A complexity evaluation system for mitral valve repair based on preoperative echocardiographic and machine learning.

BACKGROUND: To develop a novel complexity evaluation system for mitral valve repair based on preoperative echocardiographic data and multiple machine learning algorithms. METHODS: From March 2021 to March 2023, 231 consecutive patients underwent mitral valve repair. Clinical and echocardiographic data were included in the analysis. The end points included immediate mitral valve repair failure (mitral replacement secondary to mitral repair failure) and recurrence regurgitation (moderate or greater mitral regurgitation [MR] before discharge). Various machine learning algorithms were used to establish the complexity evaluation system. RESULTS: A total of 231 patients were included in this study; the median ejection fraction was 66% (63-70%), and 159 (68.8%) patients were men. Mitral repair was successful in 90.9% (210 of 231) of patients. The linear support vector classification model has the best prediction results in training and test cohorts and the variables of age, A2 lesions, leaflet height, MR grades, and so on were risk factors for failure of mitral valve repair. CONCLUSION: The linear support vector classification prediction model may allow the evaluation of the complexity of mitral valve repair. Age, A2 lesions, leaflet height, MR grades, and so on may be associated with mitral repair failure.

Pulmonary endarterectomy in patients with occlusive isolated pulmonary vasculitis.

BACKGROUND: Isolated pulmonary vasculitis (IPV) is a rare, insidious, and localized inflammatory disease affecting the pulmonary arteries, often leading to severe luminal obstruction. The prognosis for patients with occlusive IPV is poor, and there is currently a lack of effective treatments. The objective of this study was to evaluate the performance of pulmonary endarterectomy (PEA) as a treatment for occlusive IPV. METHODS: This single-center retrospective analysis included patients who received PEA for occlusive IPV between January 2018 and June 2022. Clinical characteristics and hemodynamic parameters were evaluated at baseline and follow-up. RESULTS: Among 114 consecutive patients who underwent PEA, occlusive IPV was identified in 7 patients. Two patients underwent bilateral PEA for the involvement of both pulmonary arteries. Patch angioplasty was performed to treat four severe constrictions. One patient died from residual pulmonary hypertension after limited PEA of a transmural vascular lesion. In addition, no obvious surgical complications were observed. Three months after PEA, a substantial relief in symptoms was achieved. Also, there is a decrease in the mean pulmonary artery pressure (median 33 [20-48] mmHg before versus median 21 [16-26] mmHg after; P < 0.018) and pulmonary arterial resistance (median 234 [131-843] dyn.s.cm-5 versus median 180 [150-372] dyn.s.cm-5; P = 0.310). Three patients experienced a relapse of restenosis of the treated arteries within a 6-month follow-up period, despite daily oral prednisolone administration. They were treated with balloon pulmonary angioplasty of both the main pulmonary arteries and branches. CONCLUSIONS: PEA is a valuable choice for treating occlusive IPV, with notable hemodynamic and clinical advantages. To increase long-term vascular patency, complete management should be optimized.

Long-term outcome prediction for chronic thromboembolic pulmonary hypertension after pulmonary endarterectomy.

BACKGROUND: The definitive treatment for chronic thromboembolic pulmonary hypertension (CTEPH) is pulmonary endarterectomy (PEA), which has good long-term outcomes. However, after surgery, a quarter of the patients still have residual pulmonary hypertension (RPH). In pulmonary hemodynamics, there are no unified criteria for RPH, even though the level may affect long-term survival. METHODS: Between March 1997 and December 2021, 253 CTEPH patients were treated at our center with PEA. Patients were evaluated retrospectively and classified into early (1997-2014) and late (2015-2021) groups. The clinical characteristics and perioperative outcomes of the two groups were compared, and risk factor analysis for RPH and long-term survival for all cases was performed. RESULTS: There was no statistically significant difference in demographics between the two groups. However, the Early Group had a significantly higher rate of perioperative death (9.8% vs. 1.2%, p = .001), RPH (48.8% vs. 14.0%, p < .001), and reperfusion pulmonary edema (18.3% vs. 2.9%, p < .001). The median follow-up time was 66.0 months, and overall survival rates at 5, 10, 15, and 18 years after PEA were 91.2%, 83.9%, 64.5%, and 46.0%, respectively. Age and postoperative systolic pulmonary artery pressure (sPAP) were independently related to long-term outcomes in the multivariate Cox analyses. Patients with postoperative sPAP less than 46 mm Hg had a higher chance of survival. CONCLUSIONS: PEA improved CTEPH hemodynamics immediately and had a positive effect on long-term survival. Patients with postoperative sPAP ≥ 46 mm Hg indicate clinically significant RPH and have a lower long-term survival rate.

