Jian-Qun Zhang

Statins decrease adverse outcomes in coronary artery bypass for extensive coronary artery disease as well as left main coronary stenosis.

The aim of this study was to evaluate the effects of preoperative and postoperative statins on coronary artery bypass grafting (CABG) for extensive coronary artery disease as well as left main coronary stenosis (LMS). The data of 626 cases of extensive coronary artery disease as well as LMS patients in Anzhen Hospital between January 1998 and March 2008 for CABG procedure were retrospectively analyzed, and were classified as preoperative statin therapy group (Group A, n = 320) or preoperative no statin therapy group (Group B, n = 306). Propensity scores were estimated to determine the probability of inclusion into statin therapy group, resulting in the successful matching of 267 pairs. The incidence of in-hospital death, and atrial fibrillation or flutter and disabling stroke was higher in Group B than in Group A. The actuarial freedom from late events at 5 yrs were 98.75%+/- 0.73% for the postoperative statin therapy group and 88.33%+/- 3.71% for the postoperative no statin therapy group respectively, P= 0.000. The logistic regression revealed that CRP (>5.0 mg/L), and elevated Troponin I, and emergent procedure, and preoperative IABP support, and EF < 40% were the independent risk factors, and preoperatively statins was the protective factor for the perioperative death; and the Cox proportional hazard also revealed that preoperative IABP support and preoperative cardiac arrest, and EF < 40% were independent risk factors, and postoperatively statins were the protective factor for the late cardiac events. Preoperative statin therapy could provide protective effect in the perioperative period. Postoperative statin usage could provide protective effect on the late cardiac events.

The Classification and Surgical Strategy of Intracardiac Leiomyomatosis

BACKGROUND There is a great deal of heterogeneity in the surgical strategy to treat intracardiac leiomyomatosis (ICL), leading to a need to create a theoretical tool to clarify this situation. METHODS The data of 14 cases of ICL surgically treated in Anzhen Hospital from February 1995 to February 2009 were retrospectively reviewed. A system for classifying ICL was proposed based on four features of the lesion: size of intracardiac component; extent of inferior vena cava (IVC) involvement; venous pathway from uterus to IVC; and laterality of the lesion in the pelvis. The 14 cases of ICL were treated through multiple surgical strategies. RESULTS There were no operative deaths. The follow-up was 73.1 +/- 59.2 months and one patient died from recurrence due to incomplete excision 5 months after the primary procedure. The 5-year survival rate calculated through Kaplan-Meier survival curve was 93.16 +/- 4.98%. Of the surviving patients, 13 had ICL, 10 were in the New York Heart Association (NYHA) class I, and three were in NYHA class II. CONCLUSION The surgical treatment of ICL can obtain a good mid- to long-term survival rate and satisfactory heart function, and the proposed classification system for ICL may be helpful to guide the selection of the surgical strategy for ICL, and may serve as the future basis for standardising the reporting of ICL management.

Surgical treatment of intracardiac leiomyomatosis

OBJECTIVES Confusion exists regarding surgical algorithms for treating intracardiac leiomyomatosis. This report outlines the surgical management and outcomes of patients with intracardiac leiomyomatosis. METHODS Sixteen cases of intracardiac leiomyomatosis surgically treated in Anzhen Hospital from February 1995 to July 2010 were reviewed retrospectively. According to relative size and location of intracardiac leiomyoma maximum diameter relative to diameter of inferior vena cava, the 16 cases were classified as type A, B, C, or D. RESULTS Of the 16 cases in this series, there were 7 type A, 2 type B, 3 type C, and 4 type D. No patients died during surgery. Mean follow-up was 90 ± 57.1 months (cumulative, 120.2 patient-years; range, 2-190 months). One patient died of recurrence 5 months after the surgery because of incomplete resection. Another patient with type D also died of recurrence 2 years after the primary procedure. A patient with type D died suddenly 10 years after the primary procedure. The 5-year and 10-year survivals calculated by the Kaplan-Meier method were 87.1% ± 8.6% and 72.5% ± 15%. Of the 13 surviving patients, 11 were in New York Heart Association functional class I and 2 were in functional class II. CONCLUSIONS Surgical treatment of intracardiac leiomyomatosis can result in satisfactory midterm to long-term survival and satisfactory heart function. Multiple surgical strategies should be tailored to the anatomic characteristics of the intracardiac leiomyoma. Recurrence of intracardiac leiomyomatosis after the resection procedure may result in unfavorable late result.

