Prenatal diagnosis, management, and outcomes of fetuses with tetralogy of Fallot in China after prenatal counseling: a prospective cohort study.

Objective: The study aimed to monitor fetuses with tetralogy of Fallot (TOF) after prenatal counseling and how it influenced the decision of parents to terminate the pregnancy. Methods: Fetuses with isolated TOF diagnosed between January 2019 and December 2021 were prospectively enrolled. The follow-up period extended until termination or 6 months after the operation. Results: Of the 1,026 fetuses diagnosed with cardiac defects, 129 were identified to have isolated TOF and completed the follow-up. A total of 55 (42.6%) fetuses were terminated, with larger maternal age (odds ratio: 0.893, 95% confidence interval: 0.806-0.989, P = 0.031) as the protective factor. The maternal anxiety score, gestational weeks, and pulmonary-to-aortic-diameter ratio lost significance in multivariate analysis. Subjectively, the two most common reasons for terminating the pregnancy were worries about the prognosis (41.8%) and concerns about the possible suffering of the unborn child (18.2%). The prenatal diagnosis was accurate in 73 of the 74 (98.6%) live births. Out of the 64 live births that underwent surgical repair in our center, 57 (89.1%) received primary repair, with a median age of 104 days, and 49 (76.6%) underwent valve-sparing repair. No perioperative death occurred. Conclusions: Termination for fetuses with TOF remains common in China. Live births with TOF can be safely and effectively managed.

Midterm Outcomes of Crosslinked Acellular Bovine Jugular Vein Conduit for Right Ventricular Outflow Tract Reconstruction.

Objectives: Conduits for reconstructing right ventricular outflow tract (RVOT) in children with congenital heart disease have evolved for better durability over the past decades, but conduits failure remains common. We designed decellularized and photooxidatively crosslinked bovine jugular vein conduit (DP-BJVC) and now aim to evaluate the midterm results of DP-BJVC for RVOT reconstruction. Methods: Ninety patients (median age: 4.2 years) undergoing RVOT reconstruction using DP-BJVC were prospectively followed for median of 4.7 years (range: 0.2-16.1 years). Kaplan-Meier analysis was used to examine the survival, freedom from conduit explantation and catheter-based reintervention. Risk factors were analyzed with Cox regression analysis. Results: Follow-up was completed in 92% of patients. There were five (5.6%) early deaths. The 10-year survival rate was 85.2%, with palliative procedure at DP-BJVC implantation as the risk factor. The 10-year freedom from conduit explantation and reintervention were 84.4 and 67.3% respectively, with previous cardiac operation as the only risk factor for explantation. Complications during the follow-up included conduit stenosis (peak gradient ≥50 mmHg) in 12 (12.9%), severe regurgitation in 2 (2.4%), and infective endocarditis in 2 (2.4%). The annual increase in gradient was highest in the first year (P = 0.003), but not appreciably afterwards. The echo-measured annulus diameter trends to increase by an average of 0.37 mm per year. Calcification appeared mild in the failed conduits. Conclusions: DP-BJVC provides satisfactory durability and functionality for RVOT reconstruction for children, with low morbidity of stenosis and endocarditis, as well as increase in diameter mildly with age in midterm follow-ups.

Clinical exome sequencing reveals a mutation in PDHA1 in Leigh syndrome: A case of a Chinese boy with lethal neuropathy.

BACKGROUND: Leigh syndrome, the most common mitochondrial syndrome in pediatrics, has diverse clinical manifestations and is genetically heterogeneous. Pathogenic mutations in more than 75 genes of two genomes (mitochondrial and nuclear) have been identified. PDHA1 encoding the E1 alpha subunit is an X-chromosome gene whose mutations cause pyruvate dehydrogenase complex deficiency. METHODS: Here, we have described a 12-year-old boy with lethal neuropathy who almost died of a sudden loss of breathing and successive cardiac arrest. Extracorporeal membrane oxygenation rescued his life. His diagnosis was corrected from Guillain-Barré syndrome to Leigh syndrome 1 month later by clinical exome sequencing. Furthermore, we used software to predict the protein structure caused by frameshift mutations. We treated the boy with vitamin B1, coenzyme Q10, and a ketogenic diet. RESULTS: A PDHA1 mutation (NM_000284.4:c.1167_1170del) was identified as the underlying cause. The amino acid mutation was p.Ser390LysfsTer33. Moreover, the protein structure prediction results suggested that the protein structure has changed. The parents of the child were negative, so the mutation was de novo. The comprehensive assessment of the mutation was pathogenic. His condition gradually improved after receiving treatment. CONCLUSION: This case suggests that gene detection should be popularized to improve diagnosis accuracy, especially in developing countries such as China.

