Objective To investigate whether the respiratory support weaning based on adaptive support ventilation ( ASV) could reduce the duration of mechanical ventilation in patients after fast-track coronary artery bypass grafting ( CABG) . Methods After CABG during the same fast-track general anesthesia, 46 patients were randomly assigned to an ASV group or a synchronized intermittent mandatory ventilation ( SIMV) group as control. The duration of mechanical ventilation, hemodynamic parameters, and airway pressures were recorded. Meanwhile, the variables and the number of the arterial blood gas were recorded. Results The duration of mechanical ventilation was shorter in the ASV group than that in the control group [ 196( 152-286) ] min vs. 253( 196-498) min, P lt;0. 05] . The duration of ICUstay was shorterin the ASV group than that in the control group [ ( 14. 5 ±0. 7) h vs. ( 16. 8 ±0. 4 ) h, P lt;0. 01] . Fewer arterial blood analyses were performed in the ASV group than those in the control group [ 5 ( 4-7) vs.7( 6-9) , P lt; 0. 05] . Conclusions A ventilation weaning protocol based on ASV is practicable. It may accelerate tracheal extubation, shorten the length of ICU stay, and simplify ventilation management in patients after fast-track CABG.
Abstract： Objective To investigate the extracellular matrix （ECM） gene expression profile of saphenous vein （SV） in end-stage renal disease （ESRD） patients undergoing coronary artery bypass grafting （CABG）. Methods Sixty-eight patients who were diagnosed as coronary artery disease by coronary angiography and admitted to Department of Cardiovascular Surgery，Zhongshan Hospital of Fudan University from July 2004 to December 2010 were enrolled in this study. According to whether or not they had preoperative ESRD history，all the 68 patients were divided into 2 groups，the ESRD group with 30 ESRD patients who needed maintenance hemodialysis，and the control group with 38 patients without preoperative renal disease. Preoperative clinical data of all the patients were collected in detail. SV samples were obtained at the time of CABG. Microarray，immunohistochemistry and Western blotting were used to investigate the expression profile of ECM genes of SV in ESRD patients undergoing CABG. Results There was no statistical difference in preoperative clinical variables between the 2 groups except the variables which were directly related to their kidney disease （P＞0.05）. There were 16 genes that were up-regulated at least 3-fold and 3 genes that were down-regulated at least 3-fold in the ECM gene expression profile of SV in the ESRD group patients before CABG. The expressions of matrix metalloproteinases-2 （MMP-2） and matrix metalloproteinases-9 （MMP-9） of the ESRD group were significantly higher than those of the control group （2.60±0.50 vs. 0.70±0.16，1.80±0.40 vs. 0.60±0.15，P＜0.01）. The expressions of tissue inhibitor of metalloproteinase-2 （TIMP-2） and tissue inhibitor of metalloproteinase-3 （TIMP-3） of the ESRD group were significantly lower than those of the control group （0.60±0.19 vs. 2.20±0.30，0.90±0.28 vs. 2.40±0.70，P＜ 0.05）. Conclusion A variety of ESRD-related risk factors of cardiovascular diseases may severely influence on the balance of ECM gene expression of SV before CABG，and the resulting imbalance is a risk factor to aggravate SV graft disease after CABG.
Objective To investigate appropriate treatment strategy and timing for patients with subacute myocardial infarction and severe ischemic mitral regurgitation （IMR）. Methods A total of 89 patients with subacute myocardial infarction and severe IMR underwent surgical treatment from January 2005 to December 2011 in Beijing Anzhen Hospital. There were 66 male patients and 23 female patients with their mean age of 64 （55-73） years. All the patients received only coronary artery bypass grafting （CABG） after 3 months of medication treatment without specific management for their IMR. Echocardiography was examined before medication treatment，preoperatively and 6 months after CABG to analyze their IMR degree and measure left ventricular end-systolic dimension （LVESD），left ventricular end diastolic dimension （LVEDD） and left ventricular ejection fraction （LVEF）. Results There was no surgery-related death，perioperative myocardial ischemia or other severe postoperative complication. Eighty-one patients （91.0%） were followed up for 6-60 months. At 6 months after CABG，mitral regurgitation area （3.1±1.3 cm2 vs. 5.6±2.3 cm2），LVEDD （51.3±4.2 mm vs. 54.3±5.5 mm） and LVESD （31.7±3.9 mm vs. 34.6±4.3 mm） were significantly decreased than preoperative values （P＜0.05），but LVEF was not statistically different from preoperative value （59.1%±3.9% vs. 58.9%±5.6%，P＞0.05）. From the third year during follow-up，all the patients received annual CT examination of their coronary artery，and no significant graft stenosis （graft stenosis＞50%） was found. Conclusion With appropriately delayed CABG and right medication treatment，patients with subacute myocardial infarction and severe IMR may no longer need concomitant surgical management for their IMR， which can decrease surgical risks and reduce treatment cost.