Complete resection of a pulmonary artery sarcoma involving the pulmonary valve and right ventricle outflow tract: a case report.

Background: Pulmonary artery sarcoma (PAS) is an extremely rare tumour, preferably treated by surgery. However, the surgical management remains largely debatable, as only less than half of patients with PAS can undergo thorough excision. Case summary: A 32-year-old man with a tumour involving the right ventricle outflow tract, pulmonary trunk extending into the bifurcation, and right pulmonary arteries underwent complete resection using a homologous pulmonary valve and vascular grafts for reconstruction, combined with right pulmonary endarterectomy (PEA) for potential seeding metastasis. Histopathological examination demonstrated undifferentiated pleomorphic sarcoma with surgical margins free of disease. The patient remains asymptomatic, and follow-up computed tomography 5 months after surgery indicated no recurrence or metastasis. Discussion: Radical resection of a PAS with reconstruction using pulmonary valve allograft and polytetrafluoroethylene vascular grafts is technically feasible and successful. Additionally, PEA may eliminate the potential intima implantation metastasis.

Re-repair vs. Replacement for Failed Mitral Valve Repair: A Systemic Review and Meta-Analysis.

Objective: The objective of this study was to compare outcomes of re-repair with those of mitral valve replacement (MVR) for failed initial mitral valve repair (MVr). Methods: We searched the Pubmed, Embase, and Cochrane Library databases for studies that compared mitral valve re-repair with MVR for the treatment of failed initial MVr. Data were extracted by two independent investigators and subjected to a meta-analysis. Odds ratio (OR), risk ratio (RR), hazard ratio (HR), ratio difference (RD), mean difference (MD), and 95% confidence interval (CI) were calculated with the Mantel-Haenszel and inverse-variance methods for mode of repair failure, perioperative outcomes, and follow-up outcomes. Results: Eight retrospective cohort studies were included, with a total of 938 patients, and mean/median follow-up ranged from 1.8 to 8.9 years. Pooled incidence of technical failure was 41% (RD: 0.41; 95% CI: 0.32 to 0.5; P = 0.00; I2 = 86%; 6 studies, 846 patients). Pooled mitral valve re-repair rate was 36% (RD: 0.36; 95% CI: 0.26-0.46; P = 0; I2 = 91%; 8 studies, 938 patients). Pooled data showed significantly lower perioperative mortality (RR: 0.22; 95% CI: 07 to 0.66; I2 = 0%; P = 0.008; 6 studies, 824 patients) and significantly lower long-term mortality (HR:0.42; 95% CI: 0.3 to 0.58; I2 = 0%; P = 0; 7 studies, 903 patients) in the re-repair group compared with MVR. Conclusions: Mitral valve re-repair was associated with better immediate and sustained outcomes for failed MVr and should be recommended if technically feasible.

Surgical and Conservative Treatment of Post-infarction Left Ventricular Pseudoaneurysm.

BACKGROUND: Post-infarction left ventricular (LV) pseudoaneurysm is a rare mechanical complication of myocardial infarction that carries a substantial risk of sudden rupture. The purpose of this study was to compare the surgical results of post-infarction LV pseudoaneurysm with those of conservative treatment. METHODS: From 2016 to 2021, 22 patients were hospitalized for LV pseudoaneurysm, including 17 cases (77.3%) caused by myocardial infarction. Of the 17 patients, 10 (58.8%) underwent surgical repair, while seven (41.2%) were treated medically. The clinical course, echocardiograph data, and surgical outcomes were analyzed. Survival rates of the surgical and conservative groups were compared. RESULTS: There were no perioperative deaths. Intra-aortic balloon pumping support was required in two (20%) patients. No follow-up mortality was observed in the surgical group and at the last follow-up, all the patients were classified as New York Heart Association class I-II. In the conservative group, there was one (14.3%) hospital death and two (28.6%) additional deaths during follow-up. A significant difference was found in survival between the two groups (P = 0.024). CONCLUSIONS: Surgical repair of post-infarction LV pseudoaneurysm can be performed with good results, while conservative treatment carries a significant risk of sudden death. Surgical repair is indicated for every patient diagnosed, even those with a small pseudoaneurysm without symptoms.

