Intracardiac thrombosis after congenital heart disease surgeries in neonates: a report of two cases.

BACKGROUND: Intracardiac thrombosis (ICT) is a rare complication after the cardiopulmonary surgery for interrupted aortic arch (IAA) or total anomalous pulmonary venous connection (TAPVC) without previous records. There are still no general guidelines regarding as the mechanism or management of postoperative ICT in neonates and younger infants. CASE PRESENTATION: We reported the conservative and surgical therapies in two neonates with intra-ventricular and intra-atrial thrombosis after the anatomical repair for IAA and TAPVC, respectively. There were no risk factors for ICT in both patients, except for the use of blood product and prothrombin complex concentrate. The surgery was indicated after TAPVC correction due to the worsening respiratory status and rapidly decreased mixed venous saturation. Anticoagulation combined with antiplatelet therapies was adopted in another patient. These two were both finally recovered, and three-month, six-month, and one-year follow-up echocardiography revealed no abnormality. CONCLUSIONS: ICT is uncommon in pediatric population after the surgery for congenital heart disease. Single ventricle palliation, heart transplantation, longer central line use, post-extracorporeal membrane oxygenation, and massive blood product use are major risk factors for postcardiotomy thrombosis. The causes of postoperative ICT are multifactorial, and the immaturity of thrombolytic and fibrinolytic system in neonates may serve as a prothrombotic factor. However, no consensus reached regarding as the therapies for postoperative ICT, and the large-scale prospective cohort study or randomized clinical trial is needed.

Non-obstructed supracardiac total anomalous pulmonary venous connection with giant superior vena cava aneurysm.

BACKGROUND: Giant superior vena cava (SVC) aneurysm in non-obstructed supracardiac total anomalous pulmonary venous connection (TAPVC) is even more rare than in obstructed one, and this combination has not been reported. CASE PRESENTATION: Here we reported a 29-year-old young lady with non-obstructed TAPVC complicated with a giant SVC aneurysm. Routine TAPVC correction and tricuspid valve repair were done. Additionally, venoctomy was carried out to seek for its histological etiology and to avoid potential complications. CONCLUSIONS: If confirmed by further and larger experiences, for patients with non-obstructed supracardiac TAPVC with giant SVC aneurysm, surgical treatment of SVC aneurysm could be more aggressive to prevent cardiovascular complications.

Percutaneous-perventricular device closure of ventricular septal defect: mid-term follow-up.

BACKGROUND: This report presents updated data and mid-term follow-up information to a former study introducing the novel technique of percutaneous-perventricular device closure of doubly committed subarterial ventricular septal defect. METHODS: Thirty-eight patients were added to the former series. There were 54 patients in total who had isolated doubly committed subarterial ventricular septal defects and underwent percutaneous-perventricular device closure. Closure outcomes and possible complications were measured in the hospital and during the 2.5-year follow-up. RESULTS: Surgery was successful in 53 patients (98.1%). There was no death, residual shunt, new valve regurgitation or arrhythmia either perioperatively or during the entire follow-up period. Only one patient developed pericardial effusion and tamponade in the former series. The mean hospital stay was 3.2 ± 0.6 days (range, 3.0 to 6.0 days), and only one unsuccessful case needed blood transfusion (1.9%). CONCLUSIONS: The percutaneous-perventricular device closure of isolated doubly committed subarterial ventricular septal defects appeared to be safe. Close monitoring for bleeding is essential postoperatively, especially in younger patients. This technique is generally safe with acceptable mid-term follow-up.

Management of a giant aortic root aneurysm in a young patient with Marfan syndrome: a case report.

INTRODUCTION: Marfan syndrome (MFS) is a common heritable connective tissue disease involving multiple organs. Even though the clinical manifestations of MFS can be various, aortic root aneurysm is estimated as one of the most serious complications. We herein describe an individualized treatment decision-making process for a 23-year-old male with MFS, suffering from a giant but stable aortic root aneurysm which is extremely rare at his age. CASE: The patient, a 23-year-old male with a family history of MFS, presented to our cardiovascular department because of progressive exertional chest distress, fatigue and occasional precordial pain. Physical examinations revealed 190.5 cm of height, high myopia, and a diastolic murmur at the aortic valve area. Laboratory examinations for systemic vasculitis and infectious diseases were negative. Transthoracic echocardiography and enhanced thoracic computed tomography (CT) scan revealed the existence of a giant aortic root aneurysm (125.1 mm in short-axis), severe aortic valve regurgitation, cardiac dilatation (LV; 99 mm in diastolic diameter) and a poor ejection fraction (EF; 18%). Considering the risk of rupture or dissection of the dilated aortic root, we performed Bentall procedure based on the results of multidisciplinary team discussion and intraoperative exploration. Postoperative thoracic CT scan revealed a normal sized reconstructed aortic root, and the patient was discharged uneventfully 7 days later. CONCLUSION: It is extremely rare to report such a giant aortic root aneurysm in a young patient. In the treatment decision-making process, the patient's specific situation should be taken into consideration. A mechanical Bentall procedure seems to be an acceptable option for some selected cases.