Abstract： Objective To evaluate clinical outcomes of plication of left ventricular aneurysm during off-pump coronary artery bypass grafting （OPCAB）. Methods A total of 114 patients who underwent coronary artery bypass grafting （CABG） and concomitant surgical treatment for left ventricular aneurysm from January 2007 to January 2011 in Beijing Anzhen Hospital were included in this study. All the patients were divided into 2 groups according to the different surgical procedures they received. In groupⅠ， there were 76 patients including 57 males and 19 females with their average age of （63.4±7.8） years who underwent CABG and left ventricular aneurysmectomy under cardiopulmonary bypass on the non-beating heart. In groupⅡ， there were 38 patients including 32 males and 6 females with their average age of （60.6±8.9） years who underwent OPCAB and plication of the left ventricular aneurysm on the beating heart. Preoperative data were not statistically different between the 2 groups except that the percentage of the left ventricular aneurysm to the left ventricle of groupⅠwas significantly larger than that of groupⅡ（42.2%±13.6% vs. 26.5%±12.3％， t=5.499， P=0.000）. Postoperative clinical outcomes and morbidities were compared between the 2 groups， and all the patients were followed up for 6 months. Results There was 2 in-hospital death in groupⅠ， one for postoperative refractory ventricular arrhythmia， and the other for severe pneumonia. There was 1 in-hospital death in groupⅡ because of perioperative myocardial infarction. Postoperative thoracic drainage， incidence of reexploration for bleeding， mechanical ventilation time and incidence of intra-aortic balloon pump （IABP） implantation were not statistically different between the 2 groups （P＞0.05）. To compare their echocardiography outcomes at early postoperative stage and 6 months after discharge with preoperative values， left ventricular end-diastolic dimensions （LVEDD） at early postoperative stage and 6 months after discharge were both signific antly decreased than preoperative value in both groups ［groupⅠ： （54.0±7.8） mm amp; （56.0±8.1） mm vs. （59.6±6.6） mm， groupⅡ： （52.0±7.2） mm amp; （53.6±5.3） mm vs. （57.9±5.4） mm］， and left ventricular ejection fraction （LVEF） at early postoperative stage and 6 months after discharge were both significantly higher than preoperative value in both groups （groupⅠ：43.5%±3.2％ amp; 55.7%±3.7% vs. 38.0%±7.4%， groupⅡ：44.7%±2.8％ amp; 57.0%±3.5% vs. 41.0%±6.6%）， but there was no statistical difference in LVEDD and LVEF between the 2 groups（P＞0.05）. Conclusion Plication of left ventricular aneurysm during OPCAB is a safe and effective surgical procedure， and possibly more appropriate for patients with a smaller left ventricular aneurysm.
Objective To evaluate the value of preoperative B-type natriuretic peptide （BNP） level in predicting new onset atrial fibrillation （AF） in patients after coronary artery bypass grafting （CABG）. Methods We electronically searched PubMed，EMbase，Cochrane library，CNKI and VIP databases from the establishment of those databases to November 2012. Evaluation standard of diagnostic tests was used to identify and screen literatures which investigated correlations between preoperative BNP levels and new onset AF of patients after CABG. Quality Assessment of Diagnostic Accuracy Studies （QUADAS） was used to evaluate study quality of included literatures. RevMan 5.0 was used for heterogeneity test. Meta-Disc 1.4 software was used for meta-analysis. Included studies were weighted and then combined. Sensitivity，specificity，diag- nostic odds ratio （DOR），positive likelihood ratio，negative likelihood ratio and corresponding 95% confidence interval（95% CI）were calculated. Summary receiver operating characteristic （SROC） curve was drawn，and the area under the SROC curve （AUC） was analyzed. Results A total of 236 studies were identi?ed，and 5 studies met the eligibility criteria including 802 patients for analysis. There were 228 patients with postoperative new onset AF，and 574 patients without postoperative AF. The quality of the included literature was relatively high. DOR of preoperative elevated BNP level with postoperative new onset AF was 4.15 with 95% CI 2.90 to 5.95. Pooled sensitivity was 0.78 with 95% CI 0.72 to 0.83，pooled specificity was 0.58 with 95% CI 0.54 to 0.58，pooled positive likelihood ratio was 1.91 with 95% CI 1.42 to 1.56，pooled negative likelihood ratio was 0.42 with 95% CI 0.32 to 0.54，and the AUC of SROC was 0.79 （Q=0.72）. Conclusion Preoperative elevated BNP level is significantly correlated with new onset AF after CABG，is a powerful predictor of postoperative AF，and can be used to predict new onset AF after CABG to a certain extent of reliability.