Materials and surface modification for tissue engineered vascular scaffolds.

Although vascular implantation has been used as an effective treatment for cardiovascular disease for many years, off-the-shelf and regenerable vascular scaffolds are still not available. Tissue engineers have tested various materials and methods of surface modification in the attempt to develop a scaffold that is more suitable for implantation. Extracellular matrix-based natural materials and biodegradable polymers, which are the focus of this review, are considered to be suitable materials for production of tissue-engineered vascular grafts. Various methods of surface modification that have been developed will also be introduced, their impacts will be summarized and assessed, and challenges for further research will briefly be discussed.

Anomalous origin of the right pulmonary artery from the ascending aorta: results of direct implantation surgical repair in 6 infants.

BACKGROUND: Anomalous origin of the right pulmonary artery from the ascending aorta (AORPA) is a rare and potential fatal kind of congenital heart disease. This study summarizes the techniques and outcomes of 6 infants with AORPA who underwent the surgical repair. METHODS: Between November 2012 and November 2014, 6 infants with AORPA received surgical repair in the Second Xiangya Hospital and were included in the present study. RESULTS: Six infants (4 male, 66.7 %) with a median age of 101.5 ± 70.0 days, and a median body weight of 4.13 ± 0.62 kg underwent the surgical repair at our institute. There were no operative, in-hospital or follow-up deaths. Clinical symptoms of all 6 patients relieved at time of discharge, and mean pulmonary artery pressure (MPAP) decreased significantly after surgery. During follow-up, there were no further operations or interventions, mild stenosis at the anastomotic site presented in one patient, and all patients were asymptomatic and in stable clinical condition. CONCLUSIONS: The short and mid-term surgical outcomes of AORPA are excellent in this group of operations. Moreover, we believe the direct implantation to be the optimal surgical strategy for the patients with the proximal form of AORPA.

Calcification resistance for photooxidatively crosslinked acellular bovine jugular vein conduits in right-side heart implantation.

This study aimed to investigate the effect of decellularization plus photooxidative crosslinking and ethanol pretreatment on bioprosthetic tissue calcification. Photooxidatively crosslinked acellular (PCA) bovine jugular vein conduits (BJVCs) and their photooxidized controls (n = 5 each) were sterilized in a graded concentration of ethanol solutions for 4 h, and used to reconstruct dog right ventricular outflow tracts. At 1-year implantation, echocardiography showed similar hemodynamic performance, but obvious calcification for the photooxidized BJVC walls. Further histological examination showed intense calcium deposition colocalized with slightly degraded elastic fibers in the photooxidized BJVC walls, with sparsely distributed punctate calcification in the valves and other areas of walls. But PCA BJVCs had apparent degradation of elastic fibers in the walls, with only sparsely distributed punctate calcification in the walls and valves. Content assay demonstrated comparable calcium content for the two groups at preimplantation, whereas less calcium for the PCA group in the walls and similar calcium in the valvular leaflets compared with the photooxidized group at 1-year retrieval. Elastin content assay presented the conduit walls of PCA group had less elastin content at preimplantation, but similar content at 1-year retrieval compared with the photooxidized group. Phospholipid analysis showed phospholipid extraction by ethanol for the PCA group was more efficacious than the photooxidized group. These results indicate that PCA BJVCs resist calcification in right-side heart implantation owing to decellularization, further photooxidative crosslinking, and subsequent phospholipid extraction by ethanol at preimplantation.

The performance of photooxidatively crosslinked acellular bovine jugular vein conduits in the reconstruction of connections between pulmonary arteries and right ventricles.

