Abstract ： Objective To evaluate the clinical validity of Physiological and Operative Severity Score for theenUmeration of Mortality and Morbidity (POSSUM) in primary lung cancer patients undergoing surgery in order to get clinical treatment reference. Methods A total of 179 patients，with 124 males and 55 females，with primary lung cancer surgery between January 2007 and October 2010 were included in the First Affiliated Hospital of Xinjiang Medical University. Their age was 59.2±11.4 years．Before the surgery，POSSUM was used to each patient to rate the results and substituted the results into Copeland equation to calculate the predicted postoperative mortality and morbidity. The actual number of complications and death were calculated after surgery and the patients were divided into one group with postoperative complications and another group without postoperative complications. The physiological score and the operative risk score were compared between the two groups. Actual number of complications and death were compared with thenumber predicted by POSSUM respectively. The clinical factors related to the actual number of complications and death were analyzed. Results Among 179 patients， there were postoperative complications in 78 patients. The physiological score and the operative severity score were significantly higher in the group in whose complications occurred compared with those without complications (16.11±2.53 points versus 14.88±1.86 points for physiological score，P=0.000 ； 13.47±2.83 points versus 12.88±2.57 points for operative severity score，P=0.000). There was no statistical difference in complication between the predicted and actual number (65/179 versus 78/179，χ2=1.968，P=0.161). There was statistical difference in death between the predicted and actual number(12/179 versus 3/179，χ2=5.636，P=0.018).Univariable analysis revealed that 5 single factors were related to the complications， only hemoglobin was related to the death. Conclusion The POSSUM gives satisfactory prediction in morbidity rate but overrates the mortality rate in primary lung cancer patients undergoing surgery， and 5 single clinical factors show a better clinical value.
Abstract： Objective To investigate the acute cardioprotective effect of 17b-estradiol (17b-E2) against severe myocardial ischemia/reperfusion (I/R) injury in rabbits and the mechanism of the effect. Methods We established the model of myocardial I/R in vivo by occluding the left anterior descending coronary artery of the rabbits (who underwent coronary occlusion for 40 minutes followed by 3 hours of reperfusion). Twentyfour New Zealand white male rabbits were randomly divided into two groups with 12 in each group. Before coronary occlusion, 1 ml of ethanol or 17b-E2 at 10 μg/kg was administered intravenously to the rabbits in the control group and the experimental group respectively. The serum levels of tumor necrosis factor-α (TNF-α) and interleukin-6 (IL-6) were measured by enzymelinked immunosorbent assay (ELISA) at the following time points: before occlusion, 40 minutes after occlusion, 1 hour, 2 hours and 3 hours after reperfusion. Activation of p38 mitogen activated protein kinase(MAPK) was determined by Western blotting analysis, and apoptosis of cardiocytes was identified by terminal deoxynucleotidlyl transferase mediated deoxyuridinebiotin dUTP Nick End Labeline (TdT)mediated dNTP nick end labeling (TUNEL) staining. Results During myocardial ischemia, TNF-α decreased significantly in the experimental group compared with the control group (F=0.007,P=0.001), while there was no difference in IL-6 between the two groups (F=0.616,P=0.095). During the process of reperfusion, the levels of TNF-α and IL-6 in the experimental group were significantly lower than those in the control group (Plt;0.01). Besides, the activation of p38 MAPK and apoptotic index for the experimental group were also lower (45.07%±2.73% vs. 61.25%±2.41%, t＝－15.398, P=0.000; 11.21%±3.85% vs. 22.02%±4.49%, t＝－6.332, P=0.000). Conclusion The cardioprotective effect of 17b-E2 against myocardial I/R may be attributed to its antiinflammatory and antiapoptotic properties, which is probably associated with the inhibition of 17bE2 on p38MAPK activity.