Objective To explore clinical application and significance of coronary angiography （CAG） prior to heart valve replacement for patients with rheumatic valvular heart disease （RVHD）. Methods We retrospectively analyzed clinical data of 313 RVHD patients who underwent heart valve replacement in the First Affiliated Hospital of Chongqing Medical University from January 2002 to June 2012. All the patients received screening CAG before surgery. According to CAG results，313 patients were divided into two groups. In the coronary artery lesion （CAL） group，there were 29 patients including 17 male and 12 female patients with their age of 60.0±5.2 years. In the non-coronary artery lesion （non-CAL）group，there were 284 patients including 98 male and 186 female patients with their age of 57.0±5.4 years. Surgicaloutcomes were compared between the two groups. Univariate analysis and multivariate logistic regression were performed to analyze risk factors of CAL for RVHD patients. Results CAG showed 29 patients with CAL，and the overall prevalence of CAL was 9.27%. In CAL group，11 patients underwent concomitant coronary artery bypass grafting with 2.2 grafts for each patient on the average. Postoperatively 1 patient （3.45%） died of low cardiac output syndrome （LCOS）. In non-CAL group，5 patients （1.76%） postoperatively died mainly because of LCOS，ventricular fibrillation，sudden cardiac arrest or respiratory failure. Cardiopulmonary bypass time and aortic cross-clamp time of CAL group were significantly longer than those of non-CAL group （P＜0.05）. There was no statistical difference in postoperative mortality，incidence of LCOS，acute renal failure，respiratory failure，reexploration for bleeding，intraoperative blood loss，mechanical ventilation time or hospital stay between the two groups（P＞0.05）. There was no significant correlation between the types of valvular lesions and CAL. Age≥ 55 years （OR=5.534，P=0.005），male gender （OR=2.335，P=0.038） and diabetes mellitus （OR=4.265，P=0.006） were independent risk factors of CAL for RVHD patients undergoing heart valve replacement. Conclusion For RVHD patients with independent risk factors of CAL （age≥55 years，male gender and diabetes mellitus），CAG must beseriously considered before heart valve replacement. RVHD patients with CAL can obtain similarly satisfactory surgicaloutcomes of heart valve replacement as RVHD patients without CAL by appropriate surgical strategy and strengthened perio-perative management.
Objective To summarize clinical characteristics and treatment results of adult patients with coronary heart disease and ventricular aneurysm，and evaluate surgical outcomes. Methods Clinical data of 86 adult patients with coronary heart disease and ventricular aneurysm who underwent surgical treatment in Fu Wai Hospital from January 2011 to November 2012 were retrospectively analyzed. There were 70 male and 16 female patients with their average age of 57.7±10.6 years and average body weight of 71.7±10.5 kg. Preoperative echocardiography or left ventriculography showed left ventricular thrombus in 22 patients. Coronary angiography showed 47 patients with 3 vessel disease，29 patientswith 2 vessel disease，and 10 patients with single vessel disease. Sixteen patients underwent direct linear suturing of theaneurysm off pump，39 patients underwent simple linear suturing under cardiopulmonary bypass，15 patients received endoventricular purse-string reconstruction，and 16 patients received endoventricular purse-string reconstruction and patch plasty. Three patients underwent reexploration for bleeding. Sixty-four patients received concomitant coronary artery bypass grafting（CABG）. Results Postoperatively 2 patients（2.3%） died of refractory ventricular fibrillation and multiple organ dysfunction syndrome respectively. Patients undergoing concomitant CABG received 2.3±1.2 grafts on the average. Seventy-eightpatients （92.9%） were followed up for 2-24 months after discharge. During follow-up，patients’ angina symptoms significantlyresolved，heart function improved in varying degrees，and no new sign of myocardial ischemia was found on electrocardiogram.Left ventricular ejection fraction （LVEF） was significantly higher than preoperative LVEF（51%±7% vs. 41%±9% ，t=6.20，P=0.00），and left ventricular end-diastolic diameter （LVEDD） was significantly smaller than preoperative LVEDD （54.2±6.2 mm vs. 56.0±6.8 mm，t=4.60，P=0.00） . Conclusion Ventricular aneurysm repair and concomitant CABG （or ventricular septal perforation repair，mitral valvuloplasty et al） are positive and effective treatment strategies for postinfarction ventricular aneurysm. Satisfactory clinical outcomes can be achieved by individualized treatment based on appropriate surgical strategies according to the size of ventricular aneurysm.