In this study, valved photooxidatively crosslinked acellular bovine jugular vein conduits (BJVCs) were implanted in young dogs to reconstruct the connections of pulmonary arteries and right ventricles, with acellular conduits used as controls. All acellular conduits had moderate to severe valvular dysfunction and were explanted at 1-month implantation (n = 5). Histological examination showed inflammatory cell infiltration and intimal hyperplasia in the walls, and severe inflammatory cell infiltration and thrombosis in the valves. The photooxidatively crosslinked acellular conduits were retrieved at 1-month (n = 5) and 6-month (n = 5) implantations respectively. These conduits had excellent valvular function at retrieval. Their walls and valves were still soft and smooth without calcification and hemangioma. Endothelialization in valves and luminal walls was unsatisfied at 1-month retrieval, and was improved at 6-month retrieval. Host cells infiltrated and migrated from outer layer to the middle layer, with tissue remolding and regeneration found in these recellular regions. Histological examination and tissue content assay demonstrated that degeneration and regeneration of collagens and glycosaminoglycans were comparable, but elastic fibers gradually degraded. Photooxidatively crosslinked acellular BJVCs resist calcification and thrombosis and have regeneration patterns, with excellent hemodynamic performance.

Detection of nanobacteria-like material from calcified cardiac valves with rheumatic heart disease.

BACKGROUND: Nanobacterium contributes to pathological calcification in human renal stones and psammoma bodies in ovarian cancer. Pathological calcification is also present in cardiac valves with rheumatic heart disease. The aim of this study was to detect, isolate, culture, and characterize nanobacteria-like material from human calcified cardiac valves with rheumatic heart disease. METHODS: Normal and calcified cardiac valve groups, as well as positive (nanobacteria strain Se90) and negative (serum radiated with 30 kGy of γ-ray) control groups, were included in this study. Part of each valve was immunostained with nanobacterial antibody 8D10, and the remaining parts were homogenized, filtered, and maintained in culture. The cultures were checked with a microscope weekly. Culture medium at different time points was analyzed with a spectrophotometer. The cultures maintained for 3 weeks were further examined with immunofluorescence double staining and transmission electron microscopy. RESULTS: While 26 of 29 calcified valves stained positive for 8D10 antibody, all normal valves stained negative. Mobile tiny particles were observed under a microscope in the calcified valve group and the Se90 group. Optical densities were significantly different among groups (P<.001). Immunofluorescence double staining displayed tiny green fluorescence particles in the calcified valve group, in the Se90 group, and in two samples of the normal valve group. Transmission electron microscopy analysis indicated that cultured particles from calcified valves ranging in size from 88 to 341 nm had an obvious cell membrane structure similar to that of Se90. CONCLUSIONS: The nanobacteria-like material has been isolated and cultured from calcified cardiac valves with rheumatic heart disease, and its characteristics are similar to those of Se90.

[Correlation of serum levels of VEGF and SDF-1 with the number and function of circulating EPCs in children with cyanotic congenital heart disease].

OBJECTIVE: To examine the number and function of circulating endothelial progenitor cells (EPCs) in children with cyanotic congenital heart diseases (CHD) and study their correlation with serum levels of vascular endothelial growth factor (VEGF) and stromal cell derived factor-1 (SDF-1). METHODS: Fifteen children with tetralogy of Fallot (cyanotic group) and 15 age-and sex-matched children with ventricular septal defect (control group) were enrolled. Serum levels of VEGF and SDF-1 were measured using ELISA. Mononuclear cells were isolated from peripheral blood by Ficoll density gradient centrifugation and cultured in vitro. EPCs were identified by immunofluorescence and were counted under a microscope. Modified Boyden chamber assay and the MTT assay were used to measure the migration and proliferation capacities of EPCs. EPCs adhesion ability assay was performed by replating cells on fibronectin-coated dishes, and then adherent cells were counted. The correlations of serum levels of VEGF and SDF-1 with the number and function of circulating EPCs were assessed by linear regression analysis. RESULTS: Serum levels of VEGF (201.42+/-44.74 ng/L vs 113.56+/-35.62 ng/L; P<0.05) and SDF-1 (3.45+/-1.07 ng/L vs 1.05+/-0.99 ng/L; P<0.05) in the cyanotic group were higher than those in the control group. There was a positive correlation between serum levels of VEGF and SDF-1(r=0.675, P<0.01). The number of EPCs (*200 field) in the cyanotic group significantly increased compared with that of the control group (72.2+/-9.73 vs 51.2+/-3.83; P<0.01). The functional activities of EPCs, including proliferation, migration and adhesion capacities, were augmented in the cyanotic group compared with those in the control group. The increased number and function of EPCs and the increased serum levels of VEGF and SDF-1 were consistent in the cyanotic group, with a correlation coefficient of 0.8395, 0.5491, 0.6376 and 0.7392 respectively. CONCLUSIONS: The number and functional activity of EPCs as well as serum levels of VEGF and SDF-1 increased in children with cyanotic CHD. Serum levels of VEGF and SDF-1 were correlated to the number and functional activity of EPCs. Serum VEGF and SDF-1 together with circulating EPCs may play important roles in the pathology and physiology in these patients.