Abstract: Objective To evaluate the biological characteristics of decellularized bovine jugular vein valved conduit treated with dyemediated photo oxidation. Methods From July 2009 to July 2010, this study was carried out in Xijing Hospital affiliated to the Fourth Military Medical University. Forty bovine jugular vein valved conduits were obtained from Qinchuan scalpers aged between 2 to 6 years with the weight ranged from 200 to 400 kg. Then, the 40 conduits were divided into four groups by random digital table with 10 in each group. The conduits were treated with glutaraldehyde in the glutaraldehyde group (GA group), were decellularized in the decellularized group (DC group), were decellularized and treated with dyemediated photo oxidation in the decellularized and dyemediated photo oxidation treated group (DP group) , and were not dealt with in the control group (CO group). Thickness, appearance, histology, water content, shrinkage temperature, breaking strength, and soluble protein level of the conduit wall and valve were detected and compared among the four groups. Results Thickness and water content of the conduit wall and valve in the DP group were similar to those in the CO group (Pgt;0.05), while thickness of both wall and valve in the DP group was less than those in the GA group (wall: 0.8±0.1 mm vs. 1.1±0.1 mm; valve: 02±0.1 mm vs. 0.3±0.1 mm, Plt;0.05), and water content of the conduit wall and valve in the DP group was more than those in the GA group (wall: 86.1%±2.2% vs. 70.4%±2.8%; valve: 87.1%±2.5% vs. 72.1%±3.1%, Plt;0.05). The breaking strength and shrinkage temperature of the DP group were similar to those of the GA group (Pgt;0.05), while the shrinkage temperature (wall: 84.7±1.4 ℃ vs. 70.4±0.3 ℃; valve: 85.7±1.5 ℃ vs. 70.7±0.6 ℃, Plt;0.05) and the breaking strength (wall: 10.4±1.1 N vs. 6.8±1.0 N; valve: 8.0±0.9 N vs. 3.2±0.6 N, Plt;0.05) of the DP group were higher than those in the CO group. Conclusion Decellularized bovine jugular vein valved conduits treated with dyemediated photo oxidation have nice biological characteristics.Key words: Dyemediated photo oxidation; Decellularized; Bovine jugular vein valved conduit; Biological characteristics
Abstract： Objective To identify the risk factors for shortterm adverse events in infants with congenital heart diseases receiving open heart surgical correction with cardiopulmonary bypass (CPB), in order to improve the outcome by adopting appropriate treatment measures. Methods We retrospectively analyzed the clinical data of 98 consecutive children with congenital heart diseases who underwent surgical correction with CPB in Beijing Fu Wai Hospital from November 2009 to December 2009. The patients were divided into two groups according to the postoperative complications. Among the patients without complications（n=40）: there were 24 males and 16 females with an age of 7.60±0.40 months and a weight of 7.80±0.30 kg. In the patients with complications (n=58): there were 42 males and 16 females with an age of 6.20±0.40 months and a weight of 6.70±0.20 kg. In both groups, perioperative data were recorded, including preoperative fast blood glucose, creatinine, time of aortic crossclamp, modified or zerobalanced ultrafiltration, postoperative glucose level, concentration of lactate, notrope score and complications. Risk stratification was performed by Risk Adjusted Classification for Congenital Heart Surgery (RACHS-1). Univariate analysis and logistic regression analysis were used to identify the risk factors for shortterm adverse events. Results One patient(1.02%) died of circulatory failure during the perioperative period. Thirtyseven patients [CM(159mm]were supported by at least 2 vasoactive drugs for more than 48hours,29 by mechanical ventilation for more than 24 hours, 5 needed reintubation, 1 experienced tracheotomy, 31 suffered from noscomial infection, 4 had wound infection, 3 developed renal failure, and 1 developed hepatic dysfunction. By logistic regression analysis, age (OR=0.750, P=0.012), percutaneous oxygen saturation (OR=0.840,P=0.005), aortic crossclamp time (OR=1.040, P=0.008), postoperative glucose level (patients with a mean glucose level lower or equal to 8.33 mmol/L had a probability of developing adverse outcomes five times higher; OR=5.051, P=0.011) were found to be the risk factors for shortterm adverse outcomes. Conclusion Age, percutaneous oxygen saturation and aortic crossclamp time are associated with the shortterm adverse outcome of infants undergoing congenital heart disease correction with CPB. The present results do not support perioperative hyperglycemia as a risk factor for adverse outcome.
