Yingbin Xiao

Outcomes of ventricular assist device support in young patients with small body surface area.

OBJECTIVE Although the ventricular assist device (VAD) has been a well-established therapy for larger adolescents and adult patients with advanced heart failure, current experience with the use of VAD for mechanical circulatory support in infants and young children with small body surface area is still limited. METHODS Between January 1999 and December 2009, 56 small children with body surface area<1.2 m² were implanted with Berlin Heart EXCOR pediatric VAD in Germany Heart Institute Berlin. The etiology of end-stage myocardial failure included non-congenital (75%) and congenital heart disease (25%); the median age at implant was 1 year (12 days to 14 years), and the median support time was 55 days (1-432 days). RESULTS Of the 56 pediatric patients, 24 were bridged to heart transplantation, 12 were explanted following myocardial recovery, two continued to receive support, and the other 18 died on support. The accurate rate of survival on VAD support was 81.1% ± 5.8% and 51.4% ± 9.3% at 30 days and 1 year after EXCOR implantation. Patients receiving biventricular support had a trend towards higher post-implantation mortality as compared with children implanted with left ventricular assist device (LVAD) (P = 0.09). Lower post-implantation survival was also observed in patients with congenital cardiac disease compared with children with a non-congenital etiology (P < 0.001). CONCLUSIONS Berlin Heart EXCOR pediatric VAD could provide satisfactory and safe circulatory support for small children with end-stage heart disease.

Ventilator-associated pneumonia after cardiac surgery: A meta-analysis and systematic review

OBJECTIVE Ventilator-associated pneumonia (VAP) is the most common and serious nosocomial infection that threatens patients who have undergone cardiac surgery. This article summarizes its clinical characteristics and provides theoretical evidence for prevention and treatment. METHODS A literature search was conducted using PubMed, Embase, the Cochrane Library, and Web of Knowledge databases and by manual search. Data involving the prevalence, etiology, risk factors, or clinical outcomes were extracted for systematic review and meta-analysis. RESULTS Eleven studies on VAP after cardiac surgery were included. When the results were merged the VAP rate was 21.27/1000 ventilator-days. The prevalence reached 6.37% of all patients and 35.2% of patients who were on mechanical ventilation for more than 48 hours. Among the isolated pathogens, Pseudomonas aeruginosa had the highest detection rate, with an average of 23.19%, followed by Staphylococcus aureus (20.15%), Haemophilus influenzae (19.53%), Acinetobacter baumannii (10.68%), Escherichia coli (10.18%), Klebsiella pneumoniae (9.52%), and Candida albicans (7.20%). Risk factors were also analyzed. We found that New York Heart Association cardiac function class IV, pulmonary hypertension, chronic obstructive pulmonary disease, peripheral vascular disease, renal disease, emergency surgery, intra-aortic balloon counterpulsation, cardiopulmonary bypass time, aortic crossclamp time, mechanical ventilation time, reintervention, and reintubation were closely related to the occurrence of VAP; there was no association with gender and diabetes mellitus. Once patients had VAP, mortality and length of stay in the intensive care unit were significantly increased. CONCLUSIONS VAP in patients after cardiac surgery is common and has a poor prognosis. It is mainly caused by gram-negative bacteria, and could be affected by a series of factors.

Emergent Endovascular vs. Open Surgery Repair for Ruptured Abdominal Aortic Aneurysms: A Meta-Analysis

Objectives To systematically review studies comparing peri-operative mortality and length of hospital stay in patients with ruptured abdominal aortic aneurysms (rAAAs) who underwent endovascular aneurysm repair (EVAR) to patients who underwent open surgical repair (OSR). Methods The Medline, Cochrane, EMBASE, and Google Scholar databases were searched until Apr 30, 2013 using keywords such as abdominal aortic aneurysm, emergent, emergency, rupture, leaking, acute, endovascular, stent, graft, and endoscopic. The primary outcome was peri-operative mortality and the secondary outcome was length of hospital stay. Results A total of 18 studies (2 randomized controlled trials, 5 prospective studies, and 11 retrospective studies) with a total of 135,734 rAAA patients were included. rAAA patients who underwent EVAR had significantly lower peri-operative mortality compared to those who underwent OSR (overall OR = 0.62, 95% CI = 0.58 to 0.67, P<0.001). rAAA patients with EVAR also had a significantly shorter mean length of hospital stay compared to those with OSR (difference in mean length of stay ranged from −2.00 to −19.10 days, with the overall estimate being −5.25 days (95% CI = −9.23 to −1.26, P = 0.010). There was no publication bias and sensitivity analysis showed good reliability. Conclusions EVAR confers significant benefits in terms of peri-operative mortality and length of hospital stay. There is a need for more randomized controlled trials to compare outcomes of EVAR and OSR for rAAA.

