Hansong Sun

Extracorporeal membrane oxygenation for treatment of cardiac failure in adult patients

This report reviews our experience in venoarterial extracorporeal membrane oxygenation (ECMO) support treatment in adult patients with cardiac failure, as well as analysis of the risk factors of early mortality. From February 2005 to June 2008, 45 patients undergoing cardiogenic shock required temporary ECMO support. They were divided into three groups: post-cardiotomy (n=31) and post-transplantation (n=5) heart failure, decompensated heart failure (n=9). ECMO implantation was performed through the femoral vessels, or axillary artery, or through the right atrium and ascending aorta. Average support duration was 126.7+/-104.3 h. Twenty-seven patients could be successfully weaned from support (60%); additionally, five were bridged to heart transplantation. The in-hospital mortality was 42% (19/45). Twenty-six patients (58%) could be successfully discharged. Additional intra-aortic balloon pumps were used in 11 patients, and six of them were successfully discharged. The mortality rate was obviously high for patients with acute renal failure treated by continuous renal replacement therapy (CRRT) under ECMO support (7/9 patients). The dominant mode of death was multisystem organ failure (9/19). ECMO offers effective cardiopulmonary support in adults. The better outcome requires a multidisciplinary approach to prevent complications unique to itself and limit organ injury before and during this support.

Increasing Long-Term Major Vascular Events and Resource Consumption in Patients Receiving Off-Pump Coronary Artery Bypass A Single-Center Prospective Observational Study

Background— Despite its widespread use and short-term efficacy, substantial uncertainty remains about the long-term outcomes and cost-effectiveness of off-pump coronary artery bypass (OPCAB). Methods and Results— A retrospective review of prospectively collected data was conducted of 6665 consecutive patients undergoing isolated coronary artery bypass graft (CABG) at our institution during 1999 to 2006. All patients were followed up until September 30, 2008. Short- and long-term outcomes were compared between OPCAB and conventional CABG. The 2 main long-term outcome measures were repeat revascularization and the composite outcome of major vascular events. Cost comparison at 2 years in a propensity-matched sample during follow-up was also a study interest. The overall mean baseline age was 60.3±8.6 years, and 17.0% were women. Compared with conventional CABG, patients who underwent OPCAB had lower rates of atrial fibrillation (P=0.003) and requirements for blood transfusion (P=0.03) and ventilation time >24 hours (P<0.001). After an average of 4.5 years of follow-up, the rates of repeat revascularization (adjusted hazard ratio, 1.40; 95% confidence interval, 1.03 to 1.89) and major vascular events (adjusted hazard ratio, 1.23; 95% confidence interval, 1.09 to 1.39) were significantly higher in the OPCAB than the conventional CABG group. At 2 years, OPCAB was associated with increased additional direct costs per patient compared with conventional CABG and had a similar survival rate. Conclusions— Compared with conventional CABG, OPCAB is associated with small short-term gain but increased long-term risks of repeat revascularization and major vascular events, especially among high-risk patients. Moreover, OPCAB consumes more resources and is less cost-effective in the long run.

Efficacy of Long-Term β-Blocker Therapy for Secondary Prevention of Long-Term Outcomes After Coronary Artery Bypass Grafting Surgery

Background— Conflicting results from recent observational studies have raised questions concerning the benefit of &bgr;-blockers for patients undergoing coronary artery bypass grafting (CABG). Furthermore, the efficacy of long-term &bgr;-blocker therapy in CABG patients after hospital discharge is uncertain. Methods and Results— The study included 5926 consecutive patients who underwent CABG and were discharged alive. The prevalence and consistency of &bgr;-blocker use were determined in patients with and without a history of myocardial infarction (MI). &bgr;-Blockers were always used in 1280 patients (50.9%) with and 1642 patients (48.1%) without previous MI after CABG. Compared with always users (n=2922, 49.3%), the risk of all-cause death was significantly higher among inconsistent &bgr;-blocker users (hazard ratio [HR], 1.96; 95% confidence interval [CI], 1.50–2.57), and never using &bgr;-blockers was associated with increased risk of both all-cause death (HR, 1.42; 95% CI, 1.01–2.00) and the composite of adverse cardiovascular events (HR, 1.29; 95% CI, 1.10–1.50). In the cohort without MI, the HR for all-cause death was 1.70 (95% CI, 1.17–2.48) in inconsistent users and 1.23 (95% CI, 0.76–1.99) in never users. In the MI cohort, mortality was higher for inconsistent users (HR, 2.14; 95% CI, 1.43–3.20) and for never users (HR, 1.59; 95% CI, 1.07–2.63). Consistent results were obtained in equivalent sensitivity analyses. Conclusions— In patients with or without previous MI undergoing CABG, the consistent use of &bgr;-blockers was associated with a lower risk of long-term mortality and adverse cardiovascular events. Strategies should be developed to understand and improve discharge prescription of &bgr;-blockers and long-term patient adherence.