Giant right atrial aneurysm with atrial fibrillation.

Congenital right atrial aneurysm is a rare condition. Here we reported a 16-year-old male with giant right atrial aneurysm, atrial fibrillation, and atrial septal defect. Surgical resection of extensive right atrium, ASD repair, and maze procedure were performed. In the present case, we found extensive enlargement of right atrium protruding to the apex on the surface of the right ventricle. With the exist of atrial fibrillation, thrombus formation was always a lethal threat. Surgical treatment can provide excellent clinical results and further avoided life-threatening complications.

Fistula occlusion and ligation for a giant right coronary artery aneurysm concurrent with right atrial fistula: a case report.

BACKGROUND: Coronary artery aneurysms in most cases require surgical treatment once diagnosed. Lifelong anticoagulation is often needed after surgery. We herein describe a 55-year-old man who was asymptomatic and diagnosed with right giant coronary artery aneurysm combined with right atrial fistula. CASE PRESENTATION: This is a case of asymptomatic giant right coronary artery aneurysm concurrent with coronary artery fistula. Because the aneurysm was in the distal right posterior descending coronary artery, right coronary artery ligation and fistula occlusion through the right atrium were performed in the absence of cardiopulmonary bypass. The aneurysm was excluded without impacting the myocardial blood supply, and the patient was exempted from lifelong anticoagulation regimen. The follow-up revealed favorable outcomes and the patient's life expectancy was improved. CONCLUSION: Decompression and exclusion without cardiopulmonary bypass can be adopted for distal coronary artery aneurysms that do not involve or only have a limited impact on distal blood supply. This procedure can exempt the patient from the lifelong anticoagulation regimen. In addition, the risk for myocardial ischemia caused by the thrombus in the aneurysm can also be avoided. The whole procedure is comparatively easy to perform.

Physical Predictors of Cognitive Function in Individuals With Hypertension: Evidence from the CHARLS Basline Survey.

The purpose of the study was to examine the independent associations of each individual physical performance measure (i.e., grip strength, walking speed, repeated chair stands, and balance test) with subdomains of cognitive function and to determine predictors for each subdomain of cognitive function. A secondary data analysis was performed using a nationally representative middle-aged and older sample of hypertensive population. The findings showed that after adding all four physical performance measures, stronger grip strength was significantly associated with better visuospatial abilities, episodic memory, orientation/attention, and overall cognitive function. In addition, faster walking speed and faster repeated chair stands were strongly associated with better episodic memory and overall cognitive function, respectively. Because grip strength was significantly associated with several subdomains of cognitive functioning, it seems conceivable that increasing physical activity would improve both grip strength and cognitive function in patients with hypertension.

Percutaneous left ventricular transapical access guided by cardiac 3D CT angiography combined with echocardiography / 中国胸心血管外科临床杂志

@#Objective    To investigate the reliability and safety of the technique of percutaneous left ventricular transapical access guided by cardiac three dimensional CT angiography (3D-CTA) combined with echocardiography applied in structural heart defects. Methods    The clinical data of 9 patients (7 males and 2 females with a median age of 50 years ranging from 43 to 64 years) with paravalvular leaks closed by percutaneous left ventricular transapical access in West China Hospital, from April 2015 to August 2018, were retrospectively analyzed. We applied preoperative cardiac 3D-CTA to define the puncture site and trace, which was established by combining with real-time guidance of transesophageal echocardiography (TEE/3D-TEE), and an occluder was deployed at the apical access point for hemostasis with real-time guidance of transthoracic echocardiography (TTE). Results    The puncture needles were successfully introduced into the left ventricular cavity at one time in all patients without injury of lung tissue, coronary artery or papillary muscle. There was no occluder displacement or apex bleeding. One patient developed pleural effusion caused by intercostal artery injury. Conclusion    That cardiac 3D-CTA is used to define puncture sites and trace with advantages of simplicity and repeatability. A safe access and secure exit of left ventricle can be achieved by combining with real-time guidance of echocardiography. There are acceptable technology-related complications.

[The Establishment of Tunica Media-induced Systemic Inflammatory Responses Animal Model].