Preoperative transcatheter occlusion of bronchopulmonary collateral artery reduces reperfusion pulmonary edema and improves early hemodynamic function after pulmonary thromboendarterectomy.

OBJECTIVE The present study assessed the effectiveness of preoperative transcatheter occlusion of the bronchopulmonary collateral artery (PTOBPCA) in reducing reperfusion pulmonary edema after pulmonary thromboendarterectomy (PEA). METHODS The data from 155 patients with chronic thromboembolic pulmonary hypertension at Anzhen Hospital, treated from January 2007 to August 2013, with PEA were retrospectively reviewed. The patients were classified into a control (group A, n = 87) and treated (group B, underwent PTOBPCA, n = 68) group. The reperfusion pulmonary edema incidence, mechanical ventilation and intensive care unit hospitalization duration, and hemodynamic function were compared between the 2 groups. RESULTS Of the 87 patients in group A, 5 died in-hospital (5.7% mortality); no patient in group B died (0% mortality; P = .035). In group A, 9 patients (10.3%) required extracorporeal membrane oxygenation (ECMO) after PEA; 1 patient (1.5%) in group B required ECMO (chi-square test, P = .026, χ(2) = 4.980). Group B had shorter intubation and intensive care unit hospitalization times, lower mean pulmonary artery pressures and pulmonary vascular resistance, higher partial pressures of oxygen in arterial blood and oxygen saturation, and decreased medical expenditure compared with group A. During a mean 37.1 ± 21.4 months of follow-up, 3 patients in group A and 2 in group B died; however, the difference in the actuarial survival at 3 years postoperatively between the 2 groups was not statistically significant. CONCLUSIONS PTOBPCA can reduce the incidence of reperfusion pulmonary edema, shorten intensive care unit hospitalization and intubation duration, improve early hemodynamic function, and reduce ECMO usage after PEA.

Prognosis of Percutaneous Coronary Intervention and Coronary Artery Bypass Grafts for Ostial Right Coronary Lesions in Propensity‐Matched Individuals

OBJECTIVE Our aim was to evaluate the relative safety and efficacy of percutaneous coronary intervention (PCI) with drug-eluting stents (DES) versus coronary artery bypass grafts (CABG) for the treatment of ostial right coronary stenosis (ORCS) lesions. METHODS Three hundred fifty-nine cases of ORCS lesion were treated via CABG (n = 232) or PCI (n = 127) procedures. Propensity scores for undergoing the CABG procedure were estimated and used to match 105 pairs of patients between the two groups. Kaplan-Meier major adverse cardiac and cerebrovascular events (MACCE)-free curves were constructed to compare long-term MACCE-free survival between the two groups. RESULTS For the 105 propensity-matched pairs, patients were more likely to undergo repeat revascularization with CABG in the PCI group than in the CABG group during the first 30 days (4 cases vs. 0 case, P= 0.043, χ(2) = 4.08) and the 1-year follow-up (5 cases vs. 0 case, P= 0.02, χ(2) = 5.17). With a mean follow-up of 12.04 ± 6.47 months and a total of 210.67 patient-years, the freedom from MACCE in the CABG group was significantly higher than that in the PCI group (Log rank test, χ(2) = 4.48, P= 0.03). There were no significant differences in the rates of death, myocardial infarction, nonfatal stroke, death/myocardium infarction/stroke, or repeated PCI between the two groups during the first 30 days and during the 1-year follow-up period. CONCLUSION For OCRS lesions, CABG provided greater protection than PCI procedure in terms of freedom from MACCE, mainly due to the reduced number of repeated revascularization procedures. CABG should be considered as first-choice revascularization strategy for ORCS lesions.

