Shengli Jiang

Combined treatment of ulinastatin and tranexamic acid provides beneficial effects by inhibiting inflammatory and fibrinolytic response in patients undergoing heart valve replacement surgery.

OBJECTIVE To investigate the effect of ulinastatin and tranexamic acid administered alone or in combination on inflammatory cytokines and fibrinolytic system in patients undergoing heart valve replacement surgery during cardiopulmonary bypass (CPB). BACKGROUND CPB-induced fibrinolytic hyperfunction and systemic inflammatory response syndrome (SIRS) are the leading causes responsible for the occurrence of postsurgical complications such as postsurgical cardiac insufficiency and lung injury, which may lead to an increase in postsurgical bleeding, prolongation of hospital stay, and increased costs. METHODS One hundred twenty patients undergoing heart valve replacement surgery during CPB were randomly assigned into 4 groups of 30 patients each: blank control group (Group C), tranexamic acid group (Group T), ulinastatin group (Group U), and tranexamic acid-ulinastatin combination group (Group D). Physiological saline, tranexamic acid, ulinastatin, and a combination of tranexamic acid and ulinastatin were given to each group, respectively. Arterial blood was collected from the radial artery at 4 time points: after induction of anesthesia (T1), unclamping the ascending aorta (T2), and at 1 hour (T3) and 24 hours (T4) after CPB. The levels of plasma tumor necrosis factor alpha (TNF-α), interleukin 6 (IL-6), neutrophil elastase (NE), and the concentrations of tissue plasminogen activator (t-PA) and α2-antiplasmin (α2-AP) were detected. The changes in the volume of pericardial mediastinal drainage after surgery were observed and recorded. RESULTS The plasma TNF-α, IL-6, and NE levels significantly increased in patients from all 4 groups at time points of T2, T3, and T4 in comparison to those before CPB (P < .05), and the plasma TNF-α and IL-6 levels in groups U and D were significantly lower than those in the other 2 groups (P < .05). The plasma t-PA, α2-AP, and D-dimer concentrations significantly increased in patients from all 4 groups at T2 and T3 compared with those before CPB (P < .05), and the plasma t-PA and D-dimer concentrations were significantly lower in groups T and D than those in groups U and C (P < .05) at T2 and T3. The plasma α2-AP concentrations in groups T and D were significantly higher than those in Group C at T3 (P < .05). The volumes of pericardial mediastinal drainage per body surface area were significantly lower in groups T and D than those in Group C 6 hours after the surgery (P < .05). CONCLUSIONS Ulinastatin inhibits the release of inflammatory medium and reduces the inflammatory response during CPB. Tranexamic acid can effectively inhibit the fibrinolytic hyperfunction caused by CPB and thus decreases postsurgical bleeding. In addition, it exhibits a minor anti-inflammatory response. As a consequence, a combined treatment of ulinastatin and tranexamic acid reduces postsurgical bleeding and shortens postoperative hospital stay in patients undergoing heart valve replacement surgery.

Congenital mitral valve regurgitation in adult patients.

OBJECTIVE Congenital mitral valve regurgitation (MVR) is a rare disease found in adults. We report on our 5-year surgical experience with congenital MVR in adults. METHODS We reviewed the data for 48 consecutive patients (26 men), aged >18 years (median, 42 years; range, 18-78 years) who underwent operations for severe congenital MVR between June 2005 and May 2010. Patients with atrioventricular septal defect were excluded. RESULTS Congenital MVR was preoperatively diagnosed in 28 cases (58%). The lesions consisted of annular dilation (100%), valvular cleft (58%), prolapsed leaflet (40%), papillary muscle abnormality (5%), commissure fusion (2%), and leaflet deficiency (2%). Mitral valve repair was performed in 42 cases (88%) by means of Carpentier techniques. The other 6 patients underwent mitral valve replacement; one of these patients died of ventricular fibrillation 2 days after surgery. There were no other hospital deaths or late mortality. At the last follow-up (median, 38 months; range, 2-50 months), all 47 patients were in New York Heart Association functional class I or II. Echocardiography evaluations for the 42 patients who underwent the repairs revealed that 32 (76%) of the patients had no or trivial MVR and 10 patients (24%) had mild MVR. No patient underwent reoperation. CONCLUSION Congenital MVR is rare and often misdiagnosed in adults. Mitral valve repair is feasible in the majority of patients, with excellent immediate and medium-term results.

