Yunhu Song

Effect of Preoperatively Continued Aspirin Use on Early and Mid-Term Outcomes in Off-Pump Coronary Bypass Surgery: A Propensity Score-Matched Study of 1418 Patients

Background To date, effect of preoperatively continued aspirin administration in off-pump coronary artery bypass grafting (CABG) is less known. We aimed to assess the effect of preoperatively continued aspirin use on early and mid-term outcomes in patients receiving off-pump CABG. Methods From October 2009 to September 2013 at the Fuwai Hospital, 709 preoperative aspirin users were matched with unique 709 nonaspirin users using propensity score matching to obtain risk-adjusted outcome comparisons between the two groups. Early outcomes were in-hospital death, stroke, intra- and post-operative blood loss, reoperation for bleeding and blood product transfusion. Major adverse cardiac events (death, myocardial infarction or repeat revascularization), angina recurrence and cardiogenic readmission were considered as mid-term endpoints. Results There were no significant differences among the groups in baseline characteristics after propensity score matching. The median intraoperative blood loss (600 ml versus 450 ml, P = 0.56), median postoperative blood loss (800 ml versus 790 ml, P = 0.60), blood transfusion requirements (25.1% versus 24.4%, P = 0.76) and composite outcome of in-hospital death, stroke and reoperation for bleeding (2.8% versus 1.6%, P = 0.10) were similar in aspirin and nonaspirin use group. At about 4 years follow-up, no significant difference was observed among the aspirin and nonaspirin use group in major adverse cardiac events free survival estimates (95.7% versus 91.5%, P = 0.23) and freedom from cardiogenic readmission (88.5% versus 85.3%, P = 0.77) whereas the angina recurrence free survival rates was 83.7% and 73.9% in the aspirin and nonaspirin use group respectively (P = 0.02), with odd ratio for preoperative aspirin estimated at 0.71 (95% confidence interval, 0.49-1.04, P = 0.08). Conclusions Preoperatively continued aspirin use was not associated with increased risk of intra- and post-operative blood loss, blood transfusion requirements and composite outcome of in-hospital death, stroke and reoperation for bleeding in off-pump CABG. Preoperative aspirin use tended to decrease the hazard of mid-term angina recurrence.

Protein analysis of atrial fibrosis via label-free proteomics in chronic atrial fibrillation patients with mitral valve disease.

Background Atrial fibrosis, as a hallmark of atrial structure remodeling, plays an important role in maintenance of chronic atrial fibrillation, but interrelationship of atrial fibrosis and atrial fibrillation is uncertain. Label-free proteomics can implement high throughput screening for finding and analyzing pivotal proteins related to the disease.. Therefore, we used label-free proteomics to explore and analyze differentially proteins in chronic atrial fibrillation patients with mitral valve disease. Methods Left and right atrial appendages obtained from patients with mitral valve disease were both in chronic atrial fibrillation (CAF, AF≥6 months, nu200a=u200a6) and in sinus rhythm (SR, nu200a=u200a6). One part of the sample was used for histological analysis and fibrosis quantification; other part were analyzed by label-free proteomic combining liquid chromatography with mass spectrometry (LC-MS), we utilized bioinformatics analysis to identify differential proteins. Results Degree of atrial fibrosis was higher in CAF patients than that of SR patients. 223 differential proteins were detected between two groups. These proteins mainly had vital functions such as cell proliferation, stress response, focal adhesion apoptosis. We evaluated that serine/threonine protein kinase N2 (PKN2), dermatopontin(DP), S100 calcium binding protein B(S100B), protein tyrosine kinase 2(PTK2) and discoidin domain receptor tyrosine kinase 2(DDR2) played important roles in fibrotic process related to atrial fibrillation. Conclusion The study presented differential proteins responsible for atrial fibrosis in chronic atrial fibrillation patients through label-free proteomic analysis. We assessed some vital proteins including their characters and roles. These findings may open up new realm for mechanism research of atrial fibrillation.

