WenJun Ding

Prophylactic Application of an Intra-Aortic Balloon Pump in High-Risk Patients Undergoing Off-Pump Coronary Artery Bypass Grafting

Background: An intra-aortic balloon pump (IABP) is the most commonly used circulatory assist device in cardiac surgery. We hypothesized that prophylactic application of an IABP improves early clinical outcome of high-risk patients undergoing scheduled off-pump coronary artery bypass grafting (OPCABG). Methods: From January 2010 to December 2013, hemodynamically stable, high-risk patients undergoing scheduled OPCABG with preincision use of an IABP were recruited to the IABP group. Using the propensity score-matching method, every patient in the IABP group was matched with another patient (the control group) with a similar propensity score who received an IABP on an as-needed basis during or after OPCABG. Surgical mortality and major morbidity rates were compared between groups. Results: A total of 116 patient pairs were included in this study. In patients in the IABP group, postoperative low cardiac output and respiratory as well as renal failure were less frequent, intensive care unit stay was shorter, and surgical mortality was lower compared to patients in the control group. In multivariate logistic regression, timing of IABP implantation, as an independent risk factor, was associated with postoperative low cardiac output (OR = 2.02, 95% CI 1.28-5.76), respiratory failure (OR = 1.86, 95% CI 1.19-4.27), renal failure (OR = 2.96, 95% CI 1.51-6.63) and surgical mortality (OR = 2.45, 95% CI 1.42-6.07). Conclusions: Prophylactic application of an IABP improves postoperative cardiac performance, reduces respiratory and renal complications, and consequently lowers surgical mortality in high-risk patients undergoing scheduled OPCABG.

Impact of mild preoperative renal insufficiency on in-hospital and long-term outcomes after off-pump coronary artery bypass grafting: a retrospective propensity score matching analysis

BackgroundMild preoperative renal insufficiency is not rare in patients receiving isolated off-pump coronary artery bypass grafting surgery (OPCAB) surgery. However, there is less study aimed to evaluate the impact of mild preoperative renal insufficiency on in-hospital and follow-up outcomes after isolated OPCAB surgery. This single-centre, retrospective propensity score matching study aimed to evaluate the impact of mild preoperative renal insufficiency on in-hospital and long-term outcomes after first isolated OPCAB surgery.MethodsAfter propensity score matching, 1236 patients with preoperative estimated glomerular filtration rate (eGFR) of more than 60xa0ml/min/1.73xa0m2 undergoing first isolated OPCAB surgery from January 2007 to December 2011 were entered into this study and were divided to normal group (eGFRu2009≥u200990xa0ml/min/1.73xa0m2, nu2009=u2009618) and mild group (eGFR of 60–89xa0ml/min/1.73xa0m2, nu2009=u2009618). The in-hospital and long-term outcomes were investigated and retrospectively analyzed.ResultsThe 2 propensity score-matched groups had similar baseline and procedural characteristics except the baseline eGFR. Thirty-five patients died during the same hospitalization or within 30xa0days of operation, with a surgical mortality of 2.8xa0%. Sixty-seven patients died during follow-up, with a long-term survival of 94.1xa0%. Univariate factor analysis showed that the 2 propensity score-matched groups have similar rates among in-hospital outcomes. Kaplan-Meier curves displayed a similar in-hospital survival between the 2 groups (χ2u2009=u20090.728, pu2009=u20090.393), while a better long-term survival in patients with normal preoperative renal function compared with mild preoperative renal insufficiency (χ2u2009=u20094.722, pu2009=u20090.030). After Cox proportional model was used, the hazard ratio for long-term mortality in patients with mild preoperative renal insufficiency compared with normal preoperative renal function was 1.72 (95 % CI 1.06–2.83, pu2009=u20090.032).ConclusionsMild preoperative renal insufficiency compared with normal preoperative renal function reduced long-term survival, without evidence of worse in-hospital outcomes.

