Objective To investigate the surgical therapy for chronic total occlusion (CTO) of coronary artery with offpump coronary artery bypass grafting (OPCAB). Methods From Aug. 1999 to Oct. 2007, 696 patients with 853 totally occluded coronary arteries (127 coronary arteries lack of opacification while the other 726 arteries with reverse flow showed by coronary angiography) underwent OPCAB. A total of 2 231 grafts were constructed including 136 placed to coronary endarterectomy (CE) targets and 28 arterialized middle cardiac veins. Blood flow was detected during operation in 26 coronary arteries with no opacification in preoperative angiography, while no blood flow was detected in 63 coronary arteries with opacification in preoperative angiography. Cardiopulmonary bypass was applied in 15 cases because of a poor hemodynamics and 6 of which were assisted with intraaortic balloon pump(IABP). Results All patients survived the operation. 6 died in hospital because of low cardiac output (2 cases), renal failure (2 cases), perioperative cardiac infarction (1 case) or cerebrovascular accident (1 case). Stress ulceration occurred in one case, mediastinal infection occurred in another case after operation. Both were treated medically and recovered. 692 patients were followed up and the rate of flup was 99.42%(685/686)， with 4 withdrawal. Freedom from cardiac angina was 99.85%(685/686) and cardiac functional grading (NYHA) was Ⅰ-Ⅱ. Conclusion OPCAB can be well performed in patients with chronic total occlusion of coronary arteries. The ralue of coronary angiography for evaluating totally occluded coronary artery is limited, and endoscope or intravascular ultrasound techniques may be helpful.
Objective To analyze the prognostic factors in the postoperative patients with prolonged mechanical ventilation after extracorporeal circulation.Methods From Oct 2004 to Oct 2007，35 cases of postoperative patients after extracorporeal circulation required mechanical ventilation for ≥24 hours in ICU were enrolled.The patients were divided into death group and survival group.Preoperative variables including blood glucose，serum albumin，creatinine and ejection fraction（EF），intra-operative variables such as cardiopulmonary bypass（CPB） duration，aortic cross clamp（ACC） time，blood transfusion，and postoperative variables such as vital sign arrival at ICU，renal function，drainage in first 24 hours，APACHEⅡ score，ventilation duration were analyzed retrospectively.Results There were significant differences in blood glucose，serum albumin，EF，CPB，ACC，fresh frozen plasma transfusion，APACHEⅡ，creatinine，APTT and oxygenation index between the death group（12 cases，34.29%） and the survival group（23 cases，65.71%）.Stepwise logistic regression analysis indicated that EF（OR=0.7973，95%CI 0.6417-0.9906） and APACHEⅡ（OR=1.8588，95%CI 1.1071-3.1210） were predictors of prognosis.Conclusions High mortality is found in postoperative patients after extracorporeal circulation with prolonged mechanical ventilation.The main predictors of prognosis were EF and APACHEⅡ.It’s important to assess preoperative condition for cardiac surgical patients completely and provide more intensive perioperative care.
Objective To explore the risk factors affecting the prognosis of patients with acute kidney injury (AKI) after extracorporeal circulation surgery who receive continuous renal replacement therapy (CRRT). Methods Patients who developed AKI and underwent CRRT treatment after extracorporeal circulation surgery at the First Affiliated Hospital of Chongqing Medical University between May 2019 and May 2024 were retrospectively selected. According to the prognosis, patients were divided into the good prognosis group and the poor prognosis group. Basic information, duration of extracorporeal circulation during surgery, aortic occlusion time, timing and duration of CRRT initiation therapy, relevant laboratory indicators before surgery, during CRRT intervention, and upon discharge or death were collected. The risk factors affecting the prognosis of such patients were analyzed. Results A total of 45 patients were included. Among them, there were 20 cases in the good prognosis group and 25 cases in the poor prognosis group. There was no statistically significant difference in the basic information between the two groups (P>0.05). Compared with the poor prognosis group, the good prognosis group had decreased preoperative urea nitrogen and increased hemoglobin levels, reduced levels of alanine aminotransferase and aspartate aminotransferase during the initiation of CRRT treatment, and reduced levels of white blood cell count, neutrophil percentage, alanine aminotransferase and aspartate aminotransferase and elevated platelet count before discharge or death (P<0.05). The results of multivariate logistic regression analysis showed that the total duration of CRRT treatment [odds ratio (OR)=1.007, 95% confidence interval (CI) (1.000, 1.015), P=0.046], white blood cell count before discharge or death [OR=1.541, 95%CI (1.011, 2.349), P=0.044], and platelet count before discharge or death [OR=0.964, 95%CI (0.937, 0.991), P=0.010] could affect patient prognosis. Conclusions In patients with AKI after extracorporeal circulation surgery, if combined with renal dysfuction and anemia before surgery, liver function damage and secondary infection during CRRT initiation therapy may be related to poor patient prognosis. The longer the duration of CRRT treatment, the higher the white blood cells before discharge or death, and the lower the platelet count are independent risk factors for poor prognosis in patients.