Efficacy of Chronic -Blocker Therapy for Secondary Prevention on Long-Term Outcomes After Coronary Artery Bypass Grafting Surgery

Background— Conflicting results from recent observational studies have raised questions concerning the benefit of &bgr;-blockers for patients undergoing coronary artery bypass grafting (CABG). Furthermore, the efficacy of long-term &bgr;-blocker therapy in CABG patients after hospital discharge is uncertain. Methods and Results— The study included 5926 consecutive patients who underwent CABG and were discharged alive. The prevalence and consistency of &bgr;-blocker use were determined in patients with and without a history of myocardial infarction (MI). &bgr;-Blockers were always used in 1280 patients (50.9%) with and 1642 patients (48.1%) without previous MI after CABG. Compared with always users (n=2922, 49.3%), the risk of all-cause death was significantly higher among inconsistent &bgr;-blocker users (hazard ratio [HR], 1.96; 95% confidence interval [CI], 1.50–2.57), and never using &bgr;-blockers was associated with increased risk of both all-cause death (HR, 1.42; 95% CI, 1.01–2.00) and the composite of adverse cardiovascular events (HR, 1.29; 95% CI, 1.10–1.50). In the cohort without MI, the HR for all-cause death was 1.70 (95% CI, 1.17–2.48) in inconsistent users and 1.23 (95% CI, 0.76–1.99) in never users. In the MI cohort, mortality was higher for inconsistent users (HR, 2.14; 95% CI, 1.43–3.20) and for never users (HR, 1.59; 95% CI, 1.07–2.63). Consistent results were obtained in equivalent sensitivity analyses. Conclusions— In patients with or without previous MI undergoing CABG, the consistent use of &bgr;-blockers was associated with a lower risk of long-term mortality and adverse cardiovascular events. Strategies should be developed to understand and improve discharge prescription of &bgr;-blockers and long-term patient adherence.

Venoarterial Extracorporeal Membrane Oxygenation in Adult Patients: Predictors of Mortality.

Background: Extracorporeal membrane oxygenation is a cardiopulmonary supportive therapy. In this study, we reviewed our experience with extracorporeal membrane oxygenation support and tried to identify measurable values which might predict in-hospital mortality. Methods: From January 2004 through December 2008, 50 of 21,298 adult patients received venoarterial extracorporeal membrane oxygenation. We retrospectively analyzed clinical records of these 50 consecutive patients. Details of demographics, preoperative measurements, clinical characteristics at the time of extracorporeal membrane oxygenation implantation, extracorporeal membrane oxygenation-related complications and in-hospital mortality were collected. Logistic regression analyses were performed to investigate predictors of mortality. A p-value ≤ 0.05 was accepted as significant. Results: Thirty-eight patients were weaned from extracorporeal membrane oxygenation and 33 patients survived to discharge. The overall survival rate was 66%. In a multiple logistic regression analysis, blood lactate level before initiation of extracorporeal membrane oxygenation was a risk factor associated with in-hospital mortality (OR 1.27 95% CI 1.042-1.542). To evaluate the utility of the lactate in predicting mortality, a conventional receiver operating characteristic curve was produced. Sensitivity and specificity were optimal at a cut-off point of 12.6mmol/L, with an area under the curve of 0.752. The positive and negative predictive values were 73.3% and 83.9%, respectively. Conclusions: Extracorporeal membrane oxygenation is a justifiable alternative treatment for postoperative refractory cardiac and pulmonary dysfunction which could rescue more than sixty percent of otherwise fatal patients. Patients with pre-extracorporeal membrane oxygenation lactate levels above 12.6mmol/L are at higher risks for in-hospital death. Evidence-based therapy for this group of high risk patients is needed.BACKGROUND Extracorporeal membrane oxygenation is a cardiopulmonary supportive therapy. In this study, we reviewed our experience with extracorporeal membrane oxygenation support and tried to identify measurable values which might predict in-hospital mortality. METHODS From January 2004 through December 2008, 50 of 21,298 adult patients received venoarterial extracorporeal membrane oxygenation. We retrospectively analyzed clinical records of these 50 consecutive patients. Details of demographics, preoperative measurements, clinical characteristics at the time of extracorporeal membrane oxygenation implantation, extracorporeal membrane oxygenation-related complications and in-hospital mortality were collected. Logistic regression analyses were performed to investigate predictors of mortality. A p-value < or = 0.05 was accepted as significant. RESULTS Thirty-eight patients were weaned from extracorporeal membrane oxygenation and 33 patients survived to discharge. The overall survival rate was 66%. In a multiple logistic regression analysis, blood lactate level before initiation of extracorporeal membrane oxygenation was a risk factor associated with in-hospital mortality (OR 1.27 95% CI 1.042-1.542). To evaluate the utility of the lactate in predicting mortality, a conventional receiver operating characteristic curve was produced. Sensitivity and specificity were optimal at a cut-off point of 12.6 mmol/L, with an area under the curve of 0.752. The positive and negative predictive values were 73.3% and 83.9%, respectively. CONCLUSIONS Extracorporeal membrane oxygenation is a justifiable alternative treatment for postoperative refractory cardiac and pulmonary dysfunction which could rescue more than sixty percent of otherwise fatal patients. Patients with pre-extracorporeal membrane oxygenation lactate levels above 12.6 mmol/L are at higher risks for in-hospital death. Evidence-based therapy for this group of high risk patients is needed.