Early clinical outcomes of on-pump beating-heart versus off-pump technique for surgical revascularization in patients with severe left ventricular dysfunction: the experience of a single center

BackgroundLimited experiences of applying an on-pump beating-heart technique for surgical revascularization in patients with severe left ventricular dysfunction have been reported. Which strategy, either off-pump coronary artery bypass grafting (CABG) or on-pump beating-heart CABG surgery, is the best strategy for surgical revascularization in patients with severe left ventricular dysfunction is still controversial. This single-center study aimed to evaluate the impacts of an on-pump beating-heart versus an off-pump technique for surgical revascularization on the early clinical outcomes in patients with a left ventricular ejection fraction (LVEF) of 35% or less to explore which technique would be more suitable for surgical revascularization in patients with severe left ventricular dysfunction.MethodsA total of 216 consecutive patients with an echocardiographic estimated LVEF of 35% or less who underwent non-emergency, primary, isolated CABG from January 2010 to December 2014 were included in this study and were divided into either an ONBEAT group (patients who received on-pump beating-heart CABG surgery, nu2009=u200988) or an OFF group (patients who received off-pump CABG surgery, nu2009=u2009128). The early clinical outcomes were investigated and compared.ResultsPatients in the ONBEAT group compared to the OFF group had a significant higher early postoperative LVEF (35.6u2009±u20092.9 vs. 34.8u2009±u20093.3%, pu2009=u20090.034) but shared a similar baseline LVEF (31.0u2009±u20092.8 vs. 31.0u2009±u20092.9%, pu2009=u20090.930). Patients in the ONBEAT group compared to the OFF group received a greater number of grafts and an increased amount of drainage during the first 24xa0h (3.7u2009±u20090.8 vs. 2.8u2009±u20090.6, pu2009<0.001; 715u2009±u2009187xa0ml vs. 520u2009±u2009148xa0ml, pu2009<0.001, respectively), without evidence of worse in-hospital mortality or major postoperative morbidity. Additionally, logistic regression analysis showed that surgical technique (on-pump beating-heart CABG vs. off-pump CABG) had no independent influence on in-hospital mortality or major postoperative morbidity in patients with preoperative LVEF of 35% or less.ConclusionsThe on-pump beating-heart technique may be an acceptable alternative to the off-pump technique for surgical revascularization in patients with an estimated LVEF of 35% or less.

Preoperative glucose level has different effects on the endogenous extracellular matrix-related gene expression in saphenous vein of type 2 diabetic patients undergoing coronary surgery

Background: Type 2 diabetes mellitus (DM) severely reduces the benefits of coronary artery bypass grafting (CABG). However, few studies investigated the correlation between preoperative glucose level and endogenous extracellular matrix (ECM)-related gene expression of saphenous vein (SV) conduits in diabetic patients. Methods: A total of 130 patients were divided into high-glucose (HG), low-glucose (LG) and control group according to the preoperative level of blood glucose. The expression of ECM-related genes was analysed by microarray. Results: Compared with control group, 30 genes showed at least a threefold change in expression in HG group; up-regulation was observed in 24 genes. However, there were only 21 ECM-related genes showed at least a threefold change in expression between the LG and control group. Compared with HG group, matrix metalloproteinases’ (MMPs) expression was significantly decreased in LG and control groups. In contrast to the decrease in MMPs’ expression, expression of tissue inhibitors of metalloproteinases (TIMPs) was increased. Conclusion: This study suggested that different preoperative diabetic status affected the expression of ECM-related genes in SV. ECM-related genes were more significantly imbalanced in diabetic patients with uncontrolled preoperative blood glucose than those with well-controlled preoperative blood glucose.

Impact of Presurgical Mild Acute Respiratory Distress Syndrome on Surgical Mortality After Surgical Repair of Acute Type A Aortic Dissection

To evaluate the impact of presurgical mild acute respiratory distress syndrome (ARDS) on surgical mortality in patients undergoing surgical repair of acute type A aortic dissection by means of deep hypothermic circulatory arrest (DHCA) in a single-center, retrospective study.From January 2011 to December 2015, 333 eligible patients were divided into either a mild-ARDS group (n = 136) or a no-ARDS group (n = 197). The definition of mild ARDS referred to the recent revision of ARDS definition (Berlin criteria). The surgical mortality and major postoperative morbidity were investigated and analyzed.A total of 136 patients developed presurgical mild ARDS, with an incidence of 40.8%. No significant difference emerged between the 2 groups in major postoperative morbidity except for pulmonary complications. Multivariate logistic regression displayed that the risk of postoperative pulmonary complications in patients with presurgical mild ARDS was 4.25 times that in patients without presurgical ARDS (OR = 4.25, 95% CI 2.05-7.72). Twenty-four patients died after surgery, with significantly higher surgical mortality in the mild-ARDS group compared with the no-ARDS group (12.5% versus 3.6%, P = 0.002). Kaplan-Meier curves showed a poor surgical survival in the mild-ARDS group (χ2=12.958, Log-Rank P < 0.001). And Cox regression revealed the hazard ratio for surgical mortality in the mild-ARDS group compared with the no-ARDS group was 2.52 (95%CI 1.41-5.32, P = 0.016).Presurgical mild ARDS increased postoperative respiratory morbidity, and then increased surgical mortality after surgical repair of acute type A aortic dissection by means of DHCA.