Objective To investigate the impact of preoperative use of low-molecular-weight heparin （LMWH） on early outcomes of off-pump coronary artery bypass grafting （OPCAB） . Methods Clinical data of 809 patients undergoingisolated OPCAB from April 1st，2011 to September 30th，2012 in the First Affiliated Hospital of China Medical University were retrospectively analyzed. All the patients were divided into LMWH group and control group according to preoperative use of LMWH or not. In LMWH group，there were 386 patients including 290 male and 96 female patients with their age of 49-81 years，who routinely received anticoagulation therapy with LMWH （LMWH sodium or LMWH calcium，4 000 U twice a day，subcutaneous injection） after discontinuation of anti-platelet therapy until the day before surgery. In the control group，there were 423 patients including 321 male and 102 female patients with their age of 46-78 years，who didn’t receive LMWH or any other anticoagulant after discontinuation of anti-platelet therapy. Postoperative mortality，incidence of perioperative myocardial infarction （MI），operation time，amount of blood loss and transfusion，and incidence of postoperative acute renal injury were compared between the 2 groups. Results Intraoperative blood loss （296±94 ml vs. 249±81 ml，P=0.03），postoperative thoracic drainage （526±159 ml vs. 410±125 ml，P=0.02），blood transfusion （2.6±1.1 U vs. 1.4±0.9 U，P=0.04） and operation time （172±34 min vs. 154±41 min，P=0.04） of LMWH group were significantly larger or longer than those of the control group. There was no statistical difference in postoperative mortality（1.0% vs. 1.2%，P=1.00）or incidence of perioperative MI（4.4% vs. 3.8%，P=0.55）between the 2 groups. Conclusion For OPCAB patientswith stable ischemic heart disease，preoperative management without use of LMWH can decrease operation time and amountof blood loss and transfusion without increasing postoperative mortality or incidence of perioperative MI.
Abstract： Objective To evaluate clinical outcomes of endoscopic vein harvesting （EVH）for coronary artery bypass grafting（CABG） in diabetic patients. Methods In this prospective non-randomized control study, patients with type 2 diabetes who underwent CABG from December 2010 to Febuary 2012 in West China Hospital were enrolled. Based on different vein graft harvesting technique, these patients were divided into two groups: an EVH group and a conventional vein harvesting（CVH）group. Perioperative complications were compared between the two groups. Interventional or CT coronary angiogram was used to evaluate bypass graft patency during follow-up. Results A total of 51 patients with type 2 diabetes were enrolled in this study with 24 patients in the EVH group and 27 patients in the CVH group. There was no statistical difference in age, weight, and comorbidities between the two groups. There was no statistical difference in cardiopulmonary bypass time and aortic cross-clamping time between the two groups （67.2±9.8 min versus 68.3±14.5 min, P＞0.05; 62.4±11.3 min versus 65.2±10.3 min, P＞ 0.05）. The vein graft harvesting time （35.6±6.4 min versus 45.2±11.4 min, P＜ 0.05）and rate of delayed leg wound healing（0.0% with 0/24 versus 18.5% with 5/27, P＜0.05） of the EVH group were significantly shorter or lower than those of CVH group.There was no statistical difference in major postoperative complications with respect to venous graft failure rate and chest pain during short term follow-up（9.1 months in the CVH group and 9.4 months in the EVH group） between the two groups. Conclusion EVH is a safe, effective, minimally invasive and quick vein graft harvesting technique for CABG in diabetic patients.
Abstract： Objectives To evaluate the early and mid-term follow-up outcomes of “one-stop” hybrid coronary revascularization strategy for patients with multivessel coronary artery disease. Methods From June 2007 to December 2009, 104 consecutive patients underwent “one-stop”hybrid coronary revascularization in Fu Wai Hospital. There were 93 male patients and 11 female patients with mean age of （61.8±10.2）years（ranging from 35 to 81 years）. All the patients had multivessel coronary artery disease including left anterior descending （LAD）coronary artery stenosis, and underwent “one-stop”hybrid coronary revascularization. “One-stop”hybrid procedure was first performed through a lower partial sternotomy at the second left intercostal space. The distal anastomosis of in situ left internal mammary artery （LIMA）to LAD graft was completed. Angiography was performed immediately to confirm patency of the LIMA graft after closure of the thorax. A 300 mg loading dose of clopidogrel was administered through a nasogastric tube after confirmation of LIMA graft patency. Intravenous unfractionated heparin was administered to obtain an activated clotting time of greater than 250 s. Then percutaneous coronary intervention（PCI）was performed on the non-LAD lesions. Results All the patients underwent“one-stop”hybrid coronary revascularization including grafted LIMA to LAD，and one hundred and ninety one drug eluting stents and three bare metal stents were used for other non-LAD lesions. No death event occurred during surgery and in hospital. All the patients were followed up for a mean duration of 1.5 years. There was no myocardial infarction, neurologic event or death occurred during follow-up except one patient with stent stenosis who was treated by PCI. Conclusion “One-stop” hybrid coronary revascularization is a feasible and safe alternative for patients with multivessel coronary artery disease.