Surgery on a Patient with Iatrogenic Aortic Valve Leaflet Perforation after Repair of a Congenital Ventricular Septal Defect

Aortic valve regurgitation caused by a leaflet perforation occurs most often with infective endocarditis involving the aortic valve. Although rare, leaflet perforation can be caused by suture-related injury during cardiac operations, such as mitral valve replacement, ventricular septal defect (VSD) repair, and repair of an ostium primum atrial septal defect. Few reports have described this form of iatrogenic aortic valve leaflet perforation. We used a pericardial patch in a successful repair of an iatrogenic perforation in an aortic valve leaflet that occurred after simple VSD repair.

Successful surgical treatment of intramural aortoatrial fistula, severe aortic regurgitation, mitral prolapse, and tricuspid insufficiency in a patient with Ehlers-Danlos syndrome type IV.

Patients with Ehlers-Danlos syndrome (EDS) type IV, an inherited connective tissue disorder, are predisposed to vascular and digestive ruptures, and arterial ruptures account for the majority of deaths. A 31-year-old man with EDS presented with an intramural aortoatrial fistula, severe aortic regurgitation, mitral valve prolapse, and severe tricuspid valve insufficiency combined with a severely dilated left ventricle. Determining the best surgical option for the patient was not easy, especially regarding the course of action for the aortic root with a tear in the sinus of Valsalva. The fistula tract was closed at the aorta with suture and with a patch in the right atrium, the mitral valve was repaired with edge-to-edge suture and then annuloplasty with a Cosgrove ring, the aortic valve was replaced with a mechanical prosthesis, and a modified De Vega technique was used for the tricuspid valvuloplasty. The postoperative course was uncomplicated, and the patient was discharged 2 weeks later. The considerations made to arrive at the chosen surgical course of action in this complex case are reviewed.

Effect of Subzero-Balanced Ultrafiltration on Lung Gas Exchange Capacity after Cardiopulmonary Bypass in Adult Patients with Heart Valve Disease

OBJECTIVES This study was conducted to evaluate the effect of a new ultrafiltration technique--the subzero-balanced ultrafiltration (SBUF)--on lung gas exchange capacity after cardiopulmonary bypass (CPB) in adult patients with heart valve disease. BACKGROUND Attenuation of lung gas exchange capacity is one of the most common manifestations of an inflammatory response after CPB. METHODS Ninety-four patients who required CPB for cardiac surgery were randomized into 2 groups according to whether they received SBUF. Gas exchange capacity expressed as the oxygen index (OI), the respiratory index (RI), and the alveolar-arterial oxygen pressure difference (P(A-a)O2) were measured after intubation (T1), at the termination of CPB (T2), on admission to the intensive care unit (ICU) (T3), at postoperative hour 6 (T4), and at postoperative hour 12 (T5). RESULTS There were no significant differences in gas exchange capacity between the 2 groups at T1, T4, and T5. CPB produced significant changes in OI, RI, and P(A-a)O2 in the control group, whereas these changes were not significantly different in the study group. The OI in the study group was significantly higher at T2, and RI and P(A-a)O2 were significantly lower at T2 and T3. In the study group, the intubation time was shorter, and the transfusion volume within 24 hours postoperatively was less. The 2 groups were comparable with respect to the incidence of respiratory complications, length of stay in the ICU, duration of hospital stay, need for infusions of inotropic agents, and drainage volumes within 24 hours postoperatively. CONCLUSIONS SBUF during CPB can produce an immediate improvement in lung gas exchange capacity, which may effectively minimize pulmonary dysfunction in adult patients undergoing cardiac surgery.

Iatrogenic Aortic Valve Perforation after Ventricular Septal Defect Repair

Iatrogenic aortic valve (AV) perforation during non-aortic cardiac operations is a rare complication. The suture-related inadvertent injury to an AV leaflet can produce leaflet perforation with aortic regurgitation after ventricular septal defect repair (VSDR). We report three consecutive patients who had iatrogenic aortic leaflet perforation during VSDR in other hospitals and referred to our hospital for reoperation. In all three cases, the perforated AV leaflets were preserved and repaired by autologous pericardial patch or direct local closure.

Is long-term warfarin therapy necessary in Chinese patients with atrial fibrillation after bioprosthetic mitral valve replacement and left atrial appendage obliteration?