Early Results of Coronary Endarterectomy Combined with Coronary Artery Bypass Grafting in Patients with Diffused Coronary Artery Disease

Background:It is still a challenge for the cardiac surgeons to achieve adequate revascularization for diffused coronary artery disease (CAD). Coronary endarterectomy (CE) offers an alternative choice of coronary artery reconstruction and revascularization. In this study, short-term result of CE combined with coronary artery bypass graft (CABG) was discussed in the treatment for the diffused CAD. Methods:From January 2012 to April 2014, 221 cases of CABG were performed by the same surgeon in our unit. Among these cases, 38 cases of CE + CABG were performed, which was about 17.2% (38/221) of the cohort. All these patients were divided into two groups: CE + CABG group (Group A) and CABG alone group (Group B). All clinical data were compared between the two groups, and postoperative complications and in-hospital mortality were analyzed. The categorical and continuous variables were analyzed by Chi-square test and Students t-test respectively. Results:Diabetes mellitus, hypertension, hyperlipidemia, and peripheral vascular disease were more common in group A. In this cohort, a total of 50 vessels were endarterectomized. Among them, CE was performed on left anterior descending artery in 11 cases, on right coronary artery in 29 cases, on diagonal artery in 3 cases, on intermediate artery in 2 cases, on obtuse marginal artery in 5 cases. There was no hospital mortality in both groups. The intro-aortic balloon pump was required in 3 cases in Group A (3/38), which was more often than that in Group B (3/183). At the time of follow-up, coronary computed tomography angiogram showed all the grafts with CE were patent (50/50). There is no cardio-related mortality in both groups. All these patients were free from coronary re-intervention. Conclusions:Coronary endarterectomy + CABG can offer satisfactory result for patients with diffused CAD in a short-term after the operation.

Patients with Congenital Systemic-to-Pulmonary Shunts and Increased Pulmonary Vascular Resistance: What Predicts Postoperative Survival?

Background We carried out a retrospective data review of patients with systemic to pulmonary shunts that underwent surgical repair between February 1990 and February 2012 in order to assess preoperative pulmonary vascular dynamic risk factors for predicting early and late deaths due presumably to pulmonary vascular disease. Methods and Results A total of 1024 cases of congenital systemic-to-pulmonary shunt and advanced pulmonary vascular disease beyond infancy and early childhood were closed surgically. The mean follow up duration was 8.5±5.5 (range 0.7 to 20) years. Sixty-one in-hospital deaths (5.96%, 61/1024) occurred after the shunt closure procedure and there were 46 late deaths, yielding 107 total deaths. We analyzed preoperative pulmonary vascular resistance index (PVRI), pulmonary vascular resistance index on pure oxygen challenge (PVRIO), difference between PVRI and PVRIO (PVRID), Qp∶Qs, and Rp∶Rs as individual risk predictors. The results showed that these individual factors all predicted in-hospital death and total death with PVRIO showing better performance than other risk factors. A multivariable Cox regression model was built,and suggested that PVRID and Qp∶Qs were informative factors for predicting survival time from late death and closure of congenital septal defects was safe with a PVRIO<10.3 WU.m2 and PVRID>7.3 WU.m2 on 100% oxygen. Conclusions All 4 variables, PVRI, PVRIO, PVRID and Qp∶Qs, should be considered in deciding surgical closure of congenital septal defects and a PVRIO<10.3 WU.m2 and PVRID>7.3 WU.m2 on 100% oxygen are associated with a favorable risk benefit profile for the procedure.

Differentiation of mouse-induced pluripotent stem cells into cardiomyocytes in vitro

Abstract In order to investigate the effective method to induce mice-induced pluripotent stem (miPS) cells into cardiomyocytes in vitro and to investigate the effect of vitamin C on cardiomyocyte differentiation from miPS cells to find a highly efficient and clinically safe method. MiPS cells were isolated and expanded to form embryoid bodies (EBs) using the hanging drop way. EBs were induced using differentiation medium containing vitamin C (10−4 mmol/ml). The control group did not receive any form of inducer. The time and frequency at which beating cardiomyocytes appeared and the percentage of beating colonies were determined to investigate the function of vitamin C on cardiac myocytes differentiation from miPS cells. Beating cell areas were found in (62.5 ± 1.7%) of EBs when using differentiation medium containing vitamin C, which was at a significantly greater frequency than in the control group (7.6 ± 2.6%). Beating cardiomyocytes within the two groups were positive for troponin (cTnT) staining. Vitamin C markedly increased the productivity of miPS cell differentiation into cardiomyocytes, as supported by expression of the unique cardiac protein cTnT. The vitamin C is suitable candidate for the induction of miPS cell differentiation into cardiomyocytes in vitro.