Can serum levels of alkaline phosphatase and phosphate predict cardiovascular diseases and total mortality in individuals with preserved renal function? A systemic review and meta-analysis.

Background It is demonstrated that elevated serum levels of alkaline phosphatase (ALP) and phosphate indicate a higher risks of cardiovascular disease (CVD) and total mortality in population with chronic kidney disease (CKD), but it remains unclear whether this association exists in people with normal or preserved renal function. Method Clinical trials were searched from Embase and PubMed from inception to 2013 December using the keywords “ALP”, “phosphate”, “CVD”, “mortality” and so on, and finally 24 trials with a total of 147634 patients were included in this study. Dose-response and semi-parametric meta-analyses were performed. Results A linear association of serum levels of ALP and phosphate with risks of coronary heart disease (CHD) events, CVD events and deaths was identified. The relative risk(RR)of ALP for CVD deaths was 1.02 (95% confidence interval [CI], 1.01–1.04). The RR of phosphate for CVD deaths and events was 1.05 (95% CI, 1.02–1.09) and 1.04 (95% CI: 1.03–1.06), respectively. A non-linear association of ALP and phosphate with total mortality was identified. Compared with the reference category of ALP and phosphate, the pooled RR of ALP for total mortality was 1.57 (95% CI, 1.27–1.95) for the high ALP group, while the RR of phosphate for total mortality was 1.33 (95% CI, 1.21–1.46) for the high phosphate group. It was observed in subgroup analysis that higher levels of serum ALP and phosphate seemed to indicate a higher mortality rate in diabetic patients and those having previous CVD. The higher total mortality rate was more obvious in the men and Asians with high ALP. Conclusion A non-linear relationship exists between serum levels of ALP and phosphate and risk of total mortality. There appears to be a positive association of serum levels of ALP/phosphate with total mortality in people with normal or preserved renal function, while the relationship between ALP and CVD is still ambiguous.

Hypoxia-induced SOCS3 is limiting STAT3 phosphorylation and NF-κB activation in congenital heart disease.

Suppressor of cytokine signaling 3 (SOCS3) is a critical attenuator of the JAK-STAT signaling pathway, and it is involved in mediating the intensity and duration of STAT3 activation in the process of myocardial protection. Nuclear factor-κB (NF-κB) has emerged as a decisive transcription factor in cardiac myocyte compensatory responses to stress that enhance survival. However, the expression, activation and regulation of this signaling molecule in response to hypoxic stress have not been elucidated. We investigated 40 infants with cyanotic or acyanotic cardiac defects, as well as H9c2 embryonic rat cardiomyocytes, to examine the effect of hypoxia on the expression or activation of SOCS3, STAT3 and NF-κB in vivo and in vitro. We found an increase in endogenous cardiac SOCS3, p-STAT3 and AC-RelA activation in the myocardium of infants with cyanotic cardiac defects. In hypoxic cultivated H9c2 cells, SOCS3, STAT3 and AC-RelA activity slowly increased and then reached a stable expression. We evaluated the interaction of SOCS3 with STAT3 and NF-κB by transfecting the SOCS3 plasmid to hypoxic cultured H9c2 cells. Forced expression of SOCS3suppressed tyrosine phosphorylation of STAT3 and transcription of the C-myc and interleukin-6 genes. AC-RelA activation was also suppressed by over expression of SOCS3. These findings suggest that the mechanism of a positive transactivation loop that maintains higher levels of NF-κB and p-STAT3 and the negative feedback factor SOCS3, which maintains balanced NF-κB and p-STAT3 activities, is important in the process of myocardial adaptation to chronic hypoxia. SOCS3 is a rapid hypoxia inducible gene and acts to inhibit activation of the cellular signaling pathway in a classical negative feedback loop. Upregulated SOCS3 might play an important role in cardiocytes during chronic hypoxia as SOCS3 regulates cell signaling crosstalking between NF-κB and p-STAT3 under stressful conditions.