Focal adhesion kinase mediates atrial fibrosis via the AKT/S6K signaling pathway in chronic atrial fibrillation patients with rheumatic mitral valve disease

BACKGROUNDnAtrial fibrosis, as a hallmark of atrial structural remodeling, plays a critical role in the maintenance of chronic atrial fibrillation (AF), but the mechanisms responsible for atrial fibrosis are still uncertain. Fibrogenesis represents a complex process in which focal adhesion kinase (FAK) plays an important role. Therefore, we investigated the role of FAK-mediated signaling in atrial fibrosis in patients with chronic AF related to rheumatic mitral valve disease (RMVD).nnnMETHODSnAtrial appendages were excised from 45 patients with RMVD and either chronic AF (n=25, AF >6 months) or sinus rhythm (n=20). Fibrosis was assessed by histology, and FAK and its two downstream pathways (AKT/S6K and ERK1/2) were evaluated by western blotting. We further evaluated the role of FAK in fibrogenesis by culturing neonatal rat cardiac fibroblasts to determine the importance of FAK-regulated signaling in cardiac myofibroblast differentiation induced by transforming growth factor-β1 (TGFβ1).nnnRESULTSnOur study revealed that FAK can regulate its downstream signaling to cause fibrosis in atrial tissue and activate isolated fibroblasts. Histology revealed a significant increase in atrial fibrosis in AF patients. The phosphorylation of FAK and its downstream AKT/S6K signaling was increased secondary to TGFβ1-induced high expression of α-SMA, a marker of myofibroblast activity. FAK and AKT inhibitors suppressed α-SMA expression in TGFβ1-induced fibroblasts. However, ERK1/2 signaling seemed to be unrelated to the fibrotic process in AF patients.nnnCONCLUSIONnThe FAK-mediated AKT/S6K signaling pathway participated in atrial fibrogenesis and this finding may contribute to the prevention of atrial fibrosis associated with chronic AF in patients with underlying cardiac disease.

Efficiency of radiofrequency ablation for surgical treatment of chronic atrial fibrillation in rheumatic valvular disease

BACKGROUNDnIt remains unclear whether concomitant radiofrequency ablation procedure in valvular surgery could offer additional benefits to patients with rheumatic valvular disease. We designed a prospective and randomized control study to evaluate the efficacy of surgical radiofrequency ablation in patients with rheumatic heart disease.nnnMETHODSnFrom June 2008 to July 2011, 210 patients with chronic atrial fibrillation and rheumatic heart disease were randomized: (1) control group, patients underwent only valve replacement followed by amiodarone for rhythm control, (2) left atrial group (LA group), patients underwent valve replacement and left atrial mono-polar radiofrequency ablation, (3) bi-atrial group (BA group), patients underwent valve replacement and bi-atrial mono-polar radiofrequency ablation. The primary endpoints included: cardiac death, stroke, and recurrent AF after discharge.nnnRESULTSnThere was no perioperative death. One patient died 4 months after MVR in BA group. In univariate Cox analysis, the two ablation groups were associated with less AF (BA group vs control group: P<0.001; LA group vs control group: P<0.001) as well as atrial tachycardia arrhythmia (AF/AT/AFL) recurrent (BA group vs control group: P<0.001; LA group vs control group: P=0.02). The comparison between BA and LA groups revealed no differences in terms of AF (P=0.06) or AF/AT/AFL (P=0.09). Atrial transport function restoration rate 12 months after operation was 31.4% in LA group, 32.9% in BA group, and 8.6% in control group respectively (P<0.01).nnnCONCLUSIONSnRadiofrequency ablation concurring with valvular surgery can bring a higher sinus rhythm restoration rate when compared with medical anti-arrhythmic drug therapy in low-medium risk rheumatic heart disease. The trial was registered on Clinicaltrials.gov (registry number NCT01013688).