Decellularized and photooxidatively crosslinked bovine jugular veins as potential tissue engineering scaffolds.

Decellularization means and altering crosslinking approaches were two promising alternatives for glutaraldehyde fixation to biological tissues. Bovine jugular veins (BJVs) were decellularized by a multi-step detergent-enzymatic extraction method, then photooxidatively crosslinked. Gross and histological integrity of which was retained. Ultrastructures showed integrity of collagen fibrils and elastic fibers, and a basement membrane free luminal surface. Mechanical strength test and tissue protein extraction assay demonstrated their tissue stability. After being pre-coated with gelatin, collagen IV and fibronectin, cultured human umbilical vein endothelial cells were planted in the luminal surface of decellularized plus photooxidized BJV patches for seven days. Endothelial cells were denser in pre-coated patches than in uncoated controls. A rat subcutaneous implantation model revealed more resistance against in vivo degradation for further crosslinked BJV patches than decellularized patches at 12-week retrieval. Host cells were all layer repopulated for both. Histological examination and content assay demonstrated collagen and glycosaminoglycan components synthesis for decellularized plus photooxidized BJV patches. Decellularized and photooxidatively crosslinked BJV patches possess tissue integrity, excellent in vitro and in vivo tissue stability and repopulation patterns. Thus, they have potentials as tissue engineering scaffolds in future cardiovascular surgery.

One-stage correction of aortic coarctation and severe mitral regurgitation via left posteriolateral thoracotomy in a 2-year-old child.

We successfully treated a case of a 2-year-old male with aortic coarctation coexisting with severe mitral regurgitation via left posteriolateral thoracotomy at one stage. After a mitral valve replacement under perfused ventricular fibrillation with moderate hypothermia, we repaired the aortic coarctation with coarctation resection and end-to-end anastamosis with the aid of deep hypothermic circulatory arrest and selective low-flow cerebral perfusion. The patient had an uneventful hospital course and remains well.

[Histomorphologic properties of bovine jugular vein conduit treated withdye-mediated photooxidation following decellularization].

OBJECTIVE: To determine the histocompatibility and histoconstancy of bovine jugular vein conduit (BJVC) treated by dye-mediated photooxidation following decellularization before and after implantation in Wistar rats. METHODS: Each of 20 fresh bovine jugular veins with a retained native valve procured from a slaughterhouse was cut into 4 trial patches with valves, which were randomly divided into 4 groups. The 4 groups were treated respectively by dye-mediated photooxidation(DMP), glutaraldehyde(GA), decellularization(DC), and dye-mediated photooxidation following decellularization (DC+DMP). One of the trial patches in each group was implanted subcutaneously in the same Wistar rat. Two months later, all trial rats were killed and the specimens were retrieved. Tissue protein extraction was used to estimate the cross-linked degree of BJVC treated by dye-mediated photooxidation following decellularization. To observe the morphologic properties of the specimens, HE staining and electron microscopes were used. RESULTS: Compared with others, the patches in the DC+DMP group were flexible, stretched, and relatively intact; lining endothelium was comparatively smooth; collagen fiber structure was slightly loose intact; and many cells were uniformly infiltrated in all layers. CONCLUSION: BJVC treated by dye-mediated photooxidation following decellularization is superior to others in histocompatibility, and the rate of degradation can be regulated by the degree of dye-mediated photooxidation.

[Early surgical treatment for infants with large atrial septal defects or ventricular septal defects complicated by pneumonia: experience of 39 cases].