Dysregulated gene expression of extracellular matrix and adhesion molecules in saphenous vein conduits of hemodialysis patients

OBJECTIVEnThe incidence of cardiovascular disease was approximately 10 times higher in hemodialysis patients with end-stage renal disease than in the general population. The saphenous vein is the most commonly used conduit for coronary artery bypass grafting. However, the extracellular matrix and adhesion molecule characteristics of saphenous vein in hemodialysis patients remain unclear. The aim of the present study was to survey the extracellular matrix gene expression profile of the saphenous vein in hemodialysis patients undergoing coronary artery bypass grafting.nnnMETHODSnA total of 34 patients undergoing elective coronary artery bypass grafting were enrolled. Of the 34 patients, 15 with end-stage renal disease required maintenance hemodialysis. The control group consisted of the other 19 patients without preoperative renal disease. Samples of the saphenous vein were obtained at coronary artery bypass grafting. The expression profile of the extracellular matrix genes was analyzed by microarray. The tissue matrix metallopeptidase/tissue inhibitor of metallopeptidase protein activities in the saphenous vein were evaluated by immunocytochemistry and Western blotting.nnnRESULTSnNineteen extracellular matrix and adhesion molecule-focused genes demonstrated at least a threefold difference in expression between the 2 groups. Upregulation was observed in 16 genes, and 3 genes appeared to be downregulated. Notable imbalanced matrix metallopeptidase/tissue inhibitor of metallopeptidase protein activities of saphenous vein exposed to end-stage renal disease conditions was found.nnnCONCLUSIONSnThe results from present study suggest that the native extracellular matrix gene expression profile of the saphenous vein conduits in hemodialysis patients show signs of the vein graft disease process before coronary surgery. Furthermore, some preoperative profiles of hemodialysis patients undergoing coronary artery bypass grafting might provide some useful clues regarding vein graft quality and prompt adjustment in surgical strategy.

Disorder gene expression of extracellular matrix and adhesion molecules in saphenous vein conduits of diabetic patients

Saphenous vein (SV) is the most commonly employed conduit in coronary surgery. However, the extracellular matrix (ECM) characteristics of SV in diabetic patients still remain unclear. This study was to survey the ECM gene expression profile of SV in diabetic patients. Thirty-five patients had type 2 diabetic mellitus; the non-diabetic (control) group comprised 49 patients. The expression profile of ECM genes was analysed by microarray. Tissue MMP/TIMP protein activities were evaluated by immunocytochemistry and western-blot. In this microarray, 25 genes demonstrated at least a 3-fold difference in expression. Upregulation was observed in 20 genes, while five genes appeared to be downregulated. SV exposed to DM conditions demonstrated a notable increase in MMP-2 and MMP-9 but a significant decrease in TIMP-2 and TIMP-3 in protein concentration compared with control group. This study suggests that native ECM gene expression profile of SV in diabetic patients has showed signs of the vein graft disease process before coronary surgery. Preoperative profiles of diabetic patients might provide some useful clues regarding vein graft quality and prompt adjustment in surgical strategy.

Benefits of Early Surgery on Clinical Outcomes after Degenerative Mitral Valve Repair