Outcomes of an extended Morrow procedure without a concomitant mitral valve procedure for hypertrophic obstructive cardiomyopathy

The indications for a concomitant mitral valve (MV) procedure remain controversial for patients with hypertrophic obstructive cardiomyopathy (HOCM). According to previous studies, a concomitant MV surgery was required in 11–20% of inpatient operations. Thus, we aimed to study the outcomes of an extended Morrow procedure without a concomitant MV procedure for HOCM patients who had no intrinsic abnormalities of the MV apparatus. We retrospectively reviewed 232 consecutive HOCM patients who underwent extended Morrow procedures from January 2010 to October 2014. Only 10 (4.31%) patients with intrinsic MV diseases underwent concomitant MV procedures. Of the 232 patients, 230 had no to mild mitral regurgitation (MR) postoperatively. We separated the 232 patients into two groups according to preoperative MR degree. One group is mild MR, and the other is moderate or severe MR. The three-month, one-year, and three-year composite end-point event-free survival rates had no difference between two groups (pu2009=u20090.820). When we separated the patients to postoperative no or trace MR group and mild MR group, there was also no difference on survival rates (pu2009=u20090.830). In conclusion, concomitant mitral valve procedures are not necessary for HOCM patients with MR caused by systolic anterior motion, even moderate to severe extent.

Repair of anomalous coronary artery from the pulmonary artery: A-signal center 20-year experience

BACKGROUNDnAnomalous origin of coronary artery from the pulmonary artery (ACAPA) is a rare congenital coronary malformation with a high mortality whether in infants or adult patients. This study reviews 20years of surgical treatment in a single center and aims to establish the optimal surgical strategies for this rare pathology.nnnMETHODS AND RESULTSnFrom April 1994 to March 2015, 96 consecutive patients aged from 3months to 60years underwent coronary repair surgery. The surgical procedures included ligation (3 cases), ligation along with CABG (6 cases), transpulmonary baffling (Takeuchi Procedure, 14 cases) and directly implantation of the anomalous coronary artery (ACA) into the aorta (73 cases). Postoperative extracorporeal mechanical circulatory support (ECMO) was necessary in 4 cases. Mitral valve repair was performed in 40 patients with moderate or severe mitral regurgitation (MR). Mitral replacement was performed in one patient with severe MR. There were one early and two late deaths. One patient underwent a second operation because Baffle leaks. During mean 10.45±8.96year follow-up (1month-18years), both early and late improvement of left ventricular function was observed in most patients (8 patients lost of follow-up).nnnCONCLUSIONSnThe establishment of a two-coronary system is the main goal of surgical therapy today. In different procedures, the direct implantation of the ACA into the ascending aorta is the best method and has good long-term results. ECMO as a bridge to recovery that will play an integral part in moderns surgical treatment.

Surgical Outcome in Adolescents and Adults with Anomalous Left Coronary Artery from Pulmonary Artery

BACKGROUNDnThe outcomes of different repair strategies of an anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) in adolescent and adult patients are uncertain. The long-term outcomes of reimplantation and Takeuchi repair were compared in this study.nnnMETHODSnWe conducted a retrospective review of data collected from patients receiving ALCAPA repair at our institute from January 2005 to December 2016. Short- and long-term outcomes of reimplantation and Takeuchi repair were compared.nnnRESULTSnA total of 50 consecutive patients underwent ALCAPA repair, with an average age of 31.6 ± 15.6 years and 66% women. No significant differences were found in short-term outcomes between the 2 groups. However, at a median of 65.7 months follow-up, the major adverse cardiovascular event (MACE) (including all-cause death, admission due to heart failure, new-onset acute myocardial infarction, and repeated revascularization) rate of the Takeuchi repair group was significantly lower than that of the reimplantation group (hazard ratio, 0.21; 95% confidence interval, 0.04 to 0.97). Furthermore, the preoperative glucose level was significantly associated with increased MACE rate (hazard ratio, 10.82; 95% confidence interval, 1.20 to 97.54). Left ventricular end-diastolic diameter and ejection fraction significantly improved in both groups. However, mitral valvuloplasty did not predict long-term recovery of left ventricular function.nnnCONCLUSIONSnAlthough short-term outcomes were satisfactory in both groups, a higher MACE rate was observed in reimplantation group than Takeuchi repair group; mitral valvuloplasty was not significantly associated with improved prognosis and left ventricular reverse remodeling. Elevation of preoperative blood glucose level was significantly associated with increasing long-term MACE rate.