OBJECTIVE: To establish animal model of tunica media-induced systemic inflammatory responses and verify the stability of established model. METHODS: Tunica media of aorta was captured from C57/BL6 mouse donor, followed by the intervention of homogenization. After centrifugation, the supernatant was harvested and injected into the acceptor of C57/BL6 mouse to mimic the featured pathological changes induced by the exposure of tunica media with circulation. ELISA assay was used to detect the levels of tumor necrosis factor-α (TNF-α) and interleukin-6 (IL-6). RESULTS: The levels of TNF-α, IL-6 in the model group were significant higher than those in the control group (P<0.05). There were two peak values of both TNF-α and IL-6 identified at 3 h and 24 h after the injection of supernatant in the model group. CONCLUSION: The exposure of tunica media to circulation may induce systemic inflammatory responses.

Percutaneous Perventricular Device Closure of Ventricular Septal Defect: From Incision to Pinhole.

BACKGROUND: As an alternative to open surgical repair, perventricular device closure provides minimally invasive treatment for doubly committed subarterial ventricular septal defects. However, unlike percutaneous transcatheter access, mini-thoracotomy is still needed. This report describes the percutaneous perventricular device closure technique and its short-term results for this type of heart defect. METHODS: Sixteen patients who had isolated doubly committed subarterial ventricular septal defects underwent percutaneous perventricular device closure. By puncture of the chest wall and subsequently the infundibulum of the right ventricle under continuous guidance of transesophageal echocardiography, the guidewire and the delivery sheath were advanced into the heart to complete the perventricular closure. Closure outcomes and possible complications were measured in the hospital and during 1-year follow-up. RESULTS: Closure was successful in 15 patients (93.8%). No deaths, residual shunting, new valve regurgitation, or arrhythmias occurred either perioperatively or during the entire follow-up period. One patient had pericardial effusion and tamponade, and the procedure was converted to mini-thoracotomy perventricular closure. The mean hospital stay was 3.5 ± 2.0 days (range, 3.0 to 6.0 days), and only 1 patient required a blood transfusion (6.3%). CONCLUSIONS: Percutaneous perventricular device closure of isolated doubly committed subarterial ventricular septal defects appeared to be safe and efficacious, with acceptable short-term outcomes. Larger studies and long-term follow-up are needed for further evaluation.

Modified Warden procedure for partial anomalous pulmonary venous return to the superior vena cava.

BACKGROUND: We report the long-term outcomes of our modified Warden cavoatrial technique, originally reported in 2010, for the treatment of anomalous pulmonary veins, which insert into the superior vena cava (SVC). METHODS: This study was conducted between 2007 and 2015 in 26 patients (18 females, eight males) with a mean age of 22 years (range, 4-70 years). Twenty-four patients had a sinus venosus atrial septal defect and one patient had two partial anomalous pulmonary venous connections to the SVC. Two patients with persistent left SVC underwent right SVC division without reimplantation. RESULTS: There were no short- or long-term mortalities. The mean follow-up was 4.6 years (range, three months to eight years). All patients had unobstructed caval and pulmonary venous flow and no long-term arrhythmias. CONCLUSIONS: The modified cavoatrial anastomosis technique has shown excellent results with unobstructed pulmonary and systemic venous flow without long-term arrhythmias.

[The Association Between Bone Morphogenic Protein-4 and in-situ Saphenous Vein Graft Pathology in Diabetic Patients Undergoing Coronary Revascularization].

OBJECTIVES: This study was designed to assess the expression levels of bone morphogenic protein-4 (BMP4) in saphenous veins harvested from diabetic patients undergoing coronary artery bypass grafting (CABG), and to investigate its association with in-situ morphological and pathological changes within the venous wall. METHODS: From January 2013 to December 2014, forty patients with type 2 diabetes mellitus (DM) and risk factors matched non-DM controls (n =40) were enrolled prospectively. Of the 40 DM patients, 24 had noninsulin-dependent diabetes (NIDM) and the remaining 16 had insulin-dependent diabetes (IDM). Segments of saphenous vein without surgical dilatation from these 80 patients were obtained. Vessel wall characteristics were evaluated by hematoxylin-eosin (HE) staining, and the expression and distribution of BMP4 was assessed by Western blot assay and immunohistochemistry analysis. RESULTS: The intimal and medial thickness of the saphenous veins harvested from DM patients were higher than those from non-DM controls. Compared with non-DM patients, the expression level of BMP4 was significantly elevated in diabetic veins ( P<0.05), and BMP4 was highly expressed in smooth muscle cells located in the medial layer. Moreover, the expression levels of BMP4 in diabetic veins were significantly correlated with intimal thickness (r =0.655, P<0.01), intimal area (r =0.684, P<0.01), medial thickness (r =0.642, P<0.01) and medial area (r =0.692, P<0.01). CONCLUSIONS: The pre-existing intimal and medial hyperplasia were significantly correlated with the high expression levels of BMP4 in saphenous veins harvested from diabetic patients, implying a potential role of BMP4 in the progression of vein graft stenotic diseases in this cohort of post-CABG patients. Future studies were warranted in investigating novel therapeutic strategy targeting at BMP4 for improving long-term vein graft patency.