BACKGROUNDnThis study aimed to evaluate the clinical trends of mitral valve repair for degenerative mitral regurgitation and the benefit of early surgical intervention on repair durability in a high-volume center.nnnMETHODSnFrom January 2003 to December 2015, 1,903 consecutive patients with severe degenerative mitral regurgitation underwent mitral valve repair at our institution. The timing of surgical intervention was evaluated by guideline-related indications including symptoms, atrial fibrillation, left ventricular dysfunction, and pulmonary hypertension. Clinical outcomes and risk factors for recurrent mitral regurgitation were analyzed.nnnRESULTSnOver 13 years from 2003 to 2015, trends of preoperative characteristics demonstrated that the proportion of asymptomatic patients substantially increased. The 8-year overall survival, freedom from reoperation for mitral valve, and freedom from recurrent mitral regurgitation were 96%, 96%, and 85%, respectively. Ejection fraction less than 60%, left ventricular end-diastolic dimension greater than 60 mm, isolated anterior leaflet lesion, and intraoperative mild residual mitral regurgitation were independent predictive factors for recurrent mitral regurgitation. The incidence of recurrent mitral regurgitation was significantly lower in the early intervention group (3% versus 18%, p < 0.01). In subgroup analysis of asymptomatic patients, the incidence of recurrent mitral regurgitation was significantly lower in patients without guideline-related indications (3% versus 31%, p < 0.0001).nnnCONCLUSIONSnEarly surgical intervention for severe degenerative mitral regurgitation before symptoms, atrial fibrillation, and ventricular dysfunction are associated with excellent clinical outcomes. Besides complexity of leaflet lesion and repair quality, surgical timing also significantly affects repair durability. Early surgical intervention should therefore be recommended to reduce recurrent mitral regurgitation.

In Situ Skeletonized Right Internal Mammary Artery Bypass Grafting to Left Anterior Descending Artery: Feasibility, Mid-Term Efficacy, and Risk Factors for Graft Failure

This study aimed to evaluate the feasibility and the mid-term efficacy of an in situ skeletonized right internal mammary artery (IMA) bypass grafting to a left anterior descending artery (LAD), and to determine risk factors for IMA graft failure in a single-center study.From January 2012 to December 2015, 189 patients (173 males, 50.6 ± 6.0 years old) undergoing first isolated coronary artery bypass grafting surgery with the in situ skeletonized right IMA grafting to the LAD were included in this study. Baseline characteristics, peroperative data, and follow-up outcomes were investigated and analyzed.The length of the in situ skeletonized right IMA grafts was 18.6 ± 1.2 cm (17.0-22.0 cm). Intraoperative graft flow of the in situ skeletonized right IMA grafting to LAD was 42 ± 9 mL/minute (18-72 mL/minute) associated with measured pulsatility index of 0.8-4.3. In-hospital mortality was 0.5%. Postoperative morbidity included acute myocardial infarction (0.5%), stroke (0.5%), and deep sternal wound infections (1.1%). The mid-term survival was 97.2% and the incidence of repeat revascularization was 0.6%. The patency rate of the in situ skeletonized right IMA grafting to the LAD was 97.1% by computed tomography angiography examination during the follow-up period of 23.2 ± 9.7 months. Additionally, logistic regression analysis showed that intraoperative graft flow had an independent influence on the risk of the mid-term right IMA graft failure.The strategy of the in situ skeletonized right IMA grafting to the LAD is feasible and effective. Intraoperative graft flow was an independent risk factor for the mid-term right IMA graft failure.

Sequential Saphenous Vein Coronary Bypass Grafting: Does the Number of Distal Anastomoses per Single Vein Affect the Graft Patency?

The enormous majority of previous reports focused on evaluating the safety and efficacy of sequential saphenous vein (SV) coronary bypass grafting; however, no reports to date have revealed concern regarding the impacts of the number of distal anastomoses of sequential SV grafting on graft patency after coronary artery bypass grafting (CABG). This single-center retrospective study aimed to evaluate the impacts of three versus two distal anastomoses per single SV conduit on SV graft patency after off-pump CABG, and to determine the independent risk factors for sequential SV graft failure.From January 2011 to December 2014, 1320 eligible patients were assigned to either a triple group (three distal anastomoses of sequential SV grafting, n = 758) or a double group (two distal anastomoses of sequential SV grafting, n = 562). The primary endpoint was over a 2-year follow-up SV graft failure after off-pump CABG.The triple and double group received a similar total patency rate of sequential SV conduits (86.5% versus 87.1%, P = 0.757). The number of distal anastomoses of sequential SV grafting (three versus two) was not a predictive factor for the follow-up graft failure of sequential SV conduits (HR = 0.91, 95% CI: 0.66-2.29, P = 0.137). Moreover, the two groups received a similar follow-up survival freedom from repeat revascularization (χ2 = 1.881, log-rank P = 0.170).Three versus two distal anastomoses per single SV conduit received a similar SV graft patency. The number of distal anastomoses of sequential SV grafting was not an independent risk factor for graft failure.