Strategy of Aortic Root Enlargement in Patients Undergoing Aortic and Mitral Valve Replacement

BACKGROUND This study was undertaken to evaluate the strategy and validity of aortic root enlargement in patients undergoing aortic and mitral valve replacement. METHODS Between January 1999 and December 2008, 78 consecutive patients aged 38.5 +/- 9.4 years underwent aortic root enlargement and double valve replacement at our hospital. The body surface area was 1.4 +/- 0.18 m(2), the aortic annulus diameter was 18.26 +/- 1.34 mm, the aortic orifice area was 0.83 +/- 0.43 cm(2), and the mean aortic transvalvular pressure gradient was 47.5 +/- 35.6 mm Hg. The aortic root enlargement was performed using a Dacron patch lined with autologous pericardium on the basis of either the Nuñez (n = 36) or Manouguian (n = 42) procedure depending on how narrow the aortic root was. RESULTS Mechanical prostheses were implanted in all patients. The mean size of the aortic and mitral valves were 20.5 mm and 25.9 mm, respectively. The postoperative mean indexed effective orifice areas of the aortic and mitral valves were 1.13 +/- 0.14 cm(2)/m(2) and 1.56 +/- 0.17 cm(2)/m(2) (p < 0.01 compared with those preoperatively), respectively. The postoperative mean aortic and mitral transvalvular pressure gradients were 10.7 +/- 2.3 mm Hg and 3.7 +/- 1.6 mm Hg (p < 0.01 compared with those preoperatively), respectively. There were no reoperations for bleeding and no heart block. Valve-related complications included thromboembolism, cerebral hemorrhage, perivalvular leakage, and reoperation. There were 2 deaths, 1 early and 1 late, and survival at 1, 5, and 10 years was 98.7%, 97.4%, and 97.4%, respectively. CONCLUSIONS Aortic root enlargement in patients undergoing double valve replacement can be performed safely to avoid postoperative aortic prosthesis-patient mismatch.

Erythropoietin enhances mitochondrial biogenesis in cardiomyocytes exposed to chronic hypoxia through Akt/eNOS signalling pathway

Adaptation of cardiomyocytes to chronic hypoxia in cyanotic patients remains unclear. Mitochondrial biogenesis is enhanced in myocardium from cyanotic patients, which is possibly an adaptive response. Erythropoietin (EPO) in blood and its receptor (EPOR) on cardiomyocytes are upregulated by chronic hypoxia, suggesting that EPO–EPOR interaction is increased, which is inferred to positively regulate mitochondrial biogenesis through protein kinase B (Akt)/endothelial nitric oxide synthase (eNOS) signalling pathway. H9c2 cardiomyocytes were exposed to hypoxia (1% O2) for 1 week and treated with different doses of recombinant human erythropoietin (rhEPO). Mitochondrial number, mitochondrial DNA (mtDNA) copy number and peroxisome proliferator activated receptor gamma coactivator alpha (PGC‐1α) mRNA expression increased in a dose‐dependent manner induced by rhEPO. Akt and eNOS were significantly phosphorylated by rhEPO. Both blocking Akt with Wortmannin and silencing eNOS expression with shRNA plasmid decreased the mtDNA copy number and PGC‐1α mRNA expression induced by rhEPO. Blocking Akt was associated with the decreased phosphorylation of Akt and eNOS. RNA interference led to a reduction in the total and phosphorylated proteins of eNOS. Thus EPO enhances mitochondrial biogenesis in cardiomyocytes exposed to chronic hypoxia, at least partly through Akt/eNOS signalling, which might be an adaptive mechanism of cardiomyocytes associated with the increased EPO–EPOR interaction in patients with cyanotic congenital heart disease (CCHD).