BACKGROUND Long-term warfarin therapy has been used to decrease thromboembolic events in patients with atrial fibrillation (AF) following bioprosthetic mitral valve replacement (BMVR) and left atrial appendage obliteration (LAAO). A retrospective study was conducted to investigate the efficacy of long-term warfarin or aspirin therapy in patients with AF after BMVR and LAAO. METHODS A total of 215 patients with persistent AF were given anticoagulation therapy with warfarin for the first 3 months after BMVR and LAAO, continuing warfarin or aspirin therapy according to the surgeons preference. A yearly follow-up with patients was performed by telephone or mail for postoperative condition, cerebrovascular, and bleeding events. RESULTS Seven patients died in the first 3 months after surgery, including 6 patients from heart failure and 1 patient from sudden death. The remaining 208 patients were divided into two groups: warfarin group (n = 84 patients) and aspirin group (n = 124). The patients in the warfarin group were older than those in the aspirin group and had a lower postoperative left ventricular ejection fraction. Other baseline and operative characteristics were similar. The two groups had similar incidence of thromboembolic events (9.5% versus 8.9%, P = .873) and bleeding events（7.1% versus 3.2%, P = .207). Each group had one intracranial hemorrhage. Eleven patients expired within three months after surgery, 4（4.8%) in the warfarin group and 10（8.1%）in the aspirin group (P = .411 by Fisher exact test). Cumulative survival was not significantly different in the two groups by Kaplan-Meier analysis (P = .55, log-rank test). CONCLUSIONS At the current time in China, long-term warfarin or aspirin therapy may have no significantly different impact on long-term prognosis after 3 months anticoagulation with warfarin in patients with AF undergoing BMVR and LAAO.

Pseudoaneurysm of the Ascending Aorta Combined with Aortic Valve Infective Endocarditis following Cardiac Operations

BACKGROUND AND OBJECTIVE Aortic pseudoaneurysms are rare but life-threatening complications of aortic procedures. Operation on the femorofemoral bypass with hypothermic circulatory arrest has been the method of choice. Iatrogenic ascending aorta pseudoaneurysm combined with infective endocarditis of the aortic valve has never been reported. MATERIALS AND METHODS We describe a case of a pseudoaneurysm of the ascending aorta at the site of an aortotomy site concomitant with infective endocarditis of the aortic valve. A contrast computed tomographic scan was the investigation technology of choice. RESULTS The operation was performed on femorofemoral bypass without hypothermic circulatory arrest, which provided safe re-entry and an opportunity to replace the infected aortic valve with a mechanical prosthesis and to repair the aortic defect with a patch. CONCLUSIONS The ascending aorta pseudoaneurysm can be safely operated on with femorofemoral bypass without hypothermic cardiac arrest.

Accessory mitral valve causing left ventricular outflow tract obstruction.

We studied the clinical characteristics and operative treatment of left ventricular outflow tract obstruction (LVOTO) caused by a congenital accessory mitral valve (AMV). Two patients were admitted to our department. Preoperatively, case 1 was diagnosed as congenital heart disease with severe LVOTO and an anterior mitral valve cleft. The patient in case 2 had a congenital atrial septal defect combined with AMV and mild LVOTO, as well as mild mitral valve regurgitation. In case 1, LVOTO was caused by a type I (fixed) AMV. In case 2, the AMV was type II (mobile type). Both AMV were resected, and the concomitant cardiac disorders were treated simultaneously. The operations were successful, and the LVOTO almost disappeared. Patients with LVOTO caused by AMV should undergo operation for removal of the accessory valve. These patients should be followed up and observed periodically by Doppler echocardiography to identify any aggravation of the LVOTO.

Surgical Treatment of Early Acute Thrombosis of Mechanical Mitral Prosthesis

Prosthetic valve thrombosis is a rare but life threatening complication of mechanical heart valve prosthesis. A 44-year-old woman diagnosed with rheumatic heart disease with severe mitral valve stenosis, moderate tricuspid valve insufficiency, and atrial fibrillation underwent transseptal mitral valve replacement and tricuspid valvuloplasty in our department. Heparin and warfarin were routinely used postoperatively. Although the international normalized ratio (INR), activated partial thromboplastin time ratio, and platelet count were satisfactory, the patient presented with severe dyspnea suddenly 10 days after discharge; echocardiogram showed that the prosthetic posterior leaflet was immobile. The patient suffered cardiac arrest suddenly during the examination and cardiopulmonary resuscitation was carried out successfully. Emergent surgery was performed, confirming the prosthetic valve thrombosis. The prosthetic valve was replaced with another mechanical prosthesis. The patient recovered smoothly and was discharged 14 days later with atrial fibrillation. During the 12-months follow-up period, her prosthetic valve and heart function were normal with INR around 3.0. This case highlights the need for awareness among clinicians for the possibility of valve thrombosis in the early postoperative period.