Abstract: Objective To explore the surgical procedures and cerebral protection and improve surgical results by summarizing the experiences of surgical treatment of 68 patients of De Bakey Ⅰ aortic dissection. Methods We retrospectively analyzed the clinical data of 68 patients (including 45 males and 23 females aged 29 to 72 years with an age of 44.5±17.2 years) with De Bakey Ⅰ aortic dissection who were treated in the General Hospital of Shenyang Command between May 2004 and April 2010. Acute aortic dissection (occurring within 2 weeks) was present in 57 patients and chronic aortic dissection in 11. The intimal tear was located in the ascending aorta in 45 patients, in the aortic arch in 12 and in the descending part of the aortic arch in 11. Thirtyfive patients underwent emergency operation and 33 underwent selected or limited operation. The operations were performed under hypothermic circulation arrest plus selective antegrade cerebral perfusion or right vena cave retrograde cerebral perfusion to protect the brain. Total arch replacement and stented elephant trunk were performed in 25 patients, Bentall operation with concomitant total arch replacement and stented elephant trunk in 16 patients, pure right semi aortic arch replacement and stented elephant trunk in 15 patients, total aortic arch replacement in 7 patients, right semi aortic arch replacement and stented elephant trunk in 3 patients, and Cabrol operation with concomitant aortic conduit with valve and total arch replacement and stented elephant trunk in 2 patients. Results Five patients (4 with acute aortic dissection and 1 with chronic aortic dissection) died with an operative mortality of 7.4%(5/68). The causes of death were anastomotic bleeding during surgery in 1 patient, postoperative low cardiac output syndrome and malignant arrhythmia in 2, acute renal failure in 1 and cerebral complications in 1. During perioperative period, psychotic symptoms occurred in 5 patients, pericardial effusion in 2 patients, hoarseness in 6 patients and poor wound healing in 1 patient. All of them were cured before dehospitalization. Sixty patients (95.2%, 60/63) were followed up for 2 months to 6 years with the other 3 patients lost. During the ollow-up, sudden death occurred to 1 patient with unknown reasons, and 1 patient had pericardial effusion and symptoms improved with relevant treatment. All the other patients followed up had a good quality of life with significant improvement of heart function. Fiftyfour patients had a heart function of New York Heart Association class Ⅰ and 5 had a function of class Ⅱ. Conclusion The surgical treatment for De Bakey Ⅰ aortic dissection should be active. The beneficial results can be obtained with best choice of operative procedures, methods of cerebral protection, and adequate treatment of complications of operation.
Abstract： Objective To investigate the clinical results of offpump anatomic surgical repair for complex coarctation in adults. Methods We retrospectively analyzed the clinical data of 7 patients with complex coarctation who underwent onestage anatomic surgical repair between January 2005 and December 2008 in Fu Wai Hospital. There were 5 males and 2 females with the age ranged from 16 to 41 years, average at 24.4 years. Among all the patients, there were 2 patients of coarctation with hypoplastic aortic arch, 1 of coarctation with aortic arch aneurysm, 3 of coarctation with descending thoracic aortic aneurysm, and 1 of coarctation with B type aortic dissection. All patients were diagnosed by color echocardiography, CT or agnetic resonance imaging（MRI）. All off-pump operations were performed under general anesthesia and ambient temperature. Median sternotomy was performed in 1 patient and left thoracotomy in 6 patients. Aortic arch patching enlargement was performed in 4 patients and descending thoracic aorta replacement in 3 patients (including 1 combined with abdominal aorta replacement and 1 case of Stanford B type aortic dissection, trunk stent was transplanted at the same time). Results There was no hospital mortality or severe surgical complications. Seven patients were followed up for a period ranged from 6 to 49 months with an average time of 20.1 months. No late death or recoarctation occurred. Hoarseness occurred in one patient and presented no improvement during the 11 months follow-up. Conclusion Onestage offpump anatomic surgical repair is safe and feasible in treating adult patients with complex coarctation, and it shows a good immediate and longterm result.