Giant Primary Leiomyoma of the Right Ventricle

Abstract  Echocardiography detected a giant mass on the lateral wall of the right ventricle in a 13‐year‐old boy. The mass extended into the cavity of right ventricle without attachment to adjacent structures. We resected the mass under cardiopulmonary bypass. Histology showed it to be a primary leiomyoma of the right ventricle. (J Card Surg 2010;25:169‐171)

Effect of the Urinary Tryptin Inhibitor Ulinastatin on Cardiopulmonary Bypass-Related Inflammatory Response and Clinical Outcomes: A Meta-Analysis of Randomized Controlled Trials

PURPOSE Cardiopulmonary bypass (CPB) can cause systemic inflammatory responses and a series of subsequent complications that may harm patients. The aim of this study was to explore the effects of ulinastatin on inflammatory responses and clinical outcomes of CPB via a meta-analysis of published randomized controlled trials. METHODS A literature search was conducted, both manually and by using the PubMed, EMBASE, Cochrane Library, and Web of Knowledge databases from inception to February 2013, to identify randomized controlled trials. The abstracted efficacy measures included changes in the plasma levels of cytokines (interleukin-6 [IL-6], IL-8, and tumor necrosis factor-α [TNF-α]) measured during the perioperative period and clinical indicators of efficacy, including the duration of mechanical ventilation and the length of intensive care unit stay. Ten ulinastatin-related randomized controlled trials related to cardiac surgeries involving CPB were selected. FINDINGS In terms of cytokine concentrations, there were no significant differences between patients who received ulinastatin and those who received placebo before CPB. However, as the surgeries progressed, cytokine concentrations were all significantly lower in the ulinastatin group (P < 0.05 at 1 hour; P < 0.0001 at 6 hours), and the respective plasma concentrations returned to baseline values 24 hours after CPB. In terms of the clinical outcome indices, the length of intensive care unit stay was not significantly different, but the duration of mechanical ventilation (95% CI, -6.75 to -0.39; P = 0.03) was significantly shorter in the ulinastatin group. IMPLICATIONS This meta-analysis found that changes in inflammatory cytokines occurred in a time-dependent manner and that the use of ulinastatin resulted in decreased duration of mechanical ventilation with CPB compared with placebo.

Risk Factors for Acute Kidney Injury after Cardiovascular Surgery: Evidence from 2,157 Cases and 49,777 Controls - A Meta-Analysis.

Purpose: Cardiovascular surgery-associated acute kidney injury (AKI-CS) contributes to mortality and morbidity. However, risk factors accelerating its development are unclear. We identified risk factors for AKI-CS in patients with cardiopulmonary bypass in the hospital surgical intensive care unit to predict and minimize renal complication in future cardiac surgery. Methods: We analyzed data from 14 case-control studies published prior to June 2014 and indexed in Science Citation Index, PubMed, and other databases to determine the major risk factors for AKI-CS. Results: Analyzed risk factors were divided into three groups: preoperative, intraoperative and postoperative. Preoperative factors included: age (OR, 4.87; 95% CI, 3.50-6.24), NYHA class III/IV (OR, 2.53; 95% CI, 1.32-4.86), hypertension (OR, 1.68; 95% CI, 1.44-1.97), preoperative creatinine (OR, 0.66; 95% CI, 0.18-1.14), peripheral vascular disease (OR, 1.31 95% CI, 1.09-1.57), respiratory system disease (OR, 1.29; 95% CI, 1.10-1.50), diabetes mellitus (OR, 1.52; 95% CI, 1.07-2.16), and cerebrovascular disease (OR, 2.13; 95% CI, 1.11-4.09). Intraoperative factors were: cardiopulmonary bypass time (OR, 33.78; 95% CI, 23.15-44.41), aortic clamping time (OR, 13.24; 95% CI, 7.78-18.69), use of intra-aortic balloon pump (OR, 4.44; 95% CI, 2.37-8.30), and type of surgery (OR, 1.01; 95% CI, 0.43-2.39). Postoperative factors were: infection (OR, 3.58; 95% CI, 1.43-8.97), redo operation (OR, 2.57; 95% CI, 1.75-3.78), emergency surgery (OR, 4.76; 95% CI, 3.05-7.43), and low cardiac output (OR, 2.30; 95% CI, 1.05-5.04). Conclusions: Our results support that preoperative, intraoperative, and postoperative factors are associated with AKI-CS. Ejection fraction, BMI, acute myocardial infarction, type of surgery, and congestive heart failure were not absolutely associated with AKI.