Ostial left main coronary artery stenosis as an additional risk factor in off-pump coronary artery bypass grafting

BACKGROUND Our aim was to determine whether general left main coronary artery stenosis (LMS) and ostial LMS pose additional risks after off-pump coronary artery bypass grafting (CABG) relative to non-left main coronary artery stenosis. METHODS From January 1, 2008, to December 31, 2009, 4366 patients underwent primary isolated off-pump CABG at Beijing Anzhen Hospital. Disease was retrospectively classified as non-left main disease (n = 3523), nonostial LMS (n = 765), and ostial LMS (n = 78). Groups were propensity score matched. Kaplan-Meier freedoms from major adverse cardiac and cerebrovascular events (MACCEs) were calculated. RESULTS During the first 30 postoperative days, mortality was significantly higher in the ostial LMS group (6.41%) than in non-left main disease (0.855%, χ(2) = 7.78, P = .005) and nonostial LMS (1.28%, χ(2) = 4.71, P = .03) groups. Incidence of MACCEs was significantly higher in the ostial LMS group (20.5%) than in non-left main disease (5.98%, P = .000) and nonostial LMS (9.62%, P = .002) groups. Odds ratio for early MACCEs of ostial LMS versus non-left main disease was 3.74 (95% confidence interval, 1.72-8.17). At mean follow-up 12.8 ± 7.5 months and cumulative follow-up 498.5 patient-years, difference among groups in freedom from MACCEs did not reach statistical significance (χ(2) = 2.39, P = .303). CONCLUSIONS Ostial LMS poses additional early risks of mortality and MACCEs in off-pump CABG. Off-pump CABG for ostial LMS should proceed with greater of intraoperative surveillance and lower threshold for converting to on-pump CABG.

Sudden Thrombosis in Coronary Artery Bypass Grafting Surgery.