Objective To summarize our experience of cardiovascular surgery for patients dependent on dialysis, and evaluate its safety and efficacy.?Methods?Clinical data of 10 consecutive patients dependent on maintenance dialysis underwent cardiovascular operations between Dec. 2004 and April 2011 in Peking Union Medical College Hospital were analyzed retrospectively. There were 6 male and 4 female patients, aged between 23 to 71 （57.6±13.2） years. They were put on dialysis 3-98 （25.2±30.6） months prior to operation due to diabetic nephropathy in 6 patients, chronic glomerulitis in 3 patients and systemic lupus erythemus in 1 patient, and 8 were dependent on hemodialysis and 2 on peritoneal dialysis. Five patients underwent coronary artery bypass grafting, one underwent Bentall procedure，two underwent aortic valve replacement, one underwent mitral valve replacement, and one underwent superior vena cava thrombectomy and patch repair. Patients underwent dialysis on the day before elective operation, followed by continuous ultra-filtration during cardiopulmonary bypass, and then bedside heparin-free continuous veno-venous hyperfiltration-dialysis started 5-32 hours after the operation. Conventional peritoneal dialysis or hemodialysis was resumed 4-7 days after operation.?Results?All operations were successfully completed. Cardiopulmonary bypass time was （125.8±33.5）minutes, aortic clamp time was（77.2±25.5） minutes. One in-hospital death occurred due to septic shock after deep chest wound infection. One patient underwent re-exploration due to pericardial temponade to achieve hemostasis. Three patients experienced atrial fibrillation and were all converted to sinus rhythm by amiodarone. Nine patients recovered to discharge and were followed-up for 8-76 months. Two late deaths occurred due to intracranial hemorrhage and liver carcinoma respectively. Seven survived patients were all in New York Heart Association grade II functional class, and none of them experience major advertent cardiac events related to grafts or prosthetic valve. One patient switched to hemodialysis 14 months after discharge due to peritonitis.Conclusion?Cardiovascular surgery can be practiced in patients dependent on maintenance hemodialysis or peritoneal dialysis with appropriate peri-operative management, so that symptoms can be relieved and quality of life improved.
Patients with heparin-induced thrombocytopenia have a poor prognosis and high mortality, thus surgical risk under extracorporeal circulation increased. Early diagnosis, safe and effective alternative anticoagulation strategy are crucial for these patients to receive extracorporeal circulation surgery. This review focuses on the pathophysiology, laboratory examination, diagnosis and alternative anticoagulation strategy of extracorporeal circulation for patients with heparin-induced thrombocytopenia.
