Operability assessment in CTEPH: Lessons from the CHEST-1 study.

Pulmonary endarterectomy is the gold standard treatment for chronic thromboembolic pulmonary hypertension and is potentially curative, although some patients are unsuitable for pulmonary endarterectomy and require alternative management. Lack of standardized assessment of pulmonary endarterectomy eligibility risks suboptimal treatment in some patients. We discuss the implications for future clinical trials and practice of a unique operability assessment in patients who have chronic thromboembolic pulmonary hypertension and were initially screened for inclusion in the CHEST-1 (Chronic Thromboembolic Pulmonary Hypertension Soluble Guanylate Cyclase Stimulator Trial-1) study. The CHEST-1 study evaluated riociguat for the treatment of inoperable chronic thromboembolic pulmonary hypertension (CTEPH) or persistent/recurrent pulmonary hypertension after pulmonary endarterectomy. Screened patients who were initially considered "inoperable" underwent central independent adjudication by a committee of experienced surgeons, or local adjudication in collaboration with an experienced surgeon. Operability decisions were based on accessibility of thrombi and the association between pulmonary vascular resistance (PVR) and the extent of obstruction, using pulmonary angiography/computed tomography with ventilation/perfusion scintigraphy as the minimum diagnostic tests. Of 446 patients screened for CHEST-1, a total of 188 and 124 underwent central and local adjudication, respectively, after being initially considered to be "inoperable." After a second assessment by an experienced surgeon, 69 of these 312 "inoperable" patients were deemed operable. Rigorous measures in CHEST-1 guaranteed that only technically inoperable patients, or patients who had persistent/recurrent pulmonary hypertension, were enrolled, thus ensuring that only patients for whom surgery was not an option were enrolled. This study design sets new standards for future clinical trials and practice in CTEPH, helping to ensure that patients who have CTEPH receive optimal treatment.

Post-conditioning through lower limb ischemia-reperfusion can alleviate lung ischemia-reperfusion injury.

OBJECTIVE: Operation on the infrarenal aorta could cause ischemic-reperfusion (IR) injury in local tissues and remote organs (e.g. the lung). We aim to explore the method of reducing lung ischemia-reperfusion damage after lower limb IR with post conditioning (LIPC). METHODS: Bilateral lower limb ischemia was performed in Sprague-Dawley (SD) rats, and then animals were divided into 4 groups: IR-Sham-operated, IR, post conditioned-IR (LIPC) and bilateral lower limb ischemia (LIR). The serum free radical, histological changes, Wet/Dry (W/D) ratio, levels of TNF-α, IL-6, cytokines and chemokines were tested and compared. RESULTS: Post-conditioning could ameliorate histological injuries in the lung when compared to IR group. The serum free radical is significantly lower in LIPC group than IR groups. W/D ratio in LIPC groups is significantly lower. LIPC also could reduce the expression of cytokines and chemokines. CONCLUSION: post conditioning could reduce long-term damages of the lung after lower limb ischemic-reperfusion injury.

Preoperative transcatheter occlusion of bronchopulmonary collateral artery reduces reperfusion pulmonary edema and improves early hemodynamic function after pulmonary thromboendarterectomy.

OBJECTIVE: The present study assessed the effectiveness of preoperative transcatheter occlusion of the bronchopulmonary collateral artery (PTOBPCA) in reducing reperfusion pulmonary edema after pulmonary thromboendarterectomy (PEA). METHODS: The data from 155 patients with chronic thromboembolic pulmonary hypertension at Anzhen Hospital, treated from January 2007 to August 2013, with PEA were retrospectively reviewed. The patients were classified into a control (group A, n = 87) and treated (group B, underwent PTOBPCA, n = 68) group. The reperfusion pulmonary edema incidence, mechanical ventilation and intensive care unit hospitalization duration, and hemodynamic function were compared between the 2 groups. RESULTS: Of the 87 patients in group A, 5 died in-hospital (5.7% mortality); no patient in group B died (0% mortality; P = .035). In group A, 9 patients (10.3%) required extracorporeal membrane oxygenation (ECMO) after PEA; 1 patient (1.5%) in group B required ECMO (chi-square test, P = .026, χ(2) = 4.980). Group B had shorter intubation and intensive care unit hospitalization times, lower mean pulmonary artery pressures and pulmonary vascular resistance, higher partial pressures of oxygen in arterial blood and oxygen saturation, and decreased medical expenditure compared with group A. During a mean 37.1 ± 21.4 months of follow-up, 3 patients in group A and 2 in group B died; however, the difference in the actuarial survival at 3 years postoperatively between the 2 groups was not statistically significant. CONCLUSIONS: PTOBPCA can reduce the incidence of reperfusion pulmonary edema, shorten intensive care unit hospitalization and intubation duration, improve early hemodynamic function, and reduce ECMO usage after PEA.