Repair of Anomalous Origin of Right Coronary Artery from the Pulmonary Artery

Anomalous origin of the right coronary artery from the pulmonary artery is a rare cardiac malformation. Between July 2002 and July 2005, we operated on 4 patients with this defect. There were 2 males and 2 females, aged from 18 months to 42 years. Three patients underwent direct re-implantation of the right coronary artery into the aorta, and one had an intrapulmonary tunnel repair (intrapulmonary artery baffle with an autologous pericardial patch for tunneling to the anomalous right coronary ostium). Cardiopulmonary bypass was used in 2 patients, and an off-pump technique in the other 2. One patient had an atrial septal defect that was closed with an Amplatzer septal occluder through the right atrium under transesophageal echocardiography, without cardiopulmonary bypass. All patients survived and recovered uneventfully. Follow-up ranged from 3 to 39 months (mean, 17 months). All patients were doing well and free from symptoms, with normal exercise tolerance. Surgical correction of anomalous right coronary artery shows good early and midterm results.

The surgical management of hypertrophic obstructive cardiomyopathy with the concomitant mitral valve abnormalities

OBJECTIVES The purpose of this retrospective study was to analyse the pathogenesis and the treatment strategies of hypertrophic obstructive cardiomyopathy (HOCM) with the concomitant mitral valve abnormalities. METHODS Between October 1996 and December 2009, 76 patients with the HOCM underwent the ventricular septal myotomy-myectomy in Fuwai hospital. There were 51 males and 25 females aged between 6 and 68 years (mean: 37.18 ± 15.85 years) old. All the patients had left ventricular outflow tract (LVOT) obstruction with a resting or physically provoked gradient of ≥50 mmHg and the systolic anterior movement (SAM) of the mitral leaflets, and 64 patients had mitral regurgitation (MR). These patients underwent the ventricular septal myotomy-myectomy under general anaesthesia and cardiopulmonary bypass. The concomitant surgical procedures included mitral valve replacement (MVR, n = 14) and mitral valve plasty (MVP, n = 12). RESULTS All the surgical procedures were technically successful. In comparison with the preoperative conditions, the resting LVOT gradient had marked reduction (99.73 ± 38.61-23.55 ± 16.53 mmHg, P < 0.001), the mean septal thickness was decreased from 26.23 ± 5.24 to 17.33 ± 4.74 mm. MR had significant improvement, SAM was resolved completely or only mild. Four patients (5.3%, 4/76) died during the hospital stay. The causes of death included severe ventricular arrhythmias with low cardiac output, severe acute renal failure, septic shock with acute renal dysfunction and the complete AV block with low cardiac output. The others were followed up for 5-18 years: there were no deaths. Moderate MR was noted in two patients at 2 months or 2 years after operation respectively, who had undergone MVP with the edge-to-edge technique stitch procedure, and only had mild or trivial MR at hospital discharge, of whom one received repeat operation with MVR and the other is still in follow-up. All surviving patients were evaluated as New York Heart Association Functional class I or II, and had a significant increase in physical capacity and a significant reduction in disabling symptoms. CONCLUSIONS The ventricular septal myotomy-myectomy can be performed successfully for the severe obstructive HOCM and MR with the low morbidity and mortality and excellent survival in the great majority of patients. But for the few patients with the intrinsic mitral valve disease, the concomitant MVP or MVR may be required, and MVR should be performed only as a priority choice for the inherent risks of prosthetic valves and anticoagulation therapy.