ObjectiveTo observe the effect of preoperative hyperbaric oxygen (HBO) pretreatment on systemic inflammatory response after extracorporeal circulation. MethodsA total of 30 patients who were going to receive mitral or aortic valve replacement were randomly allocated into a control group (group C, n=15) and a pretreatment group (group P, n=15).Three sessions of HBO pretreatments were given to the patients in the group P before operation. The changes of serum concentration of inflammatory factors including tumor necrosis factor (TNF)-α, interleukin (IL)-6, IL-10, P-selectin, intercellular adhesion molecule (ICAM)-1, heat shock protein (HSP)-70 between the two groups were compared at four time points:before incision of skin (T1), 30 min after ECC(T2), 1 h (T3) and 24 h (T4) after the end of ECC. ResultsThere was no statistical difference in the serum concentration of IL-6,TNF-α, P-selectin, ICAM-1, IL-10, and HSP-70 at T1 between the two groups (P>0.05). The level of all inflammatory factors ascended in first and descended at last in both groups, which reached a peak at T3 and descended at T4. But the serum concentration at T4 was still higher than the level at T1 (P<0.05). There was a statistical difference in serum level of HSP-70 between T4 and T1 (373.3±96.7 pg/ml vs. 316.3±55.5 pg/ml, P<0.05). There were statistical differences in serum concentration of IL-6 (141.5±25.9 pg/ml vs. 119.2±31.8 pg/ml), HSP-70 (449.8±48.3 pg/ml vs. 373.3±96.7 pg/ml), and IL-10 (64.2±8.2 pg/ml vs. 90.3±14.2 pg/ml) between the group C and the group P at T4 (P<0.05). There was no statistical difference between the two groups in postoperative ICU stay time and thoracic drainage. While time of postoperative ventilation in the group P was shorter than that in the group C with a statistical difference (11.4±5.6 days vs. 15.8±5.1 days, P<0.05). ConclusionHyperbaric oxygen pretreatment before operation can abate the bad inflammatory response after heart valve replacement surgery to some extent and strengthen the anti-inflammatory protection, thereby favoring the reduction in postoperative complications.
ObjectiveBased on the rat in situ perfusion system, to explore the effect of up-regulating Chemokine (C-X-C motif) receptor 4 (CXCR4) expression on bone marrow neutrophils in modulating its ECC-related rapid release. MethodsTwelve SD rats were randomly divided into fucoidan perfusion group (F, n=6) and control group (C, n=6) after in situ perfusion system establishment. Rats in F group received perfusion of fucoidan solution (total volume 6 ml, 1 h) and C group received buffer only. Femurs from two groups were dissected after one-hour perfusion and bone marrow tissues were collected. The neutrophil CXCR4 expression in two groups were compared using flowcytometry. Eighteen SD rats were randomly divided into fucoidan perfusion group (F', n=6), fucoidan and AMD-3100 perfusion group (F+AMD3100, n=6) and control group (C', n=6) after in situ perfusion system establishment. Rats received desired interventions before stimulation from ECC plasma. After that, 40-min perfusions of buffer were added and total counts of neutrophil in perfusates were compared. ResultsThe percentages of CXCR4 (+) cell and CXCR4 expression fluorescence in F group were 4.71%±0.21% and 161.3±7.8 respectively while the values were 1.11%±0.11% and 58.4±6.5 respectively in C group. Values in F group were both significantly higher than those in C group (P<0.05). The total counts of neutrophil in perfusates from F' group, F+AMD3100 and C' group were 261 393.7±12 470.6, 872 635.2±10 430.6 and 818 675.2±10 708.8, respectively. Statistically differences were observed between each other (P<0.05). ConclusionBone marrow neutrophil CXCR4 expression of SD rat could be effectively up-regulated by perfusion of fucoidan within the in situ perfusion system. ECC-plasma-stimulated bone marrow neutrophil release in rat could be inhibited by fucoidan induced up-regulation of neutrophil CXCR4 expression, and this inhibition effect could be canceled by AMD-3100 intervention.
Abstract： Arginine vasopressin （AVP） is closely related to the pathogenesis of a variety of cardiovascular diseases and kidney diseases. Currently it is often used for the treatment of severe peripheral vasodilatory shock， and particularly beneficial for patients with refractory catecholamine-resistant vasodilatory shock. For some patients who do not have adequate AVP level in plasma after cardiovascular surgery， external low-dose AVP infusion is helpful to decrease the heart rate, and the dosage and duration of catecholamine use. Early initiation of low-dose AVP infusion may be beneficial for postoperative patients’ hemodynamic recovery without adverse complications. More randomized control trials are needed to provide evidence for rational usage， dosage and duration of AVP administration.