Abstract: Objective To investigate changes of left ventricularregional systolic function after surgical treatment of left ventricular aneurysm (LVA) by realtime threedimensional echocardiography (RT-3DE). Methods From February 2009 to February 2010, 14 consecutive patients who were diagnosed to have coronary artery diseases with LVA underwent surgical repair and coronary artery bypass grafting (LVA group) in our hospital. All patients of the LVA group were followed up for a mean period of 4 months. Twodimensional echocardiography (2DE) and RT-3DE were performed before operation and during the follow-up. Left ventricular regional ejection fraction (EF) was acquired by Qlab software analysis. At the same time, 12 healthy persons were included as controls (control group). Statistical analyses were carried out to compare left ventricular regional EF between the LVA group (before operation and 4 months after operation) and the control group. Results Contrary to the control group, preoperative regional EF of the LVA group increased from apex to base. In addition to the inferior basal segment, lateralinferior basal segment and anteriorinferior basal segment, regional EF in the remaining 14 segments were significantly lower than that of the control group (P＜0.05). At postoperative followup, regional EF recovered the increase from base to apex, and there was no significant difference between anteriorinferior segment and lateral segment regional EF of the LVA group and those of the control group (P＞0.05), while regional EF of other segments in the LVA group was lower than that in the control group (P＜0.05). Conclusion RT-3DE is an effective method to assess left ventricular regional systolic function in patients with LVA. After LVA repair and coronary artery bypass grafting, regional systolic function will restore to the normal direction of progressive increase, and some nonaneurysm segments systolic function will go back to normal.
Abstract: Objectives To evaluate the accuracy of four existing risk stratification models including the Society of Thoracic Surgeons(STS) 2008 Cardiac Surgery Risk Models for Coronary Artery Bypass Grafting (CABG), the European System for Cardiac Operative Risk Evaluation (EuroSCORE), the American College of Cardiology/American Heart Association (ACC/AHA) model, and the initial Parsonnet’s score in predicting early deaths of Chinese patients after CABG procedure. Methods We collected clinical records of 1 559 consecutive patients who had undergone isolated CABG in the Fu WaiHospital from November 2006 to December 2007. There were 264 females (16.93%) and 1 295 males (83.06%) with an average age of 60.87±9.06 years. Early death was defined as death inhospital or within 30 days after CABG. Calibration was assessed by the Hosmer-Lemeshow (H-L) test, and discrimination was assessed by the receiveroperatingcharacteristic (ROC) curve. The endpoint was early death. Results Sixteen patients(1.03%) died early after the operation. STS and ACC/AHA models had a good calibration in predicting the number of early deaths for the whole group(STS: 12.06 deaths, 95% confidence interval(CI) 5.28 to 18.85; ACC/[CM(159mm]AHA:20.67deaths, 95%CI 11.82 to 29.52 ), While EuroSCORE and Parsonnet models overestimated the number of early deaths for the whole group(EuroSCORE：36.44 deaths，95%CI 24.75 to 48.14；Parsonnet：43.87 deaths，95%CI 31.07 to 56.67). For the divided groups, STS model had a good calibration of prediction(χ2=11.46, Pgt;0.1)，while the other 3 models showed poor calibration（EuroSCORE：χ2=22.07，Plt;0.005；ACC/AHA：χ2=28.85，Plt;0.005；Parsonnet：χ2=26.74，Plt;0.005）.All the four models showed poor discrimination with area under the ROC curve lower than 0.8. Conclusion The STS model may be a potential appropriate choice for Chinese patients undergoing isolated CABG procedure.
Abstract： Objective To investigate the effects of calcium preconditioning (CP) on immature myocardial cell apoptosis and apoptosisregulated proteins. Methods The experiment was carried out from June 2000 to December 2001 in the Renmin Hospital of Wuhan University. Twelve rabbits with the age of 1421 d and the weight of 230300 g were divided into 2 groups with 6 in each group by random digital table. For rabbits in the ischemia/reperfusion group (I/R group), after Langendorff models were routinely set up, KrebsHenseleit (KH) solution was perfused for 20 minutes and reperfused for 120 minutes after 45 minutes of ischemia. For rabbits in the CP group, after Langendorff models were established, KH solution was perfused for20 minutes, and 45 seconds’ noncalcium KH solution perfusion and 5 minutes’ KH solution perfusion were repeated 3 times before 45 minutes of ischemia and 120 minutes of reperfusion of KH solution. In situ apoptosis identification and semiquantitative analysis were used to detect the myocardial cell apoptosis; agarose gel electrophoresis was used to detect the nucleosomal ladder of DNA fragments; and the expression of bcl-2, bax and fas were detected with Western blot method. Results The apoptosis rate for the CP group was lower than that of the I/R group (4.53%±1.22% vs. 12.30%±2.12%,t=7.780, P=0.000). Nucleosomal ladder of DNA fragments of the CP group was lower than that of the I/R group (OD value: 56 460±1 640 vs. 135 212±3 370,t=51.460,P=0.000). The expression of bcl-2 in the I/R group was lower than that of the CP group (OD value: 13 217±1 770 vs. 31 790±1 018,t=22.280, P=0.000). The expression of bax (OD value: 30 176±1 025 vs. 7 954±730, t=43.260, P=0.000) and fas (OD value: 29 197±1 233 vs. 8 140±867, t=34.220, P=0.000) in the I/R group was higher than that of the CP group. Conclusion CP can affect the expression of myocardial bcl-2, bax, and fas, and decrease immature myocardial cell apoptosis.