Long-term results of the edge-to-edge repair for failed mitral valve repair as a bailout option.

OBJECTIVE: We evaluate the long-term clinical and echocardiographic outcomes of edge-to-edge (E2E) repair combined with mitral annuloplasty in our institute with degenerative mitral regurgitation (MR) up to 10 years. METHODS: Twenty-six consecutive patients undergoing E2E mitral repair after failure of other conventional mitral repair technique. There were 16 (61.5%) male and the mean age was 52.2 ± 10.4 years. Mitral regurgitation was due to anterior leaflet prolapse in 12 (46.2%) patients, bileaflet prolapse in 9 (34.6%), and multiple segment posterior leaflet prolapse in 5 (19.2%). RESULTS: There were no perioperative deaths. Follow-up was 100% complete. The mean length of follow-up was 8.7 ± 0.9 years (median 8.4 years, 6.8-10.1 years). Two patients required reoperation of the MV. The freedom from reoperation and ≥ Moderate MR at 10 years was 69.9 ± 11.7%. The freedom from reoperation, ≥ Moderate MR and mitral stenosis (MS) at 10 years was (59.6 ± 10.0) %. The mean transmitral pressure gradient (TMPG) was 6.1 ± 2.5 mmHg, which was significantly elevated compared with preoperative TTE (P = 0.004). The freedom from ≥ Moderate MS at 10 years was 76.9 ± 8.3%. There were no differences between patients with and without MS at follow-up regarding the echocardiographic parameters and clinical status. CONCLUSION: There is a slowly progressive elevation of TMPG after E2E mitral repair, while mildly elevated TMPG can be tolerated in most patients. In appropriate patients, the E2E repair combined with annuloplasty provides an effective "bailout" choice.

A complexity scoring system using echocardiography for repair of degenerative mitral valve regurgitation / 中国胸心血管外科临床杂志

@#Objective     To evaluate a score system to allow stratification of complexity in degenerative mitral valve repair. Methods     We retrospectively reviewed the clinical data of 312 consecutive patients who underwent surgery for mitral valve repair and whose preoperative echocardiography was referable in our hospital from January 2012 to December 2013. A scoring system for surgical complexity was used based mainly on the preoperative echocardiography findings. Complexity of mitral valve repair was scored as 1 to 9, and patients were categorized into 3 groups based on the score for surgical complexity: a simple group (1 point), an intermediate group (2-4 points) and a complex group (≥5 points). There were 86 males and 35 females in the simple group (n=121) with an average age of 51.6±12.6 years, 105 males and 53 females in the intermediate group (n=158) with an average age of 51.1±12.8 years and 25 males and 8 females in the complex group (n=33) with an average age of 49.3±13.0 years. Results     There was significant difference in surgical complexity in different groups. In the simple, intermediate and complex groups, the mean cardiopulmonary bypass time was 111.7±45.5 min, 117.7±40.4 min and 153.4±74.2 min (P<0.001), the mean cross-clamping time was 77.5±33.8 min, 83.2±29.9 min and 108.8±56.2 min (P<0.001), and the mean number of repair techniques utilized was 2.1±0.4, 2.4±0.6 and 2.8±0.8 (P<0.001). However, there was no significant difference in the early and late outcomes in different groups. Conclusion     It is feasible to use echocardiography to quantitatively evaluate the difficulty of mitral valvuloplasty.