ObjectiveTo investigate the changes of plasma platelet activating factor (PAF) interleukin-8(IL-8) and interferon-γ (IFN-γ) in patients after surgery with extracorporeal circulation (ECC) and their clinical significance. MethodsSeventy-five patients undergoing surgery with ECC in the First College of Clinical Medicine,China Three Gorges University from June 2012 to June 2013 were enrolled in this study. According to the presence of postoperative acute lung injury/acute respiratory distress syndrome (ALI/ARDS) all the 75 patients were divided into 2 groups. In ALI/ARDS group, there were 28 patients including 20 male and 8 female patients with their age of 53.6±8.2 years. In the control group,there were 47 patients without postoperative ALI/ARDS,including 32 male and 15 female patients with their age of 56.9±11.8 years. Dynamic variations of plasma PAF,IL-8 and IFN-γ of these patients were examined with enzyme-linked immunosorbent assay (ELISA) and compared between the 2 groups. ResultsIn ALI/ARDS group,plasma IL-8 and IFN-γ reached peak levels at 48 hours after surgery and gradually decreased after that;plasma PAF reached the peak level at 96 hours after surgery and gradually decreased after that. Postoperative plasma PAF (96 hours after surgery:16 029.5±4 203.7 mU/ml vs. 4 520.1±312.2 mU/ml,P<0.05) IL-8 (48 hours after surgery:48 580.5±8 095.8 pg/ml vs. 5 990.5±1 179.0 pg/ml,P<0.05) and IFN-γ (48 hours after surgery:258.5±76.1 pg/ml vs. 26.1±11.5 pg/ml,P<0.05) of ALI/ARDS group were significantly higher than those of the control group at 48 hours,96 hours and 144 hours after surgery. ConclusionPlasma PAF,IL-8 and IFN-γ change significantly after surgery with ECC,which may play an important role in the pathogenesis of postoperative ALI/ARDS.
ObjectiveTo investigate the protective effect of atomized inhalation of nano-luteolin preparation on acute lung injury caused by extracorporeal circulation, and to explore the anti-inflammatory mechanism of luteolin, so as to provide study basis for clinical application.MethodsThirty male SD rats aged 5-6 weeks and weighting 160-190 g, were randomly divided into a preoperative baseline (BL) group, arteriovenous partial diversion (ECC) group, luteolin atomization pretreatment for 1 h group, 2 h group, and 3 h group by random number method, with 6 rats in each group. In the BL group, lung tissue samples were collected directly without any treatment. The ECC group received mechanical ventilation, and the whole body was heparinized after the jugular arteriovenous intubation. The flow was transferred for 30 minutes, followed by observation for 60 minutes, then lung tissue samples were collected. Subjects in the 1 h, 2 h and 3 h groups were placed in a small animal atomizer 1 h, 2 h and 3 h before flow transfer respectively, and the subsequent operation was the same as that in the ECC group. The inflammatory level of lung tissue was detected to evaluate the degree of pathological injury of lung tissue. Western blotting (WB) was used to detect the contents of p65, IKKα, IKKβ and IKKγ in the cytoplasm of lung tissue samples of each group.ResultsCompared with the ECC group, the levels of IL-6 and TNF-α in lung tissues and the degree of pathological injury in the 1 h, 2 h and 3 h groups decreased, and the difference between the 3 h group and the ECC group was statistically different (P<0.05). WB results showed that compared with the ECC group, the levels of p65 in lung tissue of the 1 h, 2 h and 3 h groups decreased; the levels of IKKβ in the lung tissue increased in the 1 h, 2 h and 3 h groups, and the difference of the 3 h group was statistically different from the ECC group (P<0.05).ConclusionLuteolin has a protective effect on acute lung injury induced by ECC, and atomization 3 h in advance has the best protective effect on lung. The mechanism plays a protective role in ECC-induced acute lung injury, may be through inhibition of IKKβ phosphorylation, thereby inhibiting the classical NF-κB signaling pathway.