Patients with congenital systemic-to-pulmonary shunts and increased pulmonary vascular resistance: what predicts postoperative survival?

BACKGROUND: We carried out a retrospective data review of patients with systemic to pulmonary shunts that underwent surgical repair between February 1990 and February 2012 in order to assess preoperative pulmonary vascular dynamic risk factors for predicting early and late deaths due presumably to pulmonary vascular disease. METHODS AND RESULTS: A total of 1024 cases of congenital systemic-to-pulmonary shunt and advanced pulmonary vascular disease beyond infancy and early childhood were closed surgically. The mean follow up duration was 8.5±5.5 (range 0.7 to 20) years. Sixty-one in-hospital deaths (5.96%, 61/1024) occurred after the shunt closure procedure and there were 46 late deaths, yielding 107 total deaths. We analyzed preoperative pulmonary vascular resistance index (PVRI), pulmonary vascular resistance index on pure oxygen challenge (PVRIO), difference between PVRI and PVRIO (PVRID), Qp∶Qs, and Rp∶Rs as individual risk predictors. The results showed that these individual factors all predicted in-hospital death and total death with PVRIO showing better performance than other risk factors. A multivariable Cox regression model was built,and suggested that PVRID and Qp∶Qs were informative factors for predicting survival time from late death and closure of congenital septal defects was safe with a PVRIO<10.3 WU.m(2) and PVRID>7.3 WU.m(2) on 100% oxygen. CONCLUSIONS: All 4 variables, PVRI, PVRIO, PVRID and Qp∶Qs, should be considered in deciding surgical closure of congenital septal defects and a PVRIO<10.3 WU.m(2) and PVRID>7.3 WU.m(2) on 100% oxygen are associated with a favorable risk benefit profile for the procedure.

The distinguishing cellular features of pulmonary artery smooth muscle cells from chronic thromboembolic pulmonary hypertension patients.

In chronic thromboembolic pulmonary hypertension (CTEPH), central thrombi are the most likely disease initiators, and progressive pulmonary vascular remodeling, which is characterized by marked proliferation of pulmonary artery smooth muscle cells (PASMCs), may also contribute to the long-term progression of CTEPH. This study was designed to investigate the cellular characteristics of PASMCs isolated from the organized thrombotic tissues of CTEPH. In the present study, analysis of PASMCs isolated from five CTEPH patients and three control subjects showed that cells from CTEPH patients had certain characteristics that distinguished them from control cells, including inferior or no cell-cell contact inhibition growth, increased sensitivity to hypoxia-induced proliferation, resistance to serum starvation-induced apoptosis, and mitochondrial metabolism disorder. These differences in the PASMCs in endarterectomized tissue of CTEPH patients may prove useful in understanding the pathobiology of CTEPH.

Fibrinogen Aα Thr312Ala polymorphism specifically contributes to chronic thromboembolic pulmonary hypertension by increasing fibrin resistance.