To the Editor: A 47-year-old male patient was admitted because of chest discomfort for 2 weeks. He had no obvious incentive precordial discomfort 2 weeks ago, accompanied by palpitation. He immediately went to the town hospital. Electrocardiogram (ECG) showed myocardial infarction. Coronary angiography showed coronary artery disease accompanied by a ventricular aneurysm. The patient was transferred to Beijing Anzhen Hospital. ECG showed sinus rhythm, heart axis deviation + 111°, anterior septal, anterior lateral, anterior myocardial infarction, and complete right bundle branch block. Chest X-ray showed no obvious abnormalities in heart and lung. Echocardiography showed abnormal motion of segmental ventricular wall; formation of a ventricular aneurysm in apex area of the heart, the diameter of the ventricular aneurysm was 2 cm, the diastolic function of left ventricular was reduced. Coronary angiography showed left anterior descending artery filling slowly and its intima was not smooth; the stenosis rate was 90%. The stenosis rate of the circumflex artery was 90% [Figure ​[Figure1a1a and ​andb].b]. He was diagnosed with acute anterior myocardial infarction, left ventricular aneurysm, and hypertension. Figure 1 Coronary angiography right anterior oblique 30° display. (a) The circumflex artery was filled and stenosis. Left anterior descending artery was not completely filled; (b) After the circumflex artery was filled, left anterior descending artery ... The patient received treatment of dilation of a coronary artery, anticoagulation, nourishing myocardium, and other symptomatic and supportive treatment. He underwent off-pump coronary artery bypass surgery with median incision of the sternum. Take the left internal mammary artery and the right saphenous vein in reserve. Activating clotting time (ACT) value was 391 s after intravenous injection of 75 mg heparin. Left internal mammary artery - left anterior descending artery; aorta - saphenous vein - obtuse marginal branch vascular anastomosis were performed using external fixator. Anastomotic stoma was unobstructed and nonhemorrhage. Flow meter displayed satisfactory flow in grafts. Heparin was neutralized followed by routine chest shut surgery. The patient broke out in the sudden reduction of blood pressure and ventricular fibrillation. Defibrillation (200 Ws) and emergency chest compressions were performed followed by exploratory thoracotomy surgery. Intra-aortic balloon counterpulsation (IABP) was used as an assistive device. Extracorporeal circulation was established. Heparin (250 mg) was intravenously injected. ACT value after heparin injection was 486 s, intraoperative ACT value was 610 s. Flow meter displayed no flow in grafts. A redo coronary artery bypass grafting surgery was performed. Thrombosis was found in the left internal mammary artery distal anastomosis and the left anterior descending artery, saphenous vein proximal and distal anastomosis, and the circumflex artery. The thrombus in anastomosis and grafts was carefully removed and the proximal and the distal grafts was spied. The distal circumflex artery was not satisfying. The distal left anterior descending artery was satisfying. Aorta - saphenous vein - anterior descending artery, aorta - saphenous vein - obtuse marginal branch vascular anastomosis were performed again. Anastomotic stoma was unobstructed. Extracorporeal circulation device could not stop so as to install extracorporeal membrane oxygenation (ECMO) assist device. Stop extracorporeal circulation device followed by routine chest shut surgery. The patients vital signs were closely surveilled in Intensive Care Unit (ICU). The patient accepted cardiotonic agents, anti-infection, nourishing myocardium, and other symptomatic treatment. The patient condition gradually improved, ECMO device was removed on the fourth postoperative day. Trachea cannula was removed on the fifth postoperative day. IABP device was removed on the seventh postoperative day. The patient went back to the ward on the eighth postoperative day. Heart rhythm was regular. Cardiac murmur did not exist. Chest X-ray, echocardiography, and ECG showed no abnormalities. The patient was discharged 15 days after the operation. Thrombosis is a common complication of coronary artery bypass graft surgery. The thrombosis is classified as arterial thrombosis and venous thrombosis. Venous thrombosis is common, arterial thrombosis is rare. The main causes of venous thrombosis are vascular intimal injury and blood clotting disorders. The intimal injury may activate platelet function and make platelets release thromboxane A and other clotting factors to promote thrombosis. Coagulation abnormalities may lead to increased activity of clotting factor which could cause thrombosis. Arterial thrombosis is rare and its mechanism is unknown. Currently, it is known that heparin resistance is one of the reasons for arterial thrombosis. Heparin is an acidic mucopolysaccharide composed of glucosamine L-iduronic glucoside, N-acetyl glucosamine, and D-glucuronic acid. It is mainly produced by mast cells and basophils. Despite its little content in plasma under normal physiological conditions, it has rich content in the lung, liver, and other tissues. The anticoagulant effect of heparin is strong. It enhances the affinity of antithrombin III and thrombin, accelerates thrombin inactivation, inhibits clotting factor activation, inhibits platelet adhesion and aggregation, increases protein C activation, and stimulates vascular endothelial cells to release anticoagulant and fibrinolytic substances. Heparin is widely used in cardiovascular surgery. Studies have shown that patients undergoing coronary artery bypass surgery shows heparin resistance. The incidence of this phenomenon is rising.[1] Heparin resistance refers to the phenomena that ACT value is <400 s under the use of a standard dose of heparin.[2] If ACT value is <400 s, it is not sufficient for the patient to have plasma anticoagulant capacity in vivo. Meanwhile, the use of extracorporeal circulation system will lead to excessive activation of the coagulation system.[3] Lower activity of antithrombin III may be the cause of heparin resistance.[4] However, some reports showed that there is no direct relationship between antithrombin III and heparin.[5] Patients show symptoms of heparin resistance with the high levels of platelet in the blood. The mechanism is that platelets can release platelet factor 4 which could inhibit the function of heparin. The patients with the high levels of platelet in the blood will be able to inhibit the effect of heparin to a certain extent. The reason for heparin resistance is very complex. ACT value is not a specific indicator for the anticoagulant capacity of heparin. ACT value is affected by many variables in cardiac surgery. However, clinicians still use ACT value as the detection indicator of heparin anticoagulant capabilities. Heparin resistance can lead to a variety of serious complications such as bleeding, cardiac arrhythmia, ventricular fibrillation, prolonged intubation time, and prolonged residence time in ICU. This patient who had coronary artery bypass grafting surgery may have heparin resistance which lead to thrombosis in a coronary artery, artery, and vein grafts. The mechanism of heparin resistance is unclear. It is hoped that medical workers gain experience in future clinical work. Hence, heparin resistance phenomenon can be reduced. Financial support and sponsorship This work was supported by grants from 2014 Chaoyang District, Beijing Science and Technology Program (No. SF1417); 2015 Capital Medical University Student Technological Innovation Program (No. XSKY2015192). Conflicts of interest There are no conflicts of interest.