Early results of totally endoscopic robotic aortic valve replacement: analysis of 4 cases.

OBJECTIVE: To evaluate the role of totally endoscopic robotic aortic valve replacement in cardiac surgery. METHODS: Four cases of totally robotic aortic valve replacement (AVR) were conducted from December 2016 to July 2018. All operations were completed with the Da Vinci robot Si™ system (intuitive Surgical, Inc. Sunnyvale, C.A, USA). Patients were male, with a mean age of 42.8 ± 6.2 years (range 32-49). RESULTS: AVR was completed with the Da Vinci Si™ system (intuitive Surgical, Inc. Sunnyvale, CA, USA). There was no mortality and no procedure-related morbidity. The mean cardiopulmonary bypass and mean cross-clamp time was 252 ± 13.6 min and 178.8 ± 17.1 min, respectively. The mean ICU time was 78.8 ± 27.1 h, and the mean hospital stay was 15 ± 3.5 d. During a mean follow-up of 3 years and 6 months, the patients returned to normal function, and no heart murmur was found. Compared with the operation, the body image score of the four patients increased after the operation, and the hospital anxiety and depression scale scores decreased, indicating that the patient's condition had been alleviated to a certain extent. CONCLUSION: Totally endoscopic robotic AVR is a feasible and viable choice for patients but requires further improvement for broader use.

Analysis of prognostic factors for in-hospital mortality in patients with unplanned re-exploration after cardiovascular surgery.

OBJECTIVE: To explore the prognostic factors for in-hospital mortality in patients with unplanned re-exploration after cardiovascular surgery. METHODS: We retrospectively analyzed the data of 100 patients who underwent unplanned re-exploration after cardiovascular surgery in our hospital between May 2010 and May 2020. There were 77 males and 23 females, aged (55.1 ± 15.2) years. Demographic characteristics, surgical information, perioperative complications were collected to establish a database. These patients were divided into surviving and non-surviving groups according to in-hospital mortality. Logistic regression was used for multivariable analysis to explore the prognostic factors of in-hospital mortality. These statistically significant indicators were selected for drawing the receiver operating characteristic curve of the evaluation model, calculating the area under the curve (AUC) and evaluating the effectiveness of the new model with Hosmer-Lemeshow C-statistic. RESULTS: In-hospital mortality in patients with unplanned re-exploration after cardiovascular surgery was 26.0% (26/100). Multivariate logistics regression revealed that the operation time of unplanned re-exploration, the worst blood creatinine value within 48 h before the re-exploration, the worst lactate value within 24 h after the re-exploration, cardiac insufficiency, respiratory insufficiency, and acute kidney injury were independent prognostic factors (P < 0.05). The AUC of the new assessment model constituted by these prognostic factors was 0.910, and the Hosmer-Lemeshow C-statistic was 4.153 (P = 0.762). CONCLUSIONS: Operation time of unplanned re-exploration, worst serum creatinine value within 48 h before re-exploration, worst lactate value within 24 h after re-exploration, cardiac insufficiency, respiratory insufficiency, and acute kidney injury are the main prognostic factors for in-hospital mortality in patients with unplanned re-exploration after cardiovascular surgery. Identifying these prognostic factors can effectively facilitate preventive measures and improve patient outcomes.

Clinical analysis of redo aortic root replacement after cardiac surgery: a retrospective study.

OBJECTIVES: To explore the etiology, previous cardiac procedure methods and outcomes of redo aortic root replacement after cardiac surgery. METHODS: A retrospective analysis of 41 patients who underwent aortic root replacement surgery in our hospital from February 2010 to February 2020 who underwent at least one cardiac surgery in the past, including 27 males and 14 females, with an average age of 49.5 ± 10.2 years old. Indications for reoperation include: aortic sinus dilation and ascending aortic aneurysm in 20 cases (48.8%), recurrent aortic dissection in 7 cases (17.1%), pseudoaneurysm of aortic root in 4 cases (9.8%), prosthetic valve endocarditis in 5 cases (12.2%) and paravalvular leakage in 5 cases (12.2%). According to whether the previous procedure involved aortic root surgery, they were divided into 2 groups, namely aortic root surgery-involved (ARS) group and non-aortic root surgery-involved (NRS) group. After the patients were discharged from hospitals, follow-ups were carried out through outpatient clinic or telephone for 5 years. Kaplan-Meier was used for survival analysis. RESULTS: All patients underwent Bentall procedure with a median sternum incision. Six patients (14.6%) died during the postoperative hospitalization and 3 patients (8.6%) died during the follow-up. The 1-year, 3-year, and 5-year survival in ARS group were 92.6, 92.6, and 92.6%, respectively; the 1-year, 3-year, and 5-year survival in NRS group were 100, 85.7, and 85.7%, respectively. There was no statistical difference between the two groups in the cause of redo aortic root replacement, procedure time, postoperative complications, postoperative hospital stay, hospital mortality, and 5-year cumulative survival (p > 0.05). CONCLUSIONS: Redo aortic root replacement is difficult and high risk. Bentall procedure is still a reliable surgical option for redo aortic root replacement, with good short- and mid-term results. The prognosis of redo aortic root replacement is not necessarily related to the etiology of patient's surgery and the methods of previous cardiac procedure.

Left thorax approach to repair doubly committed juxta-arterial ventricular septal defect with Da Vinci robotic system.

Robotic repair of the ventricular septal defect was performed mainly for perimembranous type via right thorax approach. Minimally invasive strategies for doubly committed juxta-arterial ventricular septal defect were limited. Here, for the first time, we successfully repaired a doubly committed juxta-arterial ventricular septal defect with Da Vinci robotic system via left thorax approach. The technique could provide excellent exposure of surgical field and accurate repair, with the advantage of reducing trauma and shortening the overall length of stay.

Immunoregulatory Siglec ligands are abundant in human and mouse aorta and are up-regulated by high glucose.

AIM: Inflammation is a driving force in development of atherosclerosis, and hyperglycemia is a significant risk factor for angiopathy. Siglec-9, expressed on human neutrophils and macrophages, engages specific glycan ligands on tissues to diminish ongoing inflammation. MATERIALS AND METHOD: Siglec-9 ligands on human aorta were characterized and the effects of high glucose exposure on the expression of ligands for Siglec-9 on human umbilical vein endothelial cells (HUV-EC-C) in vitro and ligands for the comparable siglec (Siglec-E) on mouse aorta in vivo were studied. KEY FINDINGS: Siglec-9 ligands were expressed broadly on human aorta, as well as on HUV-EC-C. Siglec-9 ligands on HUV-EC-C were sharply up-regulated under high glucose exposure in vitro, as were Siglec-E ligands on the aortas of hyperglycemic mice. Exposure of HUV-EC-C to high-glucose resulted in consistent inhibitory changes in co-cultured macrophages including increased apoptosis and decreased phagocytosis. Control of Siglec-9 ligand expression on HUV-EC-C was downstream of changes in an enzyme involved in their biosynthesis, UDP-galactose-4-epimerase (GALE) and increased cellular N-acetylgalactosamine. The alteration of GALE was associated with the regulatory microRNA hsa-let-7f. SIGNIFICANCE: We conclude that exposure to high-glucose results in up-regulation of immune inhibitory Siglec-9 sialoglycan ligands on aorta and HUV-EC-C cells downstream of altered GALE and GalNAc expression, resulting in up-regulation of apoptosis and decrease of phagocytic activity of macrophages. Changes in Siglec-9 sialoglycan ligand expression on vascular endothelial cells may be a natural response to the initial steps of atherosclerosis and might be a potential target to regulate inflammation in diabetic angiopathy.

Mechanism of genistein regulating the differentiation of vascular smooth muscle cells into osteoblasts via the OPG/RANKL pathway.

OBJECTIVE: The present study aimed to investigate the mechanism of genistein, a tyrosine kinase inhibitor, regulating the differentiation of vascular smooth muscle cells (VSMCs) into osteoblasts via the OPG/RANKL (Osteoprotegerin/Receptor Activator of Nuclear Factor-κB Ligand) pathway. METHODS: The mouse VSMCs were isolated, purified and cultured. We constructed the LV5-Tnfrsf11b overexpression lentiviral vector and LV3-OPG-309 interference lentiviral vector. The OPG overexpression was induced and the growth of VSMCs infected with the lentiviral vector was observed. The VSMC calcification and control group were treated with different doses of genistein. The mRNA and protein expression levels of OPG, α-SM-actin (smooth muscle actin), ALP (alkaline phosphatase) and OPN (osteopontin) were detected in VSMCs after treatment using RT-PCR and Western Blot. RESULT: We induced OPG overexpression and performed lentiviral vector infection of the VSMCs to suppress OPG expression, respectively, which was followed by treatment with genistein. The results showed that the relative expression of OPG was the highest in the VSMC calcification +genistein +OPG overexpression-inducing treatment group. It was the lowest in the VSMC calcification +OPG expression-suppressing treatment group. The relative expression of ALP was the highest in the VSMC calcification +OPG expression-suppressing treatment group, and the lowest in the VSMCs+genistein treatment group. CONCLUSION: OPG gene plays an important regulatory role in the growth of VSMCs, by suppressing the calcification of VSMCs. Genistein could regulate the differentiation of VSMCs into osteoblasts via the OPG/RANKL pathway in a dose-dependent manner.

Advanced research on the microRNA mechanism in heart failure.

Heart failure is the end stage of most cardiac diseases and also an important cardiovascular disease. Ventricular remodeling, a complicated pathophysiological process involving multiple molecular pathways, is a crucial mechanism for the occurrence and development of heart failure. A microRNA (miRNA) is a highly conservative noncoding molecule containing 18-25 nucleotides. miRNA is different from other RNAs. It mainly serves as an endogenous gene-regulating factor, and is a member of the complex regulatory network. It induces gene repression of target transcripts by affecting mRNA at the post-transcriptional level Vasudevan et al. (2007) . This study aimed at determining the mechanism of miRNA action in heart failure.

Results of comparing transthoracic device closure and surgical repair with right infra-axillary thoracotomy for perimembranous ventricular septal defects.

OBJECTIVES: Transthoracic device closure (TTDC) and surgical repair with right infra-axillary thoracotomy (SRRIAT) are two main alternative minimally invasive approaches for restrictive perimembranous ventricular septal defect (VSD); however, few studies have compared them with each other in terms of effectiveness and cost. METHODS: Patients with perimembranous VSD undergoing TTDC or SRRIAT from January 2012 to July 2013 were reviewed in a comparative investigation between the two procedures. RESULTS: Success from the procedures was achieved in 30 TTDC (30/33, 91%) and 96 SRRIAT patients (100%). Operation duration in the TTDC group was significantly shorter than that of the SRRIAT group (115.8 ± 43.8 vs 175.6 ± 41.3 min, P < 0.01). The total perioperative drainage, use of red blood cells, mechanical ventilation time, stay in the intensive care unit and hospital stay for the TTDC group were significantly less than those in the SRRIAT group. No deaths or complete atrioventricular block occurred in either group. One SRRIAT patient accepted a second surgery for residual shunt. TTDC costs slightly more than SRRIAT (40270.6 ± 2741.3 renmingbi [RMB] vs 32964.5 ± 8221.6 RMB, P < 0.01). CONCLUSIONS: Both TTDC and SRRIAT showed excellent outcomes and cosmetic appearance for suitable VSD candidates. Although its costs were higher, TTDC had the advantages over SRRIAT of a short operation duration and intensive care unit stay and fewer days in the hospital.

High takeoff of the right coronary artery associated with ventricular septal defect, right aortic arch, and bridging bronchus.

We report a case of a 14-year-old female with abnormally high takeoff of the right coronary artery (RCA) that was associated with a ventricular septal defect, right aortic arch, and bridging bronchus. During surgery, an exceptionally high takeoff of the RCA was discovered. Postoperative computed tomography confirmed the presence of the associated right aortic arch with anomalous branching pattern, and bridging bronchus.

High basal level of autophagy in high-altitude residents attenuates myocardial ischemia-reperfusion injury.

OBJECTIVE: Hypoxia can induce autophagy, which plays an important role in cardioprotection. The present study tested the hypothesis that patients with congenital heart disease living at a high altitude could resist ischemia-reperfusion injury better than those at a low altitude, through elevated basal autophagy by chronic hypoxia. METHODS: Twelve Tibetan patients residing at a high altitude of >3000 m and 12 Han patients residing at a low altitude of <500 m with simple atrial or ventricular septal defects were prospectively recruited. All patients underwent cardiopulmonary bypass, maintaining a flow rate of approximately 2.4 to 2.8 L/min/m2 and mean arterial pressure of ≥40 to 60 mm Hg. Myocardial ischemia-reperfusion injury between the 2 groups was compared using cardiac troponin I, brain natriuretic peptide, hematoxylin eosin staining, and the terminal deoxynucleotidyl transferase dUTP nick end labeling test. Autophagy-related proteins microtubule-associated protein 1 light chain 3 II (LC3II), Beclin1, and lysosomal-associated membrane protein 2 (LAMP2) and their upstream protein BCL2/adenovirus E1B 19-kDa protein-interacting protein 3 (Bnip3) were evaluated with Western blotting. RESULTS: The maximal cardiac troponin I concentration and increasing x-fold of brain natriuretic peptide in the high-altitude group were obviously lower than those in the low-altitude group (3.10±0.77 vs 7.10±2.28 ng/mL and 2.51±0.94 vs 14.66±6.83, respectively). The preoperative and postoperative levels of LC3II, LAMP2, and upstream Bnip3 in the high-altitude group were obviously greater. No difference was found in the Beclin1 level between the 2 groups at baseline or ischemia-reperfusion. CONCLUSIONS: Patients living at a high altitude with congenital heart disease resisted ischemia-reperfusion injury during cardiac surgery better than those at a low altitude, possibly through elevated basal autophagy induced by chronic hypoxia.

Risk factors for acute kidney injury in patients undergoing same admission coronary angiography and valve replacement.

BACKGROUND: We investigated risk factors for acute kidney injury (AKI) in patients undergoing same admission coronary angiography (CAG) and valve replacement. METHODS: Among 283 consecutive patients undergoing valve surgery between October 2010 and July 2012, 71 patients with same admission preoperative CAG were included in the study. Predictors of AKI were identified with a univariable model; then, logistic regression analysis was performed with the variables with p < 0.1 in univariable analysis and other known risk factors of AKI. RESULTS: Twenty-two (31.0%) patients developed AKI. Univariate analysis revealed that diabetes mellitus (p = 0.097), cerebrovascular disease (p = 0.03), atrial fibrillation (p = 0.097), one-stage procedure (p = 0.05), and concomitant tricuspid valvular replacement/repair (p = 0.033) were risk factors. Multivariate logistic regression analysis showed that diabetes mellitus (odds ratio [OR] 10.361, 95% CI 1.345-79.828, p = 0.025) and cerebrovascular disease (OR 26.070, 95% CI 1.695-400.939, p = 0.019) are risk factors for AKI in patients 50 years or older undergoing same admission CAG and valve replacement. One-stage procedure was not associated with a higher incidence of AKI. CONCLUSION: Diabetes mellitus and cerebrovascular disease are risk factors for AKI. Same admission CAG and valve replacement should be performed with caution in this group of patients.

The effect of the time interval between coronary angiography and on-pump cardiac surgery on risk of postoperative acute kidney injury: a meta-analysis.

BACKGROUND: Reports of the association between the time interval from coronary angiography (CAG) to cardiac surgery and risk of postoperative acute kidney injury (AKI) are controversial. We attempted to examine this association by conducting a meta-analysis. METHODS: We searched the Pubmed, MEDLINE, EMBASE, Web of Science databases, and the Cochrane Library from January 1966 to March 2013. A meta-analysis of studies reporting data for 1-day and 3-day time intervals between CAG and cardiac surgery was conducted after evaluation of heterogeneity and publication bias. Study-specific estimates were combined with inverse variance-weighted averages of logarithmic odds ratios (ORs) in fixed-effects models. RESULTS: From 8 studies involving 11542 persons, the pooled OR of AKI associated with an interval of 1 day or less between CAG and surgery was 1.21 (95% confidence interval (CI), 1.04 to 1.39) relative to an interval of more than 1 day. From 4 studies involving 5420 persons in the cardiopulmonary-bypass subgroup, the pooled OR of AKI associated with an interval of 3 days or less between CAG and surgery was 1.25 (95% CI, 1.07 to 1.43) relative to an interval of more than 3 days. The adjusted OR of the study in the cardiopulmonary bypass/ deep hypothermic circulatory arrest subgroup was 0.35 (95% CI, 0.17 to 0.73). CONCLUSIONS: A time interval of 1 day or less between CAG and on-pump cardiac surgery was significantly associated with increased risk of AKI. A delay of on-pump cardiac surgery until 24 hours after CAG can potentially decrease postoperative AKI.

Multiple thrombosis caused by arrhythmogenic right ventricular cardiomyopathy.

A 68-year-old man was transferred emergently to our department because of multichamber intracardiac thrombosis. Enhanced computed tomography revealed multichamber thrombosis in the right atrial appendage, right ventricular outlet tract. and left atrial appendage, with localized aneurysm of a much enlarged right ventricle. He underwent thrombectomy and valve repair. Here we report a rare case of arrhythmogenic right ventricular cardiomyopathy with multichamber intracardiac thrombosis.

An occult congenital fistula between the descending aorta and the left pulmonary vein in an adult presenting with recurrent episodes of hemoptysis.

We report a case of recurrent hemoptysis due to an occult congenital fistula between the descending aorta and the left pulmonary vein in a 25-year-old female patient. The anomaly was confirmed by contrast-enhanced CT scan and angiography. No abnormality was noted in the bronchia and pulmonary arteries. The patient was successfully managed by simple ligation of the fistula. To our knowledge, this is the first reported case of adult-onset hemoptysis caused by an occult congenital fistula between the descending aorta and a pulmonary vein.

Modified repair for huge unruptured aneurysm of the right sinus of valsalva.

Unruptured aneurysm of the sinus of Valsalva is a rare abnormality. In the present case, the huge aneurysm of the sinus of Valsalva was only involved in the right coronary sinus with the ostium far from its normal place. We designed a modified repair technique, with a scalloped Intergard woven vascular patch combined with aortic flap, to reconstruct the sinus of Valsalva and avoid the reimplantation of right coronary artery.

Relation between bone mineral density, bone loss and the risk of cardiovascular disease in a Chinese cohort.

Cardiovascular disease (CVD) and osteoporosis share some common risk factors such as old age, smoking, alcoholic drinking, hypertension, diabetes mellitus, and hyperlipidemia. Although previous studies have investigated the association of bone mineral density (BMD) with CVD, the results were conflicting. There are limited studies on the association of BMD loss rate with CVD. We therefore conducted a 5-year prospective study to examine the relation among BMD, bone loss, and risk of CVD in a Chinese cohort. Of 9,657 community residents 30 to 75 years old, 6,092 were enrolled in the study and followed annually for 5 years. At baseline demographic data, BMD, smoking and drinking statuses, medical history, and blood samples were collected. Cox proportional hazards analysis was used to evaluate the association of BMD and incidence of CVD. Over the 5-year follow-up period, CVD developed in 118 subjects. Baseline BMD, bone loss rate, current smoking, daily alcoholic ingestion, and higher osteoprotegerin and leptin levels were independently associated with increased risk of CVD, whereas higher baseline adiponectin level was associated with decreased risk of CVD in women and men. In conclusion, uncovering the relation linking osteoporosis and CVD is important for understanding the pathogenesis of these 2 common disorders.