Abstract： Objective To establish a risk prediction model and risk score for inhospital mortality in heart valve surgery patients, in order to promote its perioperative safety. Methods We collected records of 4 032 consecutive patients who underwent aortic valve replacement, mitral valve repair, mitral valve replacement, or aortic and mitral combination procedure in Changhai hospital from January 1,1998 to December 31,2008. Their average age was 45.90±13.60 years and included 1 876 (46.53%) males and 2 156 (53.57%) females. Based on the valve operated on, we divided the patients into three groups including mitral valve surgery group (n=1 910), aortic valve surgery group (n=724), and mitral plus aortic valve surgery group (n=1 398). The population was divided a 60% development sample (n=2 418) and a 40% validation sample (n=1 614). We identified potential risk factors, conducted univariate analysis and multifactor logistic regression to determine the independent risk factors and set up a risk model. The calibration and discrimination of the model were assessed by the HosmerLemeshow (H-L) test and [CM(159mm]the area under the receiver operating characteristic (ROC) curve,respectively. We finally produced a risk score according to the coefficient β and rank of variables in the logistic regression model. Results The general inhospital mortality of the whole group was 4.74% (191/4 032). The results of multifactor logistic regression analysis showed that eight variables including tricuspid valve incompetence with OR=1.33 and 95%CI 1.071 to 1.648, arotic valve stenosis with OR=1.34 and 95%CI 1.082 to 1.659, chronic lung disease with OR=2.11 and 95%CI 1.292 to 3.455, left ventricular ejection fraction with OR=1.55 and 95%CI 1.081 to 2.234, critical preoperative status with OR=2.69 and 95%CI 1.499 to 4.821, NYHA ⅢⅣ (New York Heart Association) with OR=2.75 and 95%CI 1.343 to 5641, concomitant coronary artery bypass graft surgery (CABG) with OR=3.02 and 95%CI 1.405 to 6.483, and serum creatinine just before surgery with OR=4.16 and 95%CI 1.979 to 8.766 were independently correlated with inhospital mortality. Our risk model showed good calibration and discriminative power for all the groups. P values of H-L test were all higher than 0.05 (development sample: χ2=1.615, P=0.830, validation sample: χ2=2.218, P=0.200, mitral valve surgery sample: χ2=5.175,P=0.470, aortic valve surgery sample: χ2=12.708, P=0.090, mitral plus aortic valve surgery sample: χ2=3.875, P=0.380), and the areas under the ROC curve were all larger than 0.70 (development sample: 0.757 with 95%CI 0.712 to 0.802, validation sample: 0.754 and 95%CI 0.701 to 0806; mitral valve surgery sample: 0.760 and 95%CI 0.706 to 0.813, aortic valve surgery sample: 0.803 and 95%CI 0.738 to 0.868, mitral plus aortic valve surgery sample: 0.727 and 95%CI 0.668 to 0.785). The risk score was successfully established: tricuspid valve regurgitation (mild:1 point, moderate: 2 points, severe:3 points), arotic valve stenosis (mild: 1 point, moderate: 2 points, severe: 3 points), chronic lung disease (3 points), left ventricular ejection fraction (40% to 50%: 2 points, 30% to 40%: 4 points, ＜30%: 6 points), critical preoperative status (3 points), NYHA IIIIV (4 points), concomitant CABG (4 points), and serum creatinine (＞110 μmol/L: 5 points).Conclusion Eight risk factors including tricuspid valve regurgitation are independent risk factors associated with inhospital mortality of heart valve surgery patients in China. The established risk model and risk score have good calibration and discrimination in predicting inhospital mortality of heart valve surgery patients.