OBJECTIVE: This research reported the experience of early surgical treatment for infants with large atrial septal defects (ASD) or ventricular septal defects (VSD) complicated by pneumonia. METHODS: Between January 2003 and January 2008, 39 infants with large ASD or VSD complicated by pneumonia were admitted to the Second Xiangya Hospital. Thirty-six patients underwent surgical repair within 7-10 days after pneumonia had been controlled. Mean age was 5.4+/-3.4 months and mean weight was 4.7+/-1.6 kg in the 36 patients. Three patients received conservative treatment due to uncontrolled lung infections. RESULTS: Of the 36 patients, 33 had successful surgery and 3 (8.3%) died of serious low cardiac output (n=1) or respiratory failure due to congenital tracheostenosis (n=2). The 33 survivors showed normal growth and development in a 6 month-5 year follow-up. Of the 3 patients receiving conservative treatment, 1 died of cardiopulmonary failure and 2 were discharged after the symptoms had been improved. CONCLUSIONS: With increasing medical experience and technique, early surgical operation may be performed with good outcomes in infants with large ASD or VSD complicated by pneumonia.

[Effect of decellular treatment on the framework of extracellular matrix in bovine jugular vein conduit].

OBJECTIVE: To investigate the effect of decellular treatment on the framework constituents of extracellular matrix and tissue stability in bovine jugular vein conduit (BJVC), and to provide an evidence for tissue engineering of vascular prosthesis. METHODS: Bovine jugular veins were obtained fresh from a local slaughterhouse and were stored in chilled PBS. In the laboratory, any fat and loose connective tissue on the outer surface of the vessel was trimmed. BJVCs were decellularized by a 3-step extraction method as detergent Triton X-100 (0.5%), Trypsin (0.025%) EDTA (0.02%), and DNase I(30kU/L) RNaseA(0.3g/L). Histological and transmission electron microscopy (TEM) techniques were used to study the framework constituents of extracellular matrix of treated the examples, and fresh tissues were used as controls. Tissue contents of hydroxyproline(alkaline hydrolysis method) and elastin (Fastin Elastin Assay) were assayed respectively in the fresh and decellularized groups (n=10). The vascular wall heat shrinking temperature and mechanical strength were measured to evaluate the tissue stability (n=10). RESULTS: Histochemical and TEM analysis of BJVCs treated with decellularization proved a complete removal of nuclear and other cell components. Tissue collagen was well kept,but elastin was partly lessened. Tissue content of hydroxyproline increased comparatively [(25.73+/-2.97)mg/g vs. (29.25+/-2.99)mg/g, P<0.05] and the elastin content obviously decreased [(159.71+/-21.06)mg/g vs. (134.91+/-35.40)mg/g, P<0.05] in the decellular treatment group compared with the control group. The heat shrinking temperature and tensile stress of decelluarized tissue were lower than those of the fresh tissue[(72.50+/-0.53) degrees C vs. (69.75+/-0.54)degrees C ,P<0.05], [(5.19+/-0.65)MPa vs. (3.13+/-0.94)MPa, P<0.05]. CONCLUSION: The basic framework of extracellular matrix in the decellularized BJVC is partly damaged and tissue stability is reduced. Decellularized BJVC should be further crosslinked before being used as a tissue engineering scaffold for clinical pulmonary artery graft.

Surgical treatment of total anomalous pulmonary venous connection.

OBJECTIVE: To summarize the surgical treatment of total anomalous pulmonary venous connection (TAPVC). METHODS: We retrospectively analyzed 49 patients with TAPVC as follows: 37 patients with supra-cardiac type in which 35 received anastomoses between the rear wall of the left atrium and the common pulmonary vein and the other 2 received anastomoses between the rear edge of the left atrium roof and the common pulmonary vein; another 12 patients with cardiac type who were incised the upper edge of coronary sinus, connected the common junction of pulmonary veins with the left atrium to form a new left atrium, and repaired the atrial septal defect with a pericardial patch. RESULTS: Forty-six patients recovered and 3 patients died. Thirty-eight patients were followed-up from 3 months to 8 years. The rest patients got fluent pulmonary vein drainage and their heart function resumed to NYHA I. CONCLUSION: TAPVC patients should be operated on immediately at definite diagnosis. The fluency of the common pulmonary vein-left atrium anastomoses and proper postoperative care can ensure a satisfactory outcome.

[Structural and hemodynamic study of right ventricular outflow tract reconstruction with valved bovine jugular vein conduit in the canine model by color Doppler echocardiography].