One-Stage Hybrid Procedure to Treat Aortic Coarctation Complicated by Intracardiac Anomalies in Two Adults.

The traditional approach for treating aortic coarctation with intracardiac anomalies in adults is surgery using 2 surgical incisions or a two-stage hybrid method with a peripheral artery pathway that requires intervention. This paper reports a one-stage hybrid procedure to treat this type of congenital heart disease using 1 surgical incision combined with an ascending aorta puncture intervention approach as transaortic intervention approach. Here, we present 2 aortic coarctation cases; 1 complicated by ventricular septal defect and patent ductus arteriosus, and another complicated by an incomplete atrioventricular septal defect and mitral valve cleft. Both were successfully treated by our one-stage hybrid approach.

Relationship between the extent of dissection and platelet activation in acute aortic dissection.

BACKGROUND: The extent of acute aortic dissection (AAD) was correlated with inflammation positively. On the other side, inflammation was negatively correlated with mean platelet volume (MPV), which can reflect platelet (PLT) activation. The aim of this study was to clarify the relationship between the extent of dissection and PLT activation. METHODS: Between February 2010 and October 2013, 147 patients with acute aortic dissection (AAD) were divided into Group 1 (Stanford A, n = 59) and Group 2 (Stanford B, n = 88). Platelet count, MPV and platelet size distribution width (PDW) were measured to assess PLT activation. Additionally, the severity of inflammation was assessed via serum C-reactive protein (CRP), white blood cell (WBC) count and the neutrophil percent (Neut%). Computerized tomography (CT) was employed to analyze the extent of AAD. Volume tear index (VTI) was calculated as the false lumen (FL) volume divided by body surface area (BSA). RESULTS: PLT count was significantly lower in group 1 than in group 2 (137.24 ± 31.04 × 10(9)/L vs 171.43 ± 27.57 × 10(9)/L, P < 0.001). The MPV/PLT ratio and PDW were significantly higher in the group 1 respectively(0.08 ± 0.02 vs 0.06 ± 0.02, P < 0.001; 22.65 ± 1.87 fl vs 20.69 ± 1.97 fl, P < 0.001). The CRP was significantly higher in group 1 than in group 2 (36.40 ± 8.89 mg/L vs 28.97 ± 8.48 mg/L, P < 0.001). VTI was significantly higher in group 1 than in group 2 (250.12 ± 27.82 vs 198.79 ± 24.52, P < 0.001). There was a significant negative correlation between VTI and PLT count (r = -0.673, P < 0.001), CRP and PLT count (r = -0.640, P < 0.001), respectively. There was a significant positive correlation between VTI and CRP (r = 0.670, P < 0.001), VTI and PDW (r = 0.601, P < 0.001), respectively. CONCLUSIONS: PLT activation and inflammation in AAD appear to be closely correlated with the extent of dissection, which possibly induced by the tear of aortic wall. Elimination of the false lumen is the goal of traditional surgery. Suppression of the PLT activation might be future targets of therapy in the prevention of systemic inflammation in AAD patients.

A Novel Hybrid Approach for Balloon Dilation of Pulmonary Vein Stenosis Following Total Anomalous Pulmonary Venous Connection Repair with Atrial Septal Patching.

Pulmonary venous obstruction after the repair of total anomalous pulmonary venous connection is a serious complication. Transcatheter interventional treatment is a palliative choice to defer the timing of surgery; however, penetrating through the patched atrial septum may be difficult. We report a technique for pulmonary venous obstruction after mixed-type total anomalous pulmonary venous connection repair using balloon dilatation of the pulmonary veins through a novel hybrid approach.

A simple technique for preparation of artificial chordal loops with a strip of paper.

Artificial chordal replacement with polytetrafluoroethylene suture lines is a well-accepted technique for mitral valve repair. This report presents a method of making chordal loops of the desired length using a strip of paper. This technique uses a simple, cost-free, and easily obtained material--a strip of paper--to prepare artificial chordal loops with its advantages.