Hybrid surgical and interventional ablation versus video-assisted thoracoscopic surgical ablation for persistent atrial fibrillation: A case control study / 中国胸心血管外科临床杂志

@#Objective To verify whether hybrid surgical and interventional ablation(HA) for the treatment of persistent atrial fibrillation (AF) is superior to video-assisted thoracoscopic surgical radiofrequency ablation (VATS-RA). Methods From September 2010 to December 2017, 79 consecutive patients with persistent AF underwent VATS-RA or HA in Fuwai Hospital. VATS-RA was performed in sixty patients (a stand-alone surgical group, 48 males and 12 females, at average age of 56.0±7.6 years, and HA was performed in nineteen patients (a hybrid group, 14 males and 5 females, at average age of 58.0±7.3 years). Follow-up was completed at 3 months, 6 months, 1 year and annually thereafter. Postoperative sinus rhythm was defined as sinus rhythm recorded in 24-hour or 7-day Holter during follow-up, without exhibited rapid atrial tachyarrhythmia≥30 s including AF, atrial flutter, or atrial tachycardia. Results Seventy-eight patients (98.7%) completed the follow-up. Although the preoperative left atrial diameter (49.1±5.3 mm) in the hybrid group was significantly greater than that in the stand-alone surgical group (41.7±6.2 mm, P<0.001). Overall sinus rhythm maintenance rate in the hybrid group was significantly greater than that in the stand-alone surgical group (94.7% versus 64.4%, P=0.011). And sinus rhythm maintenance rate free from anti-arrhythmic drugs (AADs) and catheter ablation in the hybrid group was significantly greater than that in the stand-alone surgical group (84.2% versus 50.8%, P=0.010). Conclusion HA is superior to VATS-RA in the treatment of persistent AF, but a larger sample size is needed for further validation in prospective randomized studies.

Routine use of bilateral internal mammary artery grafts for myocardial revascularization in diabetic patients: a propensity score matched study / 中国胸心血管外科临床杂志

@#Objective To evaluate the influence of diabetes on coronary artery bypass graft (CABG) surgery using bilateral internal mammary artery (BIMA). Methods From December 2015 to August 2017, 182 patients (153 males, 29 females, age of 56.5±6.8 years) underwent CABG using BIMA. The propensity score was used to create matched diabetes (n=66) and non-diabetes (n=66) cohorts. The operative data, post-operative outcomes and coronary computed tomographic angiography (CTA) of the diabetes group (53 males, 13 females, age of 57.8±7.2 years) and the non-diabetes group (56 males, 10 females, age of 56.3±6.0 years) were analyzed retrospectively. Results There was no peri-operative mortality. There was no difference in operative sternal wound complication (P=0.466), or graft patency (P=0.730 for internal mammary arteries and 0.684 for saphenous vein grafts) between the matched diabetes and the non-diabetes groups. However, patients with elevated glycated hemoglobin (HbA1c) (n=54) had more sternal wound complications (P=0.006). The level of Hb1Ac of the patients with sternal wound complication was significantly higher than that of the patients without sternal wound complication. Conclusion BIMA grafting may be performed routinely even in diabetic patients, without increased complications. However, elevated HbA1c level should be avoided to reduce sternal wound complication.

Skeletonized versus pedicled harvesting of bilateral internal mammary artery in coronary artery bypass graft: A case control study / 中国胸心血管外科临床杂志

@#Objective     To evaluate the safety and efficacy of skeletonized and pedicled harvesting of bilateral internal mammary artery (BIMA) in coronary artery bypass graft (CABG) surgery. Methods     From December 2015 to May 2017, 152 patients (128 males, 24 females, age of 56.5±6.8 years) underwent CABG using either skeletonized BIMA (s-BIMA group, n=73) or pedicled BIMA(p-BIMA group, n=79). The operative data and post-operative outcomes were analyzed in the s-BIMA group (61 males, 12 females, age of 56.6±7.0 years) and the p-BIMA group (67 males, 12 females, age of 56.3±6.7 years). Results     There was no peri-operative mortality. There was no statistical difference in operative time, cardiopulmonary bypass time, aortic cross-clamp time or internal mammary artery graft flow between the two groups. One patient(1.4%) in the s-BIMA group suffered from severe sternal wound complication, which was major sternal wound complication. Five patients (6.3%) in the p-BIMA group suffered from sternal wound complications, including 1(1.3%) with severe complication and 4(5.1%) with minor complication. One(1.4%) patient in the s-BIMA group and 7 (8.9%) patients in the p-BIMA group suffered from chylothorax. The chest tube drainage significantly reduced in the s-BIMA group, both in postoperative day 1(P=0.000) and postoperative day 1-3 (P=0.001). CT angiography showed no stenosis of BIMA in both groups. Conclusion     The use of skeletonized BIMA for CABG is safe and efficacious, with less sternal wound complications, chylothorax and chest tube drainage. Skeletonization should be   suggested if BIMA is harvested in CABG.

