Preservation of Autologous Brachiocephalic Vessels with Assistance of Three-Dimensional Printing Based on Convolutional Neural Networks.

Background: Preservation of autologous brachiocephalic vessels in Stanford type A aortic dissection has good short-time outcomes. However, getting access to the details is not easy by conventional examination methods. This study is aimed at reconstructing the aortic arch model by three-dimensional (3D) printing based on convolutional neural networks (CNN) to understand the details for performing surgery. Methods: Three patients with type A aortic dissection from October 2017 to June 2018 were indicated for simplified Sun's procedure. Convolutional neural network (CNN) is used as a deep learning model, and the model was preset by transfer learning. The genetic algorithm (GA) was used to optimize the parameters. The aortic arch models were reconstructed using the segmented image. Results: The predicted damage area (mean 0.021 mm2) of the model optimized by deep learning was consistent with the experimental results (mean 0.023 mm2). Among the three patients, one patient died due to multiple organ failure and septic shock on the 11th day after surgery. The other two patients were cured, no reoperation was reported, and their cardiac functions were defined as class I during the 13 and 20 months of follow-up. Conclusion: It is feasible to use CNN to optimize the manufacturing of the aortic arch models.

Three-Dimensional Printing-Assisted Fabrication of Stent Graft to Reconstruct the Total Aortic Arch.

PURPOSE: There is a high incidence of complications after conventional open thoracic aortic arch replacement. Stent graft thoracic endovascular repair for aortic aneurysms has few complications. Vascular variability of the aortic arch branch is high and individualized aortic arch stent graft is required. We present our experience using 3-dimensional print-assisted fabrication of individualized stent grafts. DESCRIPTION: According to the patient's computed tomography angiography results before surgery, the aortic arch was printed 3-dimensionally and then an individualized stent graft was sewn. The prepared stents were placed in the descending aorta and the partial branches of the arch, and then released. EVALUATION: Intraoperative stent placement was successful. The deep hypothermic circulatory arrest time was only 5 minutes. The patient recovered well after surgery and no neurological complications occurred. Postoperative computed tomography angiography showed good stent expansion and no endoleak. CONCLUSIONS: Three-dimensional printing-assisted fabrication of a stent graft can be used for endovascular repair of the total aortic arch. This technology can be employed to construct individualized aortic arch stents accurately for different patients before surgery.

Hybrid procedure for treating adult congenital heart disease with valvular heart disease in two patients.

BACKGROUND: The traditional approach for adult congenital heart disease combined with valvular disease is surgical treatment under cardiopulmonary bypass (CPB). This approach has a high incidence of postoperative complications, especially in patients with pulmonary hypertension and old age. We present two patients in whom the hybrid procedure was used to treat congenital malformations, followed by valve formation and replacement surgery. CASE PRESENTATION: A 63-year-old man had a muscular ventricular septal defect complicated by mitral regurgitation and a 57-year-old man had patent ductus arteriosus complicated by aortic stenosis. In both of the patients, the congenital malformation was successfully treated by the hybrid procedure, followed by valve repair or replacement. Both patients had no complications. A post-procedure echocardiogram showed no residual shunt across the duct. CONCLUSIONS: Our findings suggest that the hybrid procedure is a useful alternative for treating adult congenital heart disease with valvular heart disease. This procedure reduces the surgical incision and difficulty of surgery, shortens the CPB time, avoids residual leakage after surgery, and reduces recovery and hospitalization times.

A Mechanism Study Underlying the Protective Effects of Cyclosporine-A on Lung Ischemia-Reperfusion Injury.

AIM: This study is aimed at validating the hypothesis that administration of cyclosporine-A (CsA) would be protective in lung ischemia-reperfusion (I/R) injury and in exploring the underlying mechanism. METHODS: Rabbits were divided into 4 groups: the control, sham operation, I/R, and I/R with CsA treatment. Flow cytometry was used to measure the mitochondrial membrane potential. Laser scanning confocal microscope was used to analyze mitochondrion permeability transition pore (MPTP). The apoptotic cell was detected by the TUNEL staining. Western blot was performed to analyze the protein expression levels. RESULTS: CsA not only attenuated the histopathologic alterations in lung and mitochondria after I/R injury, but also attenuated I/R injury through increasing MPP and inhibiting MPTP opening. Besides, CsA attenuated I/R injury through suppressing the release of cytochrome-c (CytC), inhibiting cell apoptosis and decreasing the expression levels of cyclophilin-D (Cyp-D), adenine nucleotide translocase 1 (ANT1) and voltage-dependent anion channel 1 (VDAC1). Finally, we found that Cyp-D knockdown inhibits I/R injury-induced MPTP opening and cell apoptosis. CONCLUSION: Our study found that the protective role of CsA on lung I/R injury depends on the inhibition of MPTP and CytC release, suppression of the activation of mitochondrial apoptosis pathway and the expressions of apoptotic-related proteins, as well as the decreased expression levels of ANT1 and VDAC1.