Mitral valve annuloplasty versus replacement for severe ischemic mitral regurgitation

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. 436 consecutive patients with severe CIMR were eligible for inclusion in the study, of which 316 (72.5%) underwent mitral valve annuloplasty (MVA) whereas 120 (27.5%) received mitral valve replacement (MVR). At 59 months (interquartile range, 37–85 months) follow-up, though the left ventricle end-diastolic diameter was markedly larger (Pu2009=u20090.019) in the MVA group than in the MVR group, no significant difference was observed in overall survival, freedom from cardiac death, or avoidance of major adverse cardiac or cerebrovascular events (MACCE). MVA provides better results in freedom from cardiac death in subgroups of age ≥65years and left ventricular ejection fraction (EF) ≥50% (Pu2009=u20090.014 and Pu2009=u20090.016, respectively), whereas MVR was associated with a lower risk of MACCE in subgroups of age <65years, EF <50% and left ventricular inferior basal wall motion abnormality (BWMA) (all Pu2009<u20090.05). In conclusion, MVR is a suitable management of patients with severe CIMR, and it is more favorable to ventricular remodeling. The choice of MVA or MVR should depend on major high-risk clinical factors.

Long‐Term Outcomes of Tricuspid Valve Surgery in Patients With Congenitally Corrected Transposition of the Great Arteries

Background Valvuloplasty is generally considered unsuccessful in patients with congenitally corrected transposition of the great arteries. Optimal timing of tricuspid valve surgery in these patients is crucial. Methods and Results We retrospectively reviewed 57 patients with congenitally corrected transposition of the great arteries undergoing tricuspid valve surgery at our institution. Eleven patients had tricuspid valve plasty and 46 had tricuspid valve replacement. Mean duration of follow‐up was 7.4±5.5 years in the group of tricuspid valve plasty and 5.6±3.6 years in the group of tricuspid valve replacement, respectively (P=0.33). For the total of 57 patients, estimates of 1‐, 5‐, and 10‐year survival or freedom from transplantation were 96.4%, 91.6%, and 75.6%, respectively. Late right ventricular ejection fraction of most patients (90%) remained preserved (≥40%) during the follow‐up. In a highly selected group of tricuspid valve plasty recipients, although long‐term survival and right ventricular function were similar compared with tricuspid valve replacement, recurrent tricuspid regurgitation was observed in 60% of these patients. Multivariate Cox regression analysis identified preoperative right ventricular end‐diastolic dimension (1‐cm increment; harzard ratio, 3.22; P=0.02) as an independent predictor of postoperative mortality or need for transplantation. Patients undergoing surgery with a right ventricular end‐diastolic dimension ≥60 mm had a significant lower survival rate compared with those with a right ventricular end‐diastolic dimension <60 mm (P=0.003). Conclusions Tricuspid valve surgery in patients with congenitally corrected transposition of the great arteries could yield satisfactory long‐term outcomes. Recurrent tricuspid regurgitation was frequently observed in tricuspid valve plasty recipients. Preoperative right ventricular end‐diastolic dimension was a risk factor for late mortality and surgery should be performed before cardiac enlargement and dysfunction for best outcomes.

Numerical simulation study on systolic anterior motion of the mitral valve in hypertrophic obstructive cardiomyopathy

BACKGROUNDnThe hydrodynamic mechanisms of systolic anterior motion (SAM) of the mitral valve in hypertrophic obstructive cardiomyopathy (HOCM) remain unclear.nnnMETHODSnBased on computed tomography (CT) images and clinical data, pre- and post-operative computational models of the left ventricle were constructed for 6 HOCM patients receiving septal myectomy. SAM was abolished in 5 patients and persisted in one after septal myectomy surgery. The obtained simulation results including flow field of the left ventricle and mechanical behaviors of the mitral valve (MV) between pre- and post-operative FSI models were compared.nnnRESULTSnThe pressure difference and shear stress on the mitral valve leaflets (MVL) were relatively high pre-operatively, and decreased significantly after satisfactory surgery, but remained high following failed surgery. The significant increase in coaptation-to-septal distance was found when SAM was abolished.nnnCONCLUSIONSnOur results indicated that high pressure difference and shear stress on the MVL might directly initiate SAM in HOCM. Successful septal myectomy enlarged the coaptation-to-septal distance sufficiently to keep the MVL away from the ejection flow, thereby eliminating SAM.