BACKGROUND: Polymorphisms are associated with chronic thromboembolic pulmonary hypertension (CTEPH) and pulmonary thromboembolism (PTE), but no polymorphism specific to CTEPH but not PTE has yet been reported. Fibrin resistance is associated with CTEPH, but the mechanism has not been elucidated. METHODS: Polymorphisms were analyzed in 101 CTEPH subjects, 102 PTE subjects and 108 healthy controls by Massarray or restriction fragment length polymorphism (RFLP). Plasmin-mediated cleavage of fibrin was characterized in 69 subjects (29 with CTEPH, 21 with PTE and 19 controls). RESULTS: Genotype frequencies and allele frequencies of fibrinogen Aα Thr312Ala were significantly higher in CTEPH subjects than in controls and PTE subjects, while there was no difference between PTE subjects and controls. The odd ratio (OR 2.037) and 95% confidence interval (95% CI, 1.262-3.289) showed that Thr312Ala polymorphism was a risk factor for CTEPH but not PTE. Fibrin from CTEPH subjects was more resistant to lysis than that from PTE subjects and controls. Fibrin resistance was significantly different between Aα Thr312Ala (A/G) genotypes within CTEPH subjects, and the fibrin with GG genotype was more resistant than that with AA and AG genotype. CONCLUSIONS: Fibrinogen Aα Thr312Ala (A/G) polymorphism was associated with CTEPH, but not PTE, suggesting that the fibrinogen Aα Thr312Ala polymorphism may act as a potential biomarker in identifying CTEPH from PTE. GG genotype polymorphism contributes to CTEPH through increasing fibrin resistance, implying that PTE subjects with fibrinogen Aα GG genotype may need long-term anticoagulation therapy.

Pulmonary oligemia maneuver can alleviate pulmonary artery injury during pulmonary thromboendarterectomy procedure.

BACKGROUND: Pulmonary thromboendarterectomy (PTE) has evolved as a treatment of choice for chronic thromboembolic pulmonary hypertension (CTEPH). This study aimed to characterize if pulmonary oligemia maneuver (POM) can alleviate pulmonary artery injury during PTE procedure. METHODS: A total of 112 cases of CTEPH admitted to Beijing Anzhen Hospital from March 2002 to August 2011 received PTE procedure. They were retrospectively classified as non-POM group (group A, n = 55) or POM group (group B, n = 57). Members from group B received POM during rewarming period, whereas members from group A did not. RESULTS: There were three (5.45%) early deaths in group A, no death in group B (0) (Fisher's exact test, P = 0.118). Six patients in group A needed extracorporeal membrane oxygenation (ECMO) as life support after the PTE procedure, no patients in group B needed ECMO (Fisher's exact test, P = 0.013). The patients in group B had a shorter intubation and ICU stay, lower mean pulmonary arterial pressure (mPAP) and pulmonary vascular resistance (PVR), higher partial pressure of oxygen in artery (PaO2) and arterial oxygen saturation (SaO2) and less medical expenditure than patients in group A. With a mean follow-up time of (58.3 ± 30.6) months, two patients in group A and one patient in group B died. The difference of the actuarial survival after the procedure between the two groups did not reach statistical significance. Three months post the PTE procedure, the difference of residual occluded pulmonary segment between the two groups did not reach statistical significance (P = 0.393). CONCLUSION: POM can alleviate pulmonary artery injury, shorten ICU stay and intubation time, and lower down the rate of ECMO after PTE procedure.

The wall eclipsing sign on pulmonary artery computed tomography angiography is pathognomonic for pulmonary artery sarcoma.

BACKGROUND: The objective of this study was to evaluate the imaging characteristics of pulmonary artery sarcoma (PAS) on pulmonary artery computed tomography angiography (PACTA) that can be used to differentiate between PAS and pulmonary thromboembolic diseases, including chronic thromboembolic pulmonary hypertension (CTEPH) and acute pulmonary embolism (APE). METHODS: The clinical data and imaging characteristics of 12 patients with PAS, 156 patients with CTEPH, and 426 patients with APE who were treated at Beijing Anzhen Hospital from January 2007 to August 2013 were retrospectively analyzed. All patients underwent PACTA before treatment, and the diagnoses of PAS and CTEPH were all confirmed by surgical biopsy. RESULTS: All 12 PAS patients were initially misdiagnosed and received inappropriate thrombolytic and/or anticoagulant therapy before they were referred for surgical intervention. The mean time from PACTA to surgical intervention was 5.5±3.7 months (range 2-11 months). On PACTA, the PAS lesion always eclipsed the wall of the pulmonary artery before infiltrating outside the pulmonary artery, which was termed the wall eclipsing sign. This sign was observed in all PAS patients but was not observed in any CTEPH or APE patients. CONCLUSIONS: PAS is a rare neoplasm with a poor prognosis, and is easily misdiagnosed as thromboembolic disease. The wall eclipsing sign on PACTA is pathognomonic for PAS, and patients with this sign should be investigated to confirm the diagnosis and should undergo surgical intervention as soon as possible, rather than receiving thrombolytic or anticoagulant therapy.