[Clinical analysis of total aortic arch reconstruction with a novel individualized combined branched stent grafting technique for patients with Stanford A aortic dissection].

OBJECTIVE: To compare the clinical efficacy between total aortic arch reconstruction with a individualized combined branched stent grafting technique and total aortic arch replacement combined with stented elephant trunk implantation for patients with Stanford A aortic dissection. METHODS: Totally 44 patients with Stanford A aortic dissection treated with surgical treatment from January 2007 to July 2013 were included in this study. The patients were divided into two groups. Group A (n = 22) patients were treated by total arch replacement with stented elephant trunk procedure. Group B (n = 22) patients received individualized combined branched stent grafting technique. Age, gender and disease severity were similar between the two groups (all P > 0.05). Echocardiography and aortic CT angiography were performed pre-operation and at 1 month after operation. RESULTS: Operation was successful in all 44 patients. Cardiopulmonary bypass time, aortic cross clamp time, circulation arrest time and duration of ventilator assisted breathing were significantly longer, postoperative drainage volume and blood transfusion volume were significantly larger and hospitalization cost was significantly higher in group A patients compared those in group B patients (t = 2.791 to 43.465, all P < 0.05). One month after operation, the maximum internal diameter of aorta was smaller than pre-operation in both group A ((33 ± 1) mm vs. (45 ± 6) mm, t = 10.076, P = 0.000) and group B ((33 ± 2) mm vs. (45 ± 8) mm, t = 5.979, P = 0.000) . Left ventricular ejection fraction had no significant difference before and 1 month after operation in both groups (P > 0.05). CONCLUSION: The total aortic arch reconstruction with individualized combined branched stent grafting technique is technically easier, shortens the operation time, reduces the blood transfusion volume compared to the classical aortic arch operation.

A combined branched stent grafting technique to reconstruct total aortic arch in the treatment of stanford A aortic dissection.

Traditional total arch replacement technology and artificial blood vessels are designed for patients with Stanford A aortic dissection who have 3 branches (brachiocephalic trunk, left common carotid artery, and left subclavian artery) arising from the arch of the aorta. However, if there is anatomical variation of the aortic arch branches, the operation will be very difficult. The number of primary branches of the aortic arch can be reduced to 1 or 2 or increased to 4 to 6. Also, anastomoses of the graft to the left subclavian artery and descending aorta are usually very difficult because of the deep surgical field. Moreover, once bleeding occurs after the anastomoses, hemostasis in the deep field is difficult. Therefore, we applied a "combined branched" stent grafting technique for total arch reconstruction to reduce such problems.

[Efficacy comparison between total aortic arch reconstruction with open placement of triple-branched stent graft and total aortic replacement combined with stented elephant trunk implantation for patients with Stanford A aortic dissection].

OBJECTIVE: To compare the clinical efficacy between total aortic arch reconstruction with open triple-branched stent graft placement and total aortic replacement combined with stented elephant trunk implantation for patients with Stanford A aortic dissection. METHODS: Patients with Stanford A aortic dissection treated with surgical treatment from January 2006 to May 2011 were included in this study. The patients were divided into two groups. Group I (n = 20) patients were treated by total arch replacement with stented elephant trunk procedure. Group II (n = 8) patients received open triple-branched stent graft placement. Echocardiography and aortic CT angiography were performed before and at 1 month after operation. RESULTS: Age, gender and disease severity were similar between the 2 groups (all P > 0.05). Operation was successful in all 28 patients. Cardiopulmonary bypass time, aortic cross clamp time, circulation arrest time and duration of ventilator assisted breathing were significantly longer; postoperative drainage volume and blood transfusion volume were significantly larger and hospitalization cost was significantly higher in group I patients compared those in group II patients (all P < 0.05). One month after operation, the maximum internal diameter of aorta was smaller than pre-operation in both group I [(30.2 ± 3.1) mm vs. (42.5 ± 6.5) mm, P < 0.05] and group II [(31.5 ± 2.5) mm vs. (44.1 ± 7.3) mm, P < 0.05]. CONCLUSIONS: Short-term procedural success rate was similar between the two groups. The total aortic arch reconstruction with open triple-branched stent graft placement procedure is simpler, shortens the operation time, reduces the blood transfusion volume and is more cost-effective compared to the classical aortic arch operation.

Early and midterm results of repair of Ebstein's anomaly with autologous pericardium.