Response to Letters Regarding Article, “Efficacy of Long-Term β-Blocker Therapy for Secondary Prevention of Long-Term Outcomes After Coronary Artery Bypass Grafting Surgery”

Poullis states that the possible underlying pharmacokinetic mechanism might affect the efficacy of β-blockers. Actually, in our study, inconsistent users included those who had no β-blocker therapy early after the surgery but were prescribed with the medication because of frequent cardiovascular symptoms, including palpitation and angina pectoris.1 This could not be simply attributed to poor adherence and gives an explanation for the worse long-term outcomes for inconsistent users. The rate of elective coronary artery bypass grafting was 84% in the United Kingdom, 41% in the United States,2 and 98% in our study, showing great variance of patients’ characteristics across regions. Propensity score matching was performed as part of the additional sensitivity analyses to reduce the impact of treatment selection bias and potential confounding. Left internal mammary artery-to-left anterior descending artery graft was used in 95% of our patients, and was treated as a patient-level variable …

Outcomes after multidisciplinary blood management in adult patients undergoing cardiac surgery: a retrospective observational study

Abstract Background More than 250 000 patients undergo cardiac surgery in China annually, and 70% of them receive blood transfusion perioperatively. These two figures put together is a great burden on blood supply in China, and the gap between the supply and consumption of blood products is becoming more and more prominent. Accumulating evidence shows that blood transfusion is associated with increased postoperative morbidity and mortality in patients undergoing cardiac surgery. The aim of this study was to investigate a single institutions experience with implementing multidisciplinary patient blood management (PBM) strategy in adult patients undergoing cardiac surgery. Methods A multidisciplinary PBM strategy was instituted in Fuwai Hospital in January 2009. The strategy included the establishment of a multidisciplinary blood transfusion management team and the designation of a coordinator, enactment perioperative transfusion triggers (haemoglobin concentration Findings 50453 consecutive adult patients underwent coronary artery bypass grafting, valvular heart surgery, Aortic surgery, other adult cardiac or combined surgery were analyzed. 5574 cases were performed in the year of 2008, and 6336, 6663, 7075, 7620, 8387 and 8798 cases were performed from 2009 to 2014 respectively. The incidence of allogeneic red blood cell transfusion perioperatively were decreased significantly since 2009 (from 2008 to 2014: 75·3%, 58·3%, 47·5%, 33·1%, 27·5%, 27·1%, and 26·6%, p Interpretation Multidisciplinary patient blood management strategy significantly reduced the incidence of RBC transfusion and improved outcomes in adult patients underwent cardiac surgery. It also saved plenty of blood resources. Funding None.

Long-term outcomes of mitral valve annuloplasty versus subvalvular sparing replacement for severe ischemic mitral regurgitation

BACKGROUND Although practice guidelines recommend surgery for patients with severe chronic ischemic mitral regurgitation (CIMR), they do not specify whether to repair or replace the mitral valve. The purpose of this study was to evaluate the long-term outcomes in patients with severe CIMR undergoing mitral valve annuloplasty (MVA) versus subvalvular sparing mitral valve replacement (MVR). METHODS 392 consecutive patients who underwent MVA or subvalvular sparing MVR for treatment of severe CIMR were retrospectively reviewed. RESULTS After adjustment for baseline differences with multivariable regression analysis at 53 monthsfollow-up (interquartile range, 34-81 months), there was no significant difference between the two groups for risk of major adverse cardiac or cerebrovascular events (MACCE), cardiac death, or all-cause death. Propensity score matching extracted 77 pairs. During the follow-up, compared with the MVR group, both the left atrium and left ventricle end-diastolic diameter were markedly larger (p = 0.013 and p = 0.033, respectively), and the incidence of mitral regurgitation recurrence was significantly higher in the MVA group (p < 0.001). No significant difference was observed between the two propensity score-matched groups in composite in-hospital outcomes, overall survival, freedom from cardiac death or MACCE, except subvalvular sparing MVR was associated with a lower incidence of hospitalization for heart failure than MVA (p = 0.015). CONCLUSIONS Subvalvular sparing MVR is a suitable management of patients with severe CIMR, it is more favorable to ventricular remodeling and is associated with a lower incidence of hospitalization for heart failure than MVA.