High volume practice proved the safety of off-pump coronary artery bypass surgery in left main coronary artery lesions: a two-year single center experience.

BACKGROUND: Left main coronary artery (LMCA) stenosis has been recognized as a risk factor for early death among patients undergoing coronary artery bypass grafting (CABG). This study aimed to assess if LMCA lesions pose an additional risk of early or mid-term mortality and/or a major adverse cardiac and cerebrovascular event (MACCE) after off-pump coronary artery bypass grafting (OPCABG), compared with non-left main coronary artery stenosis (non-mainstem disease). METHODS: From January 1, 2009 to December 31, 2010, 4869 patients had a primary isolated OPCABG procedure at Beijing Anzhen Hospital. According to the pathology of LMCA lesions, they were retrospectively classified as a non-mainstem disease group (n = 3933) or a LMCA group (n = 936). Propensity scores were used to match the two groups, patients from the non-mainstem disease group (n = 831) were also randomly selected to match patients from the LMCA group (n = 831). Freedom from MACCE in the two groups was calculated using the Kaplan-Meier method. RESULTS: The difference in the mortality and the rate of MACCE during the first 30 days between the non-mainstem disease group and the LMCA group did not reach statistical significance (P = 0.429, P = 0.127 respectively). With a mean follow-up of (12.8 ± 7.5) months and a cumulative follow-up of 1769.6 patient-years, the difference in the freedom from MACCEs between the two groups, calculated through Kaplan-Meier method, did not reach statistical significance (P = 0.831). CONCLUSION: Analysis of a high volume of OPCABG procedures proved that LMCA lesions do not pose additional early and mid-term risk to OPCABG. Therefore, a LMCA lesion is as safe as non-mainstem disease lesion during the OPCABG procedure.

Ostial left main coronary artery stenosis as an additional risk factor in off-pump coronary artery bypass grafting.

BACKGROUND: Our aim was to determine whether general left main coronary artery stenosis (LMS) and ostial LMS pose additional risks after off-pump coronary artery bypass grafting (CABG) relative to non-left main coronary artery stenosis. METHODS: From January 1, 2008, to December 31, 2009, 4366 patients underwent primary isolated off-pump CABG at Beijing Anzhen Hospital. Disease was retrospectively classified as non-left main disease (n = 3523), nonostial LMS (n = 765), and ostial LMS (n = 78). Groups were propensity score matched. Kaplan-Meier freedoms from major adverse cardiac and cerebrovascular events (MACCEs) were calculated. RESULTS: During the first 30 postoperative days, mortality was significantly higher in the ostial LMS group (6.41%) than in non-left main disease (0.855%, χ(2) = 7.78, P = .005) and nonostial LMS (1.28%, χ(2) = 4.71, P = .03) groups. Incidence of MACCEs was significantly higher in the ostial LMS group (20.5%) than in non-left main disease (5.98%, P = .000) and nonostial LMS (9.62%, P = .002) groups. Odds ratio for early MACCEs of ostial LMS versus non-left main disease was 3.74 (95% confidence interval, 1.72-8.17). At mean follow-up 12.8 ± 7.5 months and cumulative follow-up 498.5 patient-years, difference among groups in freedom from MACCEs did not reach statistical significance (χ(2) = 2.39, P = .303). CONCLUSIONS: Ostial LMS poses additional early risks of mortality and MACCEs in off-pump CABG. Off-pump CABG for ostial LMS should proceed with greater of intraoperative surveillance and lower threshold for converting to on-pump CABG.