OBJECTIVE: To observe the structural and hemodynamic changes after the reconstruction of right ventricular outflow tract (RVOT) with valved bovine jugular vein conduit (BJVC) in the canine model by color Doppler echocardiography (UCG). METHODS: BJVC was used in the reconstruction of RVOT of 32 canines. UCG was used to observe the structure of the right ventricle and RVOT. The structure and hemodynamics were observed, and the diameter, width, blood velocity and pressure gradient (PG) were measured between the right ventricle and the conduits. RESULTS: In the first stage, UCG showed that PG between the right ventricle and BJVC was high in 5 canines, and a few anastomosis in BJVCs with main pulmonary artery was small. Blood velocity quickened and PG increased, and color Doppler showed that the bloodstream was very bright. In the second stage, 7 canines survived for 1 year after the implantation. One year after the operation, UCG showed that the valve closed well, no graft kinking or obvious regurgitation of the valve was observed. The PG of the valve was low. The BJVCs were unobstructed and there was no thrombus.All the valves of BJVC opened well except one. In the third stage, 20 canines survived for 1 year after the implantation. UCG showed that the valve motion was good, no graft kinking or obvious regurgitation of the valve was observed. No neoplasm was observed. CONCLUSION: UCG is one of the most useful measurements in the structural and hemodynamic study of RVOT reconstruction by BJVC in the canine model. The good evaluation of UCG implies that it is important for the study and clinical practice.

Superior vena cava reconstruction using bovine jugular vein conduit.

The glutaraldehyde-treated bovine jugular vein conduit (BJVC) is a xenograft conduit initially used for right ventricular outflow tract reconstruction and has never been used for reconstruction of superior vena cava (SVC). In September 2003, a patient with SVC obstruction underwent SVC reconstruction using BJVC. He has been alive for 42 months and free from signs and symptoms of SVC obstruction except that metastasis was found in the vertebrae. The radionuclide venography showed the graft tube was patent and only slight stenosis was found in the proximal anastomosis. The initial result supports BJVC as an acceptable alternative for SVC reconstruction.

[Bovine jugular venous conduit treated with the polyepoxy compound].

OBJECTIVE: To determine the feasibility whether the bovine jugular venous conduit (BJVC) can be fixed with polyepoxy compound (PC). METHODS: Twenty-four BJVCs were divided into 3 groups and fixed with polyepoxy compound (PC group, n = 8), glutaraldehyde (GA group, n = 8), and unfixed group (Control group, n = 8), respectively. The morphologic and mechanical properties of BJVCs in the 3 groups, including thickness, diameter, moisture content, denaturation temperature, tensile strength, elongation at break, and fixation index were measured. The rat subcutaneous model for the assessment of tissue calcification was used. The calcium content in bovine jugular vein patches and valves was determined by flame atomic absorption spectrophotometer. RESULTS: There was no difference in the wall thickness, diameter, and tissue water content between PC and the control group, but significant difference was found between GA and PC groups. The mechanical properties of PC group and GA group were not significantly different, but they were better than those of the control group. GA-fixed BJVC samples showed clear calcification, while PC fixed BJVC were calcified significantly less. CONCLUSION: PC is an effective and suitable choice for the treatment of BJVC since it can effectively preserve the structure and the anti-reflow function of valves in bovine jugular vein and it has better anti-calcification properties.

[Clinical application of video-assisted thoracoscopic surgery].

OBJECTIVE: To explore the clinical application of video-assisted thoracoscopic surgery (VATS). METHODS: We retrospectively analyzed the clinical data of 672 cases of VATS. There were 17 thoracic diseases such as emphysema, bullectomy for spontaneous pneumothorax, massive bullae, benign tumor of mediastinum, cyst of mediastinum, pulmonary benign tumors, hydropericardium, malignant pleural fluid, etc. RESULTS: The mean operation time was 57 minutes and there were no intraoperative complications. The bleeding during the operation was less than 100 mL. Postoperative pneumothorax occurred in 4 patients and among them 2 patients were of relapse after 1 month. The intrathoracic drain in most patients was removed with an average of 2. 5 days. A supplementary incision was needed in 10 cases: Six were due to the adhesion of full pleural cavity and 4 were found with the malignant tumor during the operation. CONCLUSION: VATS is an alternative approach that provides a safe, less invasive, and effective operation for treating spontaneous pneumothorax, benign tumor of mediastinum, cyst of mediastinum, pulmonary benign tumors, pericardial perfusion, and acute chest trauma patients.