BACKGROUND: The surgical management of Ebstein's anomaly represents a major challenge. METHODS: Thirty consecutive patients with Ebstein's anomaly received surgical treatment in the period from April 2002 to October 2009. Operations included annuloplasty, repair of the tricuspid valve using autologous pericardium and tricuspid valve replacement. In most cases, repair of the tricuspid valve was done using autologous pericardium instead of an annuloplasty with the anterior leaflet alone. Associated congenital malformations were also repaired during the operation. Follow-up ranged from 6 to 82 months. RESULTS: Intraoperative transesophageal echocardiography revealed no or only minimal tricuspid incompetence after cardiopulmonary bypass in 25 patients. Mild or moderate incompetence was observed in 3 and 2 patients, respectively. At the last follow-up echocardiography, 5 patients with mild and 2 patients with moderate tricuspid incompetence were detected. There was no sign of pericardial degeneration, tricuspid valve stenosis, or calcification of the pericardial patch in any patient during follow-up. CONCLUSIONS: Although further study is required to assess the long-term function of the reconstructed tricuspid valve, our early and midterm results from this current study indicate that repairing the tricuspid valve with autologous pericardium achieves reasonable outcomes in the majority of patients with Ebstein's anomaly, including pediatric and adult patients.

In-vitro seeding of human umbilical cord vein endothelial cells on hydroxyapatite for mechanical heart valve applications.

BACKGROUND AND AIM OF THE STUDY: Although heart valve replacement with either a mechanical or biological prosthesis is an effective method to treat valvular heart disease, both approaches have limitations, including thrombus formation, thromboembolism and degeneration problems. The study aim was to demonstrate the in-vitro endothelialization of hydroxyapatite (HAp) to be used as a biomaterial in heart valve prostheses. METHODS: The HAp samples were characterized using X-ray diffractometry to identify the crystalline phase, while the surface morphology of HAp discs was examined using scanning electron microscopy (SEM). Human umbilical vein endothelial cells (HUVECs) were cultured on HAp discs for 1, 3, 5, and 7 days, and on pyrolytic carbon discs for 7 days; cytotoxicity was assessed using the methyl thiazolyl tetrazolium (MTT) assay. The cells were incubated in three groups: (i) an experimental group (cultured with HAp extract); (ii) a negative control (cultured with high-density polyethylene chaff); and (iii) a positive control (culture medium containing 0.1% phenol solution). RESULTS: A morphological examination of the HAp discs revealed the presence of micropores on the disc surface, together with cultured HUVECs. After seven days of culture, the HUVECs began to form a confluent endothelial cell layer covering the HAp discs. There were no visible cells attached to the pyrolytic carbon surface. The MTT assay indicated that HAp did not exert any cytotoxic effect on HUVECs, and low optical density values were obtained in the positive controls. CONCLUSION: The study results showed that HUVECs were able to grow well on HAp discs, and that HAP possessed a good in-vitro bioactivity and biocompatibility towards these cells. Consequently, HAp might be used as a film on mechanical heart valve prostheses, and serve as a promising biomaterial for heart valve replacement.

Severe gastroparesis causing postoperative respiratory complications in a heart-lung recipient.

Heart-lung transplantation is reserved for selected patients who have end-stage cardiac and pulmonary disease. Gastroparesis, which is associated with aspiration, is commonly seen after transplantation. Here, we present a case in which gastric contents aspiration leads to Pseudomonas aeruginosa pulmonary infection, 11 months after the heart lung transplantation. We strongly recommend that early diagnosis and aggressive management of post-transplantation gastroparesis is essential to prevent lung allograft injury and pulmonary infections.

Cytotoxicity evaluation of hydroxyapatite on human umbilical cord vein endothelial cells for mechanical heart valve prosthesis applications.

BACKGROUND: Valvular heart disease is a significant cause of morbidity and mortality worldwide. Artificial heart valves are currently the most widely accepted biomedical material. However, the material's blood compatibility is still not sufficient. Biomaterial with a good biocompatibility has not yet appeared. Our initial study was to evaluate the probable cytotoxicity of hydroxyapatite (HA) on human umbilical vein endothelial cells (HUVEC) for mechanical heart valve prosthesis applications. METHODS AND RESULTS: Cell growth was tested by MTT assay and the cell relative growth rate (RGR) was calculated. Cells were cultured in media consisting of either leaching extracts of hydroxyapatite at 37 degrees C or leaching extracts at 121 degrees C or a negative and a positive control group, respectively. The cytotoxicity was graded using generally accepted standards. The RGR of cell lines cultured in the culture media consisting of either normal or heat temperature leaching extracts of hydroxyapatite and the negative controls were higher than in the positive controls. For 24 h, 48 h, and 72 h cultures, the cytotoxicity grade of HA was 0 in the normal temperature leaching extracts of hydroxyapatite and 1 in the heat temperature leaching extracts of hydroxyapatite. CONCLUSIONS: Human umbilical cord endothelial cells grew well in the HA extracts. Our results indicate that HA possesses good IN VITRO bioactivity and biocompatibility with human umbilical cord endothelial cells and could be used as film on mechanical heart valve prostheses.

Pneumonia in a heart-lung recipient after airway stent placement.

Recently, the self-expandable metallic stent (SEMS) has been added to our armamentarium. However, in the case presented here placement of the self-expandable metallic stent had catastrophic consequences 11 months later. We are of the opinion that airway stent placement may result in severe complications including clinical infection, and if it must be deployed, the proper size and positioning of the stent is always of the utmost importance.