[Early, middle and long-term clinical outcomes of coronary artery bypass grafting for left main coronary stenosis].

OBJECTIVE: To evaluate the early, middle and long-term clinical outcomes of coronary artery bypass grafting (CABG) for a special subset of left main coronary stenosis (LMS). METHODS: A total of 626 LMS patients, recruited at our hospital between January 1998 and March 2008, were classified them into the statin therapy group (Group A, n = 322) or the non-statin therapy group (Group B, n = 304) according to whether or not taking statins pre-operatively. Then their clinical data were retrospectively analyzed. RESULTS: The inhospital mortality was 4.31% (n = 27). And the mortality was 1.90% (n = 6) for Group A and 6.91% for Group B (n = 21) (χ² test, χ² = 9.642, P = 0.002). Preoperative statin therapy could lower the all-cause mortality rate (1.90% vs 6.91%, P = 0.002), the prevalence of new atrial fibrillation or flutter (14.69% vs 19.61%, P = 0.016, χ ²= 5.780) and disabling stroke (2.50% vs 4.58%, P = 0.047, χ(2) = 3.94). Among 599 CABG survivors, 565 cases (94.3%) were actually followed up with a mean duration of 55.5 ± 26.1 months (range: 2 - 98). During the follow-up period, there were 29 (4.63%) cardiac events, including 12 deaths and 17 myocardial infarctions. There were 43 (7.18%) cases with relapsing angina pectoris. The univariate analysis showed that emergency procedure, abnormal C-reactive protein (CRP), abnormal troponin I(TnI), complicated LMS pathology, preoperative IABP (intra-aortic balloon pump) support, preoperative cardiac arrest, preoperative history of myocardium infarction and no preoperative statin therapy were the risk factors for perioperative death while complicated LMS pathology, preoperative IABP support, preoperative cardiac arrest, preoperative myocardium infarction and no preoperative statin therapy were the risk factor for late cardiac events. The multivariate binary logistic regression showed that emergency procedure, preoperative IABP support, no preoperative statin therapy and preoperative IABP support were independent predictors for peri-operative death. And preoperative IABP support, preoperative cardiac arrest, no preoperative statin therapy and complicated LMS pathology were independent predictors for late cardiac events. There was no statistical significance in inhospital mortality between on pump CABG and OPCAB (off pump coronary artery bypass). CONCLUSION: The CABG procedure for LMS carries a relative high mortality. However preoperative statin therapy may offer such protective effects as lowering the all-cause mortality rate and reducing the prevalence of new atrial fibrillation or flutter and disabling stroke.

Surgical treatment of pulmonary artery sarcoma.

OBJECTIVE: The study objectives were to characterize the prognostic perspectives of pulmonary artery sarcoma and to investigate the effect of distal embolectomy on the prognosis of surgical treatment of pulmonary artery sarcoma. METHODS: Nine patients with pulmonary artery sarcoma were surgically treated at Anzhen Hospital, and the data were retrospectively reviewed. Five patients underwent only pulmonary artery sarcoma resection, and 4 patients underwent both pulmonary artery sarcoma resection and distal embolectomy. RESULTS: There was no in-hospital mortality. Four patients had lung ischemia-reperfusion injury, 3 of whom recovered with the support of extended ventilation and positive end-expiratory pressure, and 1 of whom recovered with extracorporeal membrane oxygenation support. During the follow-up, 5 patients who did not undergo distal embolectomy died 6 to 29 months after the procedure, with a median survival time of 10 months. Of the 4 patients undergoing distal embolectomy, 3 died 30, 37, and 43 months after the procedure, and 1 is still alive 39 months after the procedure. All 8 deaths were due to local or systemic recurrence. The patients who underwent distal embolectomy lived longer than the patients who did not undergo distal embolectomy (log-rank test, x(2) = 7.914, P = .005). CONCLUSIONS: Radical surgical resection provides the only chance of survival for patients with pulmonary artery sarcoma, and distal embolectomy may further extend survival for these patients.