Tumor heterogeneity in the recurrence of epithelial ovarian cancer demonstrated by polycomb group proteins.

PURPOSE: To investigate tumor heterogeneity in the recurrence of epithelial ovarian cancer demonstrated by polycomb group (PcG) proteins. METHODS: Tissue microarrays containing matched primary and recurrent ovarian tumors from the same patients were constructed for detection of PcG protein expression. Survival analyses of clinicopathological parameters and expression of PcG proteins were performed on progression-free survival (PFS) and overall survival (OS) of patients. Genetic and epigenetic heterogeneity was explored in aspects of gene copy number and microRNA (miRNA) profiling. RESULTS: PcG proteins were heterogeneously expressed in primary versus recurrent tumors (P<0.05). In univariate survival analysis of the ovarian carcinoma cohorts, a significant association of intensive expression of BMI1 and EZH2 in first-onset lymph node metastases with shortened PFS was demonstrated (P=0.010, P=0.019); and a significant association of intensive expression of BMI1 and EZH2 in recurrent tumors with shortened OS was demonstrated (P=0.042, P=0.047). Importantly, BMI1 and EZH2 expression provided significant independent prognostic parameters in multivariate analyses (P<0.05). Gene amplification did not always coincide with PcG protein expression. Eight miRNAs were found to be downregulated in recurrent tumors, among which miR-298 might indirectly regulate the expression of EZH2 through transcription factor ILF3. CONCLUSION: Tumor heterogeneity exists in the recurrence of epithelial ovarian cancer, manifested by PcG protein expression and underlying genetic and epigenetic alterations. Intensive expression of BMI1 and EZH2 are predictors of earlier relapse and shorter OS, independent of grade and chemotherapy sensitivity. EZH2 and miR-298 have great potential to be new targets for treatment of recurrent ovarian cancer.

[Promoter methylation of DAPK1, RAR-ß and MGMT in exfoliated cervical cytology and its clinical application].

OBJECTIVE: To assess the correlation of promoter methylation of DAPK1, RAR-ß and MGMT with cervical lesions from cytology to histology, and to reveal the clinical value of DNA methylation in diagnosis of cervical intraepithelial neoplasia (CIN). METHODS: A total of 103 random-selected cervical samples were collected from residual liquid-based cytology specimens after clinical use in cytopathological diagnosis in outpatient clinic of obstetrics and gynecology, Peking Union Medical Collage Hospital from March 2010 to October 2010. Informed consent was obtained from each woman before the initiation of the study. The methylation sensitive-high resolution melt (MS-HRM) assay was used to evaluate promoter methylation of three genes (DAPK1, RAR-ß and MGMT) in 103 biopsy-confirmed liquid-based cervical cytology samples. Methylation levels and high-risk HPV DNA loading (HCII values) were analyzed in relation to both cytological and histological diagnosis. RESULTS: The methylation level of all three genes showed significant difference among the different cytological groups (P = 0.000, 0.011 and 0.002, respectively). The methylation level of DAPK1 and RAR-ß showed significant difference among the different histological groups (P = 0.000 and 0.021), while there was no significant difference for MGMT. DAPK1 methylation levels was 1.47% in the CINII/high-grade precancerous lesions group, and 20.98% in the normal/CINI groups (P = 0.000), but there was no significant difference between CINII/high-grade precancerous lesions and normal/CINI groups for RAR-ß and MGMT. The combination of DAPK1/HR-HPV loading showed a sensitivity of 0.825 and an area under the receiver operating characteristic curve (ROC) curve (AUC) of 0.695 as diagnostic methods for detecting CINII/high-grade precancerous lesions. CONCLUSIONS: DNA methylation such as DAPK1 and RAR-ß, in combination with HR-HPV detection, may serve as biomarkers to detect CINII/high-grade precancerous lesions. Detection of methylated DNA from liquid-based cervical cytology specimens is technically feasible with the MS-HRM assay.