with percutaneous coronary intervention or coronary artery bypass grafting is not rare. An individualized perioperative anticoagulation regimen and minimal surgical trauma will benefit the patient's postoperative recovery. We successfully treated a 68-year-old female patient with a lesion in the left anterior descending artery and metastatic right lung carcinoma by simultaneous minimally invasive direct coronary artery bypass grafting via a small left thoracotomy and thoracoscopic wedge resection of the lung lesion. She recovered and was discharged on the eighth postoperative day. The patient showed no symptoms of myocardial ischemia postoperatively. Computed tomography scan did not indicate metastatic lesion of lung carcinoma at 1-year follow-up. In conclusion, minimally invasive direct coronary artery bypass grafting combined with thoracoscopic wedge resection is an effective minimally invasive treatment for concurrent lung cancer and coronary artery disease. This technique eliminates the risk of perioperative bleeding and provides satisfactory mid-term follow-up results.