Surgical treatment of intracardiac leiomyomatosis.

OBJECTIVES: Confusion exists regarding surgical algorithms for treating intracardiac leiomyomatosis. This report outlines the surgical management and outcomes of patients with intracardiac leiomyomatosis. METHODS: Sixteen cases of intracardiac leiomyomatosis surgically treated in Anzhen Hospital from February 1995 to July 2010 were reviewed retrospectively. According to relative size and location of intracardiac leiomyoma maximum diameter relative to diameter of inferior vena cava, the 16 cases were classified as type A, B, C, or D. RESULTS: Of the 16 cases in this series, there were 7 type A, 2 type B, 3 type C, and 4 type D. No patients died during surgery. Mean follow-up was 90 ± 57.1 months (cumulative, 120.2 patient-years; range, 2-190 months). One patient died of recurrence 5 months after the surgery because of incomplete resection. Another patient with type D also died of recurrence 2 years after the primary procedure. A patient with type D died suddenly 10 years after the primary procedure. The 5-year and 10-year survivals calculated by the Kaplan-Meier method were 87.1% ± 8.6% and 72.5% ± 15%. Of the 13 surviving patients, 11 were in New York Heart Association functional class I and 2 were in functional class II. CONCLUSIONS: Surgical treatment of intracardiac leiomyomatosis can result in satisfactory midterm to long-term survival and satisfactory heart function. Multiple surgical strategies should be tailored to the anatomic characteristics of the intracardiac leiomyoma. Recurrence of intracardiac leiomyomatosis after the resection procedure may result in unfavorable late result.

Prognosis of percutaneous coronary intervention and coronary artery bypass grafts for ostial right coronary lesions in propensity-matched individuals.

OBJECTIVE: Our aim was to evaluate the relative safety and efficacy of percutaneous coronary intervention (PCI) with drug-eluting stents (DES) versus coronary artery bypass grafts (CABG) for the treatment of ostial right coronary stenosis (ORCS) lesions. METHODS: Three hundred fifty-nine cases of ORCS lesion were treated via CABG (n = 232) or PCI (n = 127) procedures. Propensity scores for undergoing the CABG procedure were estimated and used to match 105 pairs of patients between the two groups. Kaplan-Meier major adverse cardiac and cerebrovascular events (MACCE)-free curves were constructed to compare long-term MACCE-free survival between the two groups. RESULTS: For the 105 propensity-matched pairs, patients were more likely to undergo repeat revascularization with CABG in the PCI group than in the CABG group during the first 30 days (4 cases vs. 0 case, P= 0.043, χ(2) = 4.08) and the 1-year follow-up (5 cases vs. 0 case, P= 0.02, χ(2) = 5.17). With a mean follow-up of 12.04 ± 6.47 months and a total of 210.67 patient-years, the freedom from MACCE in the CABG group was significantly higher than that in the PCI group (Log rank test, χ(2) = 4.48, P= 0.03). There were no significant differences in the rates of death, myocardial infarction, nonfatal stroke, death/myocardium infarction/stroke, or repeated PCI between the two groups during the first 30 days and during the 1-year follow-up period. CONCLUSION: For OCRS lesions, CABG provided greater protection than PCI procedure in terms of freedom from MACCE, mainly due to the reduced number of repeated revascularization procedures. CABG should be considered as first-choice revascularization strategy for ORCS lesions.

[The actuarial survival analysis to the surgical and non-surgical therapy regime for congenital heart disease with severe pulmonary hypertension].

OBJECTIVE: To investigate the relationship between the long-term outcomes of surgical treatment and preoperative pulmonary vascular resistance (PVR) or pulmonary to systemic flow ratio (Qp/Qs) in patients of congenital heart diseases with severe pulmonary hypertension (CHDSPH). METHODS: From February 1990 to July 2008, 1212 cases of CHDSPH were treated non-surgically or surgically and were retrospectively classified as non-surgical group (n = 297) and surgical group (n = 915). Propensity score of inclusion into the surgical group were estimated and 245 tribes were get with the same propensity score +/- 0.05. The Kaplan-Meier survival curves were constructed for the 245 tribes with the PVR stratum at the level of 120 kPa x L(-1) x S(-1) or with the Qp/Qs stratum at the level of 1.25. RESULTS: With the follow-up of 97 +/- 57 months, there were 44 late deaths in the surgical group and 65 late deaths in the non-surgical group. In the 245 propensity score matched tribes, the Log rank test between non-surgical group and surgical group revealed chi(2) = 0.54, P = 0.4611 for the stratum of PVR > or = 120 kPa x L(-1) x S(-1), and chi(2) = 51.68, P = 0.000 for stratum of PVR < 120 kPa x L(-1) x S(-1); the Log rank test between non-surgical group and surgical group revealed chi(2) = 0.97, P = 0.3254 for the stratum of Qp/Qs < 1.25, and chi(2) = 62.77, P = 0.000 for stratum of Qp/Qs > or = 1.25. CONCLUSION: for CHDSPH patients, the indication of the surgical closure should be defined as PVR < 120 kPa x L(-1) x S(-1) and/or its Qp/Qs > or = 1.25.

Statins decrease adverse outcomes in coronary artery bypass for extensive coronary artery disease as well as left main coronary stenosis.

The aim of this study was to evaluate the effects of preoperative and postoperative statins on coronary artery bypass grafting (CABG) for extensive coronary artery disease as well as left main coronary stenosis (LMS). The data of 626 cases of extensive coronary artery disease as well as LMS patients in Anzhen Hospital between January 1998 and March 2008 for CABG procedure were retrospectively analyzed, and were classified as preoperative statin therapy group (Group A, n = 320) or preoperative no statin therapy group (Group B, n = 306). Propensity scores were estimated to determine the probability of inclusion into statin therapy group, resulting in the successful matching of 267 pairs. The incidence of in-hospital death, and atrial fibrillation or flutter and disabling stroke was higher in Group B than in Group A. The actuarial freedom from late events at 5 yrs were 98.75%+/- 0.73% for the postoperative statin therapy group and 88.33%+/- 3.71% for the postoperative no statin therapy group respectively, P= 0.000. The logistic regression revealed that CRP (>5.0 mg/L), and elevated Troponin I, and emergent procedure, and preoperative IABP support, and EF < 40% were the independent risk factors, and preoperatively statins was the protective factor for the perioperative death; and the Cox proportional hazard also revealed that preoperative IABP support and preoperative cardiac arrest, and EF < 40% were independent risk factors, and postoperatively statins were the protective factor for the late cardiac events. Preoperative statin therapy could provide protective effect in the perioperative period. Postoperative statin usage could provide protective effect on the late cardiac events.

The unidirectional valve patch provides no benefits to early and long-term survival in patients with ventricular septal defect and severe pulmonary artery hypertension.

OBJECTIVE: Our aim was to test whether a unidirectional valve patch would provide benefit to early and long-term survival for patients with ventricular septal defect and severe pulmonary artery hypertension. METHODS: Eight hundred seventy-six cases of ventricular septal defect with severe pulmonary artery hypertension were closed with or without a unidirectional valve patch and were classified as the unidirectional valve patch (UVP) group (n = 195) and nonvalve patch (NVP) group (n = 681), respectively. Propensity scores of inclusion into the UVP group were used to match 138 pairs between the 2 groups. Kaplan-Meier survival curves were constructed to compare early and long-term survival. RESULTS: For the 138 propensity-matched pairs, there were 7 and 9 early deaths (in-hospital deaths) in the UVP and NVP groups, respectively. The difference in early mortality between the 2 groups did not reach statistical significance (chi(2) = 0.265, P = .6064). With a mean of 9.2 +/- 4.92 years' and 2511 patient-years' follow-up, there were 6 late deaths in the UVP group and 7 late deaths in the NVP group. The difference in actuarial survival at 5, 10, 15, and 18 years between the 2 groups was not significant (log-rank test, chi(2) = 0.565, P = .331). The difference in the late mortality between the groups with or without a patent patch at the time of discharge did not reach statistical significance (chi(2) = 1.140, P = .2856). There was no difference between the 2 groups in the 6-minute walk distance assessed at the last follow-up (525.9 +/- 88.0 meters for the UVP group and 536.5 +/- 95.8 meters for the NVP group, F = 1.550, P = .214). CONCLUSION: A unidirectional valve patch provides no benefits to early and long-term survival when it is used to deal with ventricular septal defect and severe pulmonary artery hypertension.

Closure of a two-hole secundum atrial septal defect through a transthoracic atrial septal defect occlusion device.

A simple method to close a 2-hole secundum atrial septal defect (ASD) is described. The right atrium was approached through a minithoracotomy. A double-ring purse string suture was made for the introducer shaft of the ASD occlusion device, and another purse string was made for a slim tissue scissors. A slim tissue scissors was introduced to the right atrium, and the bridge of tissue between the 2 holes was cut. The maximum diameter of the neo-ASD was measured. Thus, the ASD occlusion device of appropriate size could be selected and be placed in position.

The actuarial survival analysis of the surgical and non-surgical therapy regimen for chronic thromboembolic pulmonary hypertension.

AIM: To characterize the in-hospital mortality and the actuarial survival of surgical and non-surgical therapy regimen in the treatment of chronic thromboembolic pulmonary hypertension (CTEPH). METHODS: A retrospective cohort study was conducted in 504 patients with CTEPH, who were treated surgically (n = 360), or non-surgically (n = 144) in Anzhen Hospital from February 1989 to August 2007. The patients in surgical group received a standard pulmonary thromboendarterectomy (PTE), while those in non-surgical group were given thrombolytic therapy. The actuarial survival of the two groups was determined with the Kaplan-Meier survival curves. Univariate analysis and multivariate binary logistic regression and Cox proportional hazard analysis were used to identify the risk factors for the in-hospital and late deaths. RESULTS: The in-hospital mortality for the surgical group and non-surgical group were 4.44% and 3.50%, respectively. For the proximal type of CTEPH, the actuarial survival at 10 and 15 years of the surgical group and non-surgical group were 94.60 +/- 2.38%, 90.96 +/- 4.24% and 81.4 +/- 7.14%, 56.43 +/- 14.7%, respectively (chi(2) = 12.33, P = 0.0004). For the distal type of CTEPH, the actuarial survival at 10 and 15 years of the surgical group and non-surgical group were 71.78 +/- 4.66%, 29.57 +/- 15.1% and 69.84 +/- 7.78%, 32.59 +/- 13.7%, respectively (chi(2) = 0.03, P = 0.874). CONCLUSION: The PTE procedure has statistically superiority over thrombolytic therapy for the proximal type of CTEPH in terms of actuarial survival; however, for the distal type of CTEPH, the PTE procedure provides no benefits with regard to actuarial survival.

The classification and surgical strategy of intracardiac leiomyomatosis.

BACKGROUND: There is a great deal of heterogeneity in the surgical strategy to treat intracardiac leiomyomatosis (ICL), leading to a need to create a theoretical tool to clarify this situation. METHODS: The data of 14 cases of ICL surgically treated in Anzhen Hospital from February 1995 to February 2009 were retrospectively reviewed. A system for classifying ICL was proposed based on four features of the lesion: size of intracardiac component; extent of inferior vena cava (IVC) involvement; venous pathway from uterus to IVC; and laterality of the lesion in the pelvis. The 14 cases of ICL were treated through multiple surgical strategies. RESULTS: There were no operative deaths. The follow-up was 73.1 +/- 59.2 months and one patient died from recurrence due to incomplete excision 5 months after the primary procedure. The 5-year survival rate calculated through Kaplan-Meier survival curve was 93.16 +/- 4.98%. Of the surviving patients, 13 had ICL, 10 were in the New York Heart Association (NYHA) class I, and three were in NYHA class II. CONCLUSION: The surgical treatment of ICL can obtain a good mid- to long-term survival rate and satisfactory heart function, and the proposed classification system for ICL may be helpful to guide the selection of the surgical strategy for ICL, and may serve as the future basis for